Leadership Capacity Strengthening Program (LCSP) For the Ministry of Health Republic of Guinea Follow-Up Inquiry Conakry and Kankan, March 10-21, 2004 Karen Sherk April 16, 2004 Management and Leadership Program Management Sciences for Health Boston, MA 02130 Telephone: (617) 524 7766 www.msh.org/mandl This report was made possible through support provided by the US Agency for International Development, Office of Population and Reproductive Health, under the terms of Cooperative Agreement Number HRN-A-00-00-00014-00. The opinions expressed herein are those of the author(s) and do not necessarily reflect the views of the US Agency for International Development. 2 Leadership Capacity Strengthening Program (LCSP) For the Ministry of Health Republic of Guinea Follow-Up Inquiry Conakry and Kankan, March 10-21, 2004 Karen Sherk April 16, 2004 Management Sciences for Health Management and Leadership Development Project Cooperative Agreement Number HRN-A-00-00-00014-00 and PRISM project Contract Number: 675-A-03-00037-00 3 TABLE OF CONTENTS ACRONYMS 3 1. EXECUTIVE SUMMARY 4 2. BACKGROUND 5 2.1 Effects at the Personal Level 5 2.2 Effects at the Organizational Level 6 2.3 Effects at the Institutional Level and Service Delivery Level 7 2.4 LCSP Coaching Workshop 7 2.5 Facilitators’ follow-up, January 2004 8 2.6 March 2004 Follow-up to the April/May 2003 Evaluation 8 3. METHODOLOGY 8 4. FINDINGS 10 4.1 To what extent and in what ways has the LCSP continued to impact the participants’ personal behaviors? 10 4.2 What has been the impact of these personal changes on the participant’s work life? 10 4.3 To what extent and in what ways has the LCSP continued to impact of the participants’ “new approach” to management practices, especially participation, team building, and team focused orientation, and generating and seeking feedback? 11 4.4 Has the LCSP impacted the participants’ approach to leading and managing in any new ways, subsequent to the May 2003 evaluation? 14 4.5 If any participant has not continued to implement new behaviors or practices, why not? 15 4.6 Have the coaching and follow-up support provide by the Guinean facilitators been sufficient? Why or why not? 15 4.7 Any other anecdotes or stories on how the LCSP has made a direct and lasting impact on the participants’ work, effectiveness in their position, and workgroup. 16 5. CONCLUSIONS 19 6. RECOMMENDATIONS 20 6.1 Systematic program follow-up 20 6.2 Program Sustainability 22 4 ACRONYMS CTRS Regional Technical Committee of Health (Committee Technique Regional de la Santé) GTZ Deutsche Gesellschaft für Technische Zusammenarbeit IGH Inspector General for Health LCSP Leadership Capacity Strengthening Program M&E Monitoring and Evaluation M&L Management and Leadership Program MSH Management Sciences for Health MOPH Ministry of Public Health MOST Management and Organizational Sustainability Tool MSH Management Sciences for Health NGO Non-Governmental Organization PHD Préfectoral Health Director PRISM Pour Renforcer les Interventions en Santé Reproductive et MST/SIDA (USAID’s bilateral project in Guinea, implemented by MSH) RHD Regional Health Director USAID US Agency for International Development 5 1. Executive Summary The purpose of the March 2004 follow-up inquiry was to gather evidence of the continued application of the skills and practices of the Leadership Capacity Strengthening Program, or LCSP (which consisted of three leadership workshops implemented over the course of six months, between April and November 2002) by the program participants since the April/May 2003 evaluation. The March 2004 follow-up inquiry took advantage of the presence of the two local program facilitators and 7 participants (of whom 6 completed all 3 modules of the program) of the original cohort of 21 participants, who were participating as “apprentice facilitators” in Phase II of the LCSP in Kankan, Guinea. The follow-up inquiry found that participants from the LCSP continue to implement the behavioral and attitudinal changes documented in the April/May 2003 evaluation report. They continue to strive to improve their listening skills, anger management, team￾building, team participation, negotiation skills, and conflict resolution. Additionally, the participants reported a stronger collaboration between themselves, the formation of a support network, and that they seek advice and feedback from one another through this network. They are using the network to join together and make positive changes in the health system. The participants are also very notably including their partners more and more often in the decisions they are making. Other notable findings from the follow-up inquiry include: • The LCSP program has inspired an excitement and a feeling of being able to change that the participants want to share. This excitement and sense of empowerment was palpable in the regional workshops, and evident in some of the participants’ enthusiasm for becoming facilitators. • All of the participants interviewed want to see the program carried out at the regional level, and of those who are regional directors, all have intentions to implement the program in their regions. • The follow-up by local facilitators is an important element in the program as a support for continued improvement as well as a way to measure progress. All of the participants interviewed valued the follow-up visits, though informal, for the feedback, advice, and inspiration the visits gave them. Many of the participants interviewed in March 2004 felt that the follow-up by the local facilitators has, however, been insufficient. • Compared with the information gathered in April/May 2003, there is more evidence of the impact of the program on health service delivery that the participants attribute to the application of the new leadership skills they gained from the program. Recommendations are also provided. 6 2. Background Responding to the Guinean Ministry of Public Health’s (MOPH) expressed need to “reinforce management skills at all levels of the health system”, PRISM (Pour Renforcer les Interventions en Santé Reproductive et MST/SIDA, USAID’s bilateral project in Guinea, implemented by MSH) launched a leadership initiative in April 2002 with two Leadership Dialogue meetings in Conakry in collaboration with the M&L Program. These meetings became the basis for the design of the M&L Program’s pilot Leadership Capacity Strengthening Program (LCSP). LCSP participants included the MOPH Directors from all seven regions of the country, and senior Ministry staff: Chef de Cabinet of the Minister of Public Health; five advisors to the Minister; four national directors and program coordinators (e.g., hospitals, pharmacies, public health, primary health care); the heads of training, and planning and evaluation; and the inspector general for health. LCSP consisted of three workshops implemented over the course of six months, April and November 2002. The first workshop focused on leadership and self-knowledge, the second on leadership and organizational dynamics, and the third on leadership and “changing the system”. Following the first two modules, participants produced action plans to address their challenges, and received follow-up visits from their Guinean facilitators who doubled as coaches. The LCSP was evaluated by M&L in April/May 2003. The purpose of the evaluation was to obtain an initial appreciation of the effects of the LCSP six months after the conclusion of the final workshop. The specific objectives were to: • Determine the extent to which the LCSP achieved its behavioral objectives • Determine the extent to which participants achieved their own performance objectives, based on leadership challenges identified at their own level • Make recommendations for the establishment of a monitoring system that will permit the MOPH to monitor progress on a regular basis • Make recommendations to the MOPH and PRISM on the best strategies and approaches to replicate and expand LCSP to other organizational levels of the national health system The following outcomes were documented in the evaluation report: Evaluation of the Leadership Capacity Strengthening Program (LCSP) for the Ministry of Public Health, Guinea (Linde Rachel and David A. Goldenberg, Management and Leadership Program, Management Sciences for Health, July 2003): 2.1 Effects at the Personal Level All participants greatly valued those aspects of the LCSP that had to do with personal issues. Only one participant considered the personal aspects less important than the organizational aspects. Through the various challenges that they set themselves, participants were able to make advances in the following areas of their personal 7 behaviors: control of emotions such as anger and impatience, willingness to listen, greater accessibility to others, humility. As leaders, they understood that personal growth can provide a stronger basis for working with others in teams to face challenges and achieve results. However, this linkage’s actual realization varied considerably across the participants. 2.2 Effects at the Organizational Level The LCSP inculcates a new approach to solving the management problems that stand in the way of resolving broader institutional challenges. This approach includes participation, transparency, risk-taking, and a purposive team-orientation. As a group, we found the LCSP participants to be visibly inspired and engaged in their quest for self-improvement. The introduction of the four leadership functions (i.e., scanning, focusing, aligning and inspiring) did not, in and of themselves, result in “new” behaviors or practices. However, combined and packaged within the LCSP program design, they helped to convey a new approach to existing management procedures (delegation, supervision, meetings, etc). The most noteworthy features of this new approach are: • Participation According to their colleagues, the program participants have introduced a new way of discussing issues and problems (scanning) -- collectively as a team. Team members clearly appreciate the greater clarity that comes through the sharing of information, improved means of communication and opportunities for input. However, we have little evidence that they feel included in major decision-making. Instilling the skills of aligning and mobilizing in team members is likely to become easier once they feel more directly included in the decisions that affect their work. • Team Building The participants had invested considerable effort in activities that can be used to build and strengthen their teams. They used improvements in such prosaic matters as job descriptions, meeting protocol, and delegation practices to put in practice a new orientation that promotes the engagement of subordinates and encourages their input. These are important elements in laying the groundwork needed for building effective teams. We found that some LCSP participants were more appreciative of this potential than others and would hope that there will be the opportunity to reinforce this important aspect of their LCSP experience and bring it to their conscious attention. • Generating and Seeking Feedback 8 Providing and soliciting feedback promotes transparency and a sense of sharing. Participants sought to make it routine practice and, in some cases, used it to push the boundaries of risk. . The positions occupied by the members of this LCSP cohort are highly visible, potentially vulnerable and by tradition very lonely. There was a palpable sense of liberation conveyed by the participants when they discussed their discovery of new ways of sharing information and inviting feedback from peers, superiors and subordinates. • From Efficiency-Focused to Team-Focused Orientation Challenges addressed at the organizational level focused on the improvement of existing practices. All of the participants had addressed one or another of these and had been able to achieve improvements. What we think is noteworthy for this evaluation is the extent to which these improvements went beyond technical efficiency to investments in building teams that can address challenges at broader levels and achieve sustainable results. This requires attitudinal change. Based on our findings, we have developed a continuum of responses from those that are primarily efficiency-focused to those that manifests a team-development orientation. The continuum progresses from what we would call an efficiency-based model of a manager, to what M&L would call the “Manager Who Leads”. Most of the responses fell into the efficiency-oriented category, but we also noted a distinct effort to move toward the participatory mode and there is at least one participant that has consciously initiated practices that fall into the team-empowerment category. 2.3 Effects at the Institutional Level and Service Delivery Level It was not the intent of this evaluation to assess the impact of the LCSP on change at the broader institutional level or on service delivery. Still, there is some indication that the team-focused approach and certain individual behaviors promoted by the program have facilitated steps toward institutional change. For example, staff in one region were going against the standard practice of masking dismal service statistics. The respondent linked this initiative to the importance of honest feedback that had been stressed during the LCSP. 2.4 LCSP Coaching Workshop The LCSP Coaching workshop took place from April 6 through April 8, 2003. Twenty participants participated, including the entire first cohort. The participants included the eight regional directors, five of the six advisors to the minister, the Inspecteur General de la Santé (the General Health Inspector), the Chef de Cabinet, the three national directors, and the heads of the SSEI (Service des Statistique, Evaluation, et Information). The purpose of the workshop was to prepare the participants to support the next cohort through the continuation of the leadership program at a decentralized level. This workshop stressed the role of the leader as a coach. The following themes were chosen for the workshop: the basic definition, functions, and competencies of coaching; the 9 “spirit” of coaching (climate, appreciative inquiry); mental models; and questioning as a coaching tool. Since the April/May 2003 evaluation, the following activities have taken place: 2.5 Facilitators’ follow-up, January 2004 Since May 2003, the local program facilitators, Oumar Diakite and Namoudou Keita, have followed-up with the members of the original cohort of participants. Their follow￾up has included informal visits and conversations with the participants and members of their work group teams. In January 2004, Oumar Diakite attended “The WHO 3 by 5 Strategy” conference in Conakry and took advantage of the presence of 7 of the 12 participants who completed the LCSP program in its entirety, participating in all three leadership modules. He interviewed each of them with the objective of discovering where they were in applying their new leadership practices, what challenges they have overcome, and what challenges they are still facing. He summarized these findings in a report, “Programme de Renforcement des Capacités des Hauts Cadres du Ministère de la Santé en Leadership et Management: Mission de Suivi du 27 au 31 Janvier 2004” (an internal confidential report). This report also includes a comparison of the content of the participant interviews with the impressions of members of these participants’ work teams — information drawn from the facilitators’ conversations with the participants’ colleagues when informally visiting the participants’ work sites over the course of the year. 2.6 March 2004 Follow-up to the April/May 2003 Evaluation The purpose of the March 2004 follow-up inquiry took advantage of the presence of the two local facilitators as well as several members of the original cohort at the first of the LCSP regional-level workshops in Kankan to gather more information on both the findings of the January 2004 report by the facilitators, and to follow-up further on the findings of the May 2003 report. 3. Methodology The information contained in this report is based upon the report, “Programme de Renforcement des Capacités des Hauts Cadres du Ministère de la Santé en Leadership et Management: Mission de Suivi du 27 au 31 Janvier 2004” (an internal, confidential document compiled by the program facilitators) as well as conversations and structured interviews conducted in March 2004 with the local program facilitators and 7 participants (of whom 6 completed all 3 modules of the program) who participated as “apprentice facilitators” in the Phase II of the LCSP. Four of these participants were among the 7 participants interviewed in January 2004 by the program facilitators. Information for this report was also gathered from brief conversations with two central-level participants who did not come for the workshop. The report also draws upon an interview with the former Chief of Party of the PRISM project from 1999-2003 who worked closely with four 10 Regional Directors who participated in the program before, during, and after their participation. The objective of the structured interviews with the participants was to gather evidence in the following key areas of inquiry: 1. To what extent and in what ways has the LCSP continued to impact on participants’ personal behaviors? 2. What has been the impact of these personal changes on the participants’ work life? 3. To what extent and in what ways has the LCSP continued to impact on participants’ “new approach” to management practices, especially participation, team building and a team-focused orientation, and generating and seeking feedback? 4. Has the LCSP impacted participants’ approach to leading and managing in any new ways, subsequent to the May 2003 evaluation? 5. If any participant has not continued to implement new behaviors or practices, why not? 6. Have the coaching and follow-up support provided by Guinean facilitators been sufficient? If not, why not? 7. Gather and record any other anecdotes or stories on how the LCSP has made a direct and lasting impact on the participants’ work, effectiveness in their position, and workgroup. The key questions posed during the interviews were: 1. What are your current challenges? How are you applying what you learned in the program to confront these challenges? 2. What is the major element from the program that has really had an effect on you? 3. What do you think of the follow-up of this program by the program facilitators? Have the follow-up visits and support been too much, just right, or not enough? Would your experience in this program have changed if you had not had this follow-up? 4. How do you feel about becoming a new facilitator for Phase II of this program? 5. How has this program changed your relationship with other program participants? 6. Do you have any other thoughts or reflections about the program? These interviews with the participants lasted between 40 minutes to one hour fifteen minutes during the week of March 15 to 19, 2004 in Kankan, Guinea during the first two￾day dialogue of phase II of the LCSP at the regional level (including the teams of the Regional Health Directorate, the Prefectoral Health Directorate, and the Hospital Directorate), and the 3-day workshop application of the Management and Organizational Sustainability Tool (MOST) with the Regional Hospital of Kankan. Six participants from the original cohort participated in these workshops as “apprentice facilitators” with the intention of replicating the program in their own regions. 11 4. Findings 4.1 To what extent and in what ways has the LCSP continued to impact the participants’ personal behaviors? As was discovered in the April/May 2003 evaluation, the participants greatly value the personal aspects of the program and continue to implement these new behaviors in their professional and personal lives. Many participants cited improved conflict management, anger management, and listening skills, and their work teams have noted and appreciate these changes (as cited in the facilitator’s report). As in the first evaluation, several participants interviewed also explained how these behavior changes were not only useful in their professional careers and relationships, but also applicable in their personal relationships with family and friends. One participant described how he was called by his co-worker to help him resolve a marital conflict, and he used his conflict management skills to achieve this successfully. Another one gave the example of how now he sees the importance of resolving conflicts within the home that before he did not give much importance to. Two other participants also cited personal improvement in their management of family and social relations. One participant explained that he uses the philosophy of leadership in raising his children: “J’utilise beaucoup la notion de leadership pour l’encadrement de mes enfants. Je les ammene a comprendre comment vivre en société, comment ils doivent aborder des difficultés, le comportement qu’ils doivent avoir pour confronter des problèmes d’apprentissage.” (“I use the notion of leadership a lot in raising my children. I help them to understand how to live in society, how they can overcome difficulties, and how they can face problems in their leaning.”) In the facilitators’ report, it was also documented that two participants were more reserved and closed off before the program. 4.2 What has been the impact of these personal changes on the participant’s work life? Listening As was discovered in the April/May 2003 evaluation, participants continue to work on their communication skills, especially listening. Participants, and their work groups, continue to attest to the improvements in their listening skills: • “Je parle toujours en dernière position après avoir écoute tout le monde,” (“I always speak last after listening to everyone else”) said one participant who is a regional director. One of his colleagues described him in a meeting, “Je ne le reconnaissait pas, tellement il maîtrisait les débats, distribuait la parole, écoutait attentivement et n’intervenait qu’en toute dernière position.” (“I barely recognized him, how he mediated debates, gave everyone a chance to speak, listened attentively, and did not speak until everyone else had spoken.”) 12 • As another regional level participant said about himself : “Je suis moins arrogant moi-meme, j’écoute mieux les gens.” (“I myself am less arrogant, I listen more to people.”) • The facilitators also reported that several of the participants noted that they had found that if they let everyone in a meeting contribute and speak before they do, all of the essential points that they may have brought up themselves are brought up by the work teams. Anger management with co-workers The facilitators’ report cites several examples of anger management improvements. As the colleague of one regional director said: “il ne crie presque plus sur les collaborateurs comme au début.” (“He hardly ever yells at his colleagues like he did in the beginning.”) 4.3 To what extent and in what ways has the LCSP continued to impact of the participants’ “new approach” to management practices, especially participation, team building, and team focused orientation, and generating and seeking feedback? Team-building and team focused orientation In both the March 2004 interviews, and the facilitators’ report, as discovered in the initial evaluation in April/ May 2003, the participants cited improvements in the organization of meetings and staff that they link directly to skills they have gained in the leadership program. One participant cited the weekly meetings that are now held with his staff. They also gave examples of how they shared information with not only all members of their teams, as was discovered in the April/May 2003 evaluation, but also with outside partners. As many of them stated in both the interviews and the facilitators’ report: • “Je ne fais rien sans partager avec les partenaires” (“ I don’t do anything without consulting with partners.”) • “Je prends mon temps pour bien informer les collaborateurs avant chaque réunion.” (“I take my time to inform my colleagues well before every meeting.”) • One participant explained to the facilitators that all activities are now carried out by the team, and that even the Prefectual director and the hospital director are part of his team now. It was not like that before. • In the facilitators’ report, another participant gave the example of how he leaves his office unlocked now so that in his absence, his team can access his office to continue their work. Participation There were many examples of participation mentioned by the participants, both in the interviews and in the facilitators’ report. One participant mentioned that he has folders for each member of his team. While he used to keep all the information that came through the office centralized, he now puts tasks in a folder for each member of his team for them to follow-up on. Another participant noted that he makes an effort to recognize 13 the contributions of each member of his team to motivate them and encourage participation. Another Regional Health Director (RHD) recounted the story of how he motivated a member of his work team out of a pre-retirement slump to be a more productive member of his team. The co-worker’s motivation in his job had declined as his retirement approached. The RHD helped the staff member to see that if he did his work well that he would be invited to become a consultant by other organizations when he was retired, and that he may even have opportunities to travel, etc, if he worked hard in his last few years at the Regional Directorate. This has greatly changed his attitude toward his work and has made him a productive member of this regional team. Networking among cohort members and seeking feedback and advice from each other The participants interviewed described the network that has formed among the participants as a result of the program. The participants gave examples of how they actively collaborate, call each other, share information and resources, give each other advice, and band together to push for what they want. The examples of the participants consulting one another were plentiful. A very notable example was when one participant from the regional level was facing the challenge of resolving a conflict between two members of his regional team. He was unsuccessful in his attempts to resolve the situation, so he consulted with a participant from the central level when he came to visit the region. The participant from the central level helped to resolve this conflict, using conflict resolution techniques learned in the program. Another participant gave the example of how he has shared a solution he found to a staffing problem with other participants, thinking it could be feasible in other regions besides his. Another participant discussed borrowing books and printed resources from another regional director. One looked at me and smiled when I asked him about his relationship with the other participants. He held up his cellular phone and said “I have all of their numbers right here in my phone.” “On se comprendre réellement” (“We really understand each other”), a participant from the central level said. Another participant explained “Tous les DRS, on forme un bloque comme ça—ça a crée une relation très intense entre les DRS. On devient très complice.” (“All of the RHD, we form a strong alliance, that has created a very intense relationship between the RHD. We have become accomplices.”) A specific example that illustrates this is that the week after the workshop in Kankan, a national review was being held in one of the regions. The Regional Director of this particular region called the Regional Director of another region who was attending the workshop in Kankan to ask him for his help upon his return from the workshop. The RHD whose help was being sought accepted to come a few days before the review to help the director prepare for the review. One example of the participants working together is how the participants successfully maintained the regional level leadership activity in Kankan the week of March 15. The 14 program was scheduled for the week of March 15 when the new Minister of Health called to have the “Annual Review of Primary Health Care, Expanded Program of Immunizations, and Essential Drugs” the week immediately following the program commencing in the region of Kankan, giving those who came to participate as apprentice facilitators as well as the regional team of Kankan no time to prepare for the review. Several regional directors discussed the issue, and sent one representative to negotiate with the ministry to change the dates of the review so that both activities could be implemented. The negotiation was successful, the review was delayed one week and relocated to another region; this enabled full participation of the regional team and some regional directors in the LCSP program. As the former Chief of Party of PRISM commented “We’ve recently witnessed how they [the participants] maintained the regional level leadership activity. Before the leadership training, they would not have tried to do that.” Two participants described how relationships have grown between participants from the regional and the Central levels. One described that before, there was a lot of distance between them, but now they say hello to each other, they discuss issues, and they respect each other. He added that the communication between the central and regional levels has improved. Another participant at the regional level explained further that better relations and communication with the Central level (as a result of the program) have led to more constructive feedback from the central level, with the aim of improving results instead of imposing sanctions. “Mon expérience me montre une changement positif que je ne suis pas habitué à voir.” (“My experience shows me a positive change that I am not used to seeing.”) Negotiation Many participants cited improved negotiation skills that have helped them to make necessary changes in their work teams, and attract money and program assistance from partners and donors (see section 4.7 of this report). Conflict resolution Four of the seven participants interviewed cited conflict resolution skills as very valuable behaviors they gained from the program. As a result of the program, for example, one RHD implemented committees of conflict resolution in all the prefectures in his region. Others discussed the importance of seeing the point of view of the other person and understanding their perspectives. There was one very notable story that demonstrates these conflict resolution skills and collaboration among the cohort members. A central level staff member was in one of the regions for a supervision visit and he helped resolve a conflict between three Prefectoral Health Directors (PHD) in that region. The RDH was unable to resolve the conflict between two of his staff members, and so he turned to a central level staff member. The central level staff member described how he asked the three to write down what happened. Each one described the conflict. The central level staff member tried to 15 paraphrase each person’s thoughts, and then he asked each person what they had done to contribute to the conflict, and what they can do to avoid the conflict. Together they defined what each person should do to resolve the conflict, and to apologize and forgive each other. The central level staff person helped define the tasks for each person involved to take care of. The conflict was successfully resolved on this work team. 4.4 Has the LCSP impacted the participants’ approach to leading and managing in any new ways, subsequent to the May 2003 evaluation? The network that is forming among the participants in the original cohort is having another effect besides the sharing of information and consultation between the participants. The facilitators as well as the former Chief of Party of PRISM have both observed that the participants from this cohort are starting to refuse to accept political “nonsense” and are pushing back against it together. An excellent example of this is that one of the Regional Directors and one of the participants at the central level bravely presented to the regional governor at a Regional Technical Committee of Health meeting (Committee Technique Regional de la Santé, CTRS) that there are abuses going on in the system and that financial and human resources available in the country are being significantly siphoned away from the health system. In the presentation, the two participants very tactfully asked the governor to address this issue. The governor was receptive to their request and agreed. One of these participants also mentioned this in comments he made to the regional participants of the Kankan leadership dialogue. He encouraged people to push from below, and warned that if they didn’t, nothing would change in the system. Another notable change in management is taking on new initiatives and changing former ways of doing things. One participant has restructured the organization of the CTRS meeting, a bi-annual meeting of the Regional Technical Committee of Health (Committee Technique Regional de la Santé). Normally, every district in the region presents its semester data, with a question and answer session following each presentation. These presentations are given one after the other. The participant structured the meeting so that there are committees that review each district report, summarize the issues for each one, present them, and then the issues are classified as district or regional levels. That way, the discussions are based around issues, and data cannot be covered up easily. Another notable point about the participants’ new management practices is the inclusion of partners in their decision-making and planning processes. The former Chief of Party for PRISM noted that some of the regional directors were making a concerted effort for various partners in their regions to work together, and less often playing them against one another. He said that for the first time the prefectural and regional work plans integrated all partners. Many of the participants spoke about informing and integrating their partners in the work they are doing as well. 16 4.5 If any participant has not continued to implement new behaviors or practices, why not? One of the conclusions from the April/May 2003 evaluation was that, as leaders, the participants understand that personal growth can provide a stronger basis for working with others in teams to face challenges and achieve results. However, this achievement of this linkage’s varied considerably across the participants. The participants still face many challenges in personal behavioral changes. The information and anecdotes in this section come from the facilitator’s report and not from the interviews conducted with the participants in March, 2004. During the March interviews there were no direct questions posed about leadership practices that the participants themselves feel they need to improve. The information from the facilitator’s report supports the idea that although the participants understand the importance of many behavioral changes, these changes have not been fully implemented by every participant, though participants have made notable improvements in their behavioral practices. The reason they are not implementing these changes is likely due to the fact that behavior change comes slowly, as one participant pointed out. As observed more from outside perspectives, such as members of work groups and the facilitators themselves, there are behaviors that participants still need to work on. For example, the participants’ tendency to impose certain decisions was observed and cited by the participants’ work group members. In one of these cases, this participant used to be imposing all the time, according to the facilitators, so his behavior has improved since the program. The participants themselves gave examples to the facilitators of challenges they feel they still have: • One continues to work on controlling his emotions : “Je m’énerve vite et crie sur les autres” (“I get angry quickly and yell at other people.”) • “Je n’arrive pas parfois a me retenir ce qui entraînait des dissensions dans le climat de travaille. ” (“Sometimes, I am not able to pick up on what is leading to dissentions in the work climate.”) • “Je n’arrive pas à intégrer réellement les membres de l’équipe.” (“I have not been able to truly integrate all the members of my team.”) • “Je n’ai pas réussit à gérer mes supérieurs hiérachiques.” (“I have not succeeded in managing my superiors in the hierarchy.”) 4.6 Have the coaching and follow-up support provide by the Guinean facilitators been sufficient? Why or why not? At the coaching workshop in April, 2003, the members of the cohort and the facilitators planned the follow-up to the LCSP program as trimestrial visits by the national facilitators. Due to work constraints (one facilitator is a full-time PRISM employee while the other is a full time employee of the Ministry’s Regional Directorate of Kankan), the facilitators were not able to carry out these trimestrial visits. Instead, when their work￾related travel would bring them to a participant’s region, they would have an informal 17 visit and speak with the participant and members of the participant’s work team. This resulted in variable contact: one facilitator has seen each of the 12 participants who finished the program at least twice since April 2003, and the other facilitator has seen them all at least once, and more than half of them at least twice. They have also had substantial contact with the participants work teams. “It is rare that a month goes by that we don’t see a participant’s colleague,” one of the facilitators said. According to the facilitators, during their visits the participants immediately ask questions, solicit advice and feedback, confide, or recount anecdotes about how their work is going. During the interviews, the participants all concurred that these visits are very useful, encouraging, and stimulating. As one participant said: “C’est comme une rappel de vaccin, extrêmement important.” (“It is like a booster shot, extremely important.”) Many participants interviewed in March 2004 felt that the follow-up was very good but not sufficient, and would have liked to have seen the facilitators more frequently and in a more systematic way. One participant suggested creating a systematic follow-up plan and holding a round-table discussion to determine indicators for monitoring participant progress. For those participants who are now planning this activity at their regional levels, all are including a systematic follow-up component for the program in their work plans and budgets. Both facilitators have identified that finding time for a structured follow-up is a challenge. As one of them lamented “If we were independent consultants, we could follow-up more often with the participants. But we both have work priorities for our positions [at the Regional Directorate in Kankan and PRISM Faranah] that keep us from being able to do this often. But, I believe in this program… this will become part of our national history. I think about that when [balancing priorities] becomes difficult.” 4.7 Any other anecdotes or stories on how the LCSP has made a direct and lasting impact on the participants’ work, effectiveness in their position, and workgroup. Impact on service delivery Improving vaccination coverage One of the participants described how he helped improve vaccination coverage in one of the sous-prefectures in his region. In 2001, the vaccination coverage in his region was monitored. The results showed that one sous-prefecture in his region had vaccination coverage rate for fully immunized children of 0 %, even though a vaccination program had been in place there since 1992, and the vaccination coverage in the surrounding sous￾prefectures was 63 % at that time. In December 2002 and January 2003, after the start of the leadership program, he decided to take action. He described how he first did an analysis (which he referred to as “scanning”) of the sous-prefecture and “I asked ‘why?’ like we had during the leadership training.” He discovered that it is a geographically isolated (“enclavé”) and poor zone with limited personnel who had limited competency, insufficient logistical support, and a 18 budget that was no longer supporting the health centers. He organized a meeting with this community, the authorities, and those responsible for the districts in this sous￾prefecture. During the meeting, the community decided that 0 % coverage for fully immunized children was unacceptable, and that they must take action. The community agreed to reconstruct the health center there and also donated money for the repair of the center’s refrigerator and six months worth of oil to run it. The RHD also launched an awareness campaign, which announced the results of the vaccination coverage on the radio and helped make the populations of the surrounding sous-prefectures aware of the problem. The RHD described that, often, sous-prefectures do not collaborate and tend to work independently of each other. This particular sous-prefecture was surrounded by three sous-prefectures with more trained personnel, financial resources, and means of transportation than the one with the poor vaccination coverage. The RHD described how he had to convince the populations of these sous-prefectures to share their resources with their neighboring sous-prefecture, as initially there was resistance from them. He explained to them that it was in their own best interest to help, because if there was an outbreak of an epidemic, the populations of their sous-prefectures would be affected as well. He succeeded in this negotiation, and the surrounding sous-prefectures agreed to send 3 personnel and two motorcycles once a month for six months to help with the vaccination effort. The vaccination campaign concluded in June 2003, and the vaccination coverage in this particular sous-prefecture at that time was 47 %. The statistics from December 2003 showed that the sous-prefecture had a coverage rate of 62 %. The RHD attributes these results in part not only to the negotiation and conflict resolution methods he learned during the leadership program, but also to successfully delegating the program to those in charge of the sous-prefecture and the head of the health centers. This included a community meeting about the vaccination campaign once a month that enabled continued contact with all of those involved, program maintenance, and monitoring of program progress. Implementing a Model HIV/AIDS Program One participant recounted how he recently negotiated an HIV/AIDS program for his region with the Deutsche Gesellschaft für Technische Zusammenarbeit (GTZ). His region has a sero-prevalence rate of 1.9 %. He met with GTZ at a planning meeting for the CNLS (Commitee National pour la Lutte Contre le SIDA) who was proposing a model program for people living with HIV and AIDS funded by the World Bank. The participant negotiated with GTZ for them to launch the program in his region (one of 3 regions covered by GTZ) and they agreed. The participant described the first planning meeting that was held about the program. He invited representatives of all of the organizations involved in the process: representatives of SIDA III, SIDA Alert, GTZ, the Regional Directorate of Health, the Prefecture 19 Directorate of Health, the Directorate of the Regional Hospital, pharmacists, and doctors, totaling 28 people. They discussed about how they would organize themselves and how they would work together, and they created a committee which would be responsible for the program. He said that in the beginning, the people on his team thought they couldn’t do it, but this has changed and the program is going well. “Now people say, you must go see [my region for a working model of this program].” The program, which is now implemented at the regional hospital, was started in June 2003 and includes provision of testing equipment by GTZ, training in testing and counseling for staff, and anti-retroviral treatment for those living with HIV and AIDS, which started in February 2004. The regional hospital has tested more than 300 people, and so far 13 people have started ARV treatment. For the year, they anticipate treating at least 50 people with ARVs. It is the only program of this type in Guinea outside of the capital city. This Regional Director believes that he was successful in negotiating to have the program launched in his region because GTZ saw his region’s capacity to organize, to mobilize, and to work in teams. He also credits his success to his negotiation skills, which he feels were improved during the leadership program. “Avant le programme, j’avais une manque de compétence de négociation et de mobilisation… [Ce programme] m’a vraiment aidé de savoir comment se comporter face à une personne inconnue.” (“Before the program, I lacked skills in negotiation and mobilization… [This program] has really helped me to know how to act with someone I don’t know.”). Changing attitudes about inspection One of the participants, who works at the central level as the Inspector General, read everything about his department and outlined a mission that he saw for the inspections, as the inspector is usually negatively viewed and feared as a repressor. It was through the leadership program that he realized the importance of sharing his vision with not only those he worked with in inspection, but those he inspected. He created a guide for his inspections and during an inspection in January 2004, he shared his vision for inspection—that it is a service and a way to identify areas of improvement, and is not meant to lead to punishment and sanctions. When he went on an inspection of the RHD in another region, after the inspection, the RHD invited him back, which was the first time that ever happened to him, and is known to never happen with inspections. Replicating the program All the participants interviewed in March have shown excitement and enthusiasm about replicating the LCSP in their regions at the regional level. Two regions have PRISM support to do so, one of which is Kankan, where the regional program was launched. The other is Faranah, where the regional program is scheduled to begin in May 2004. Of the other regions, Boké has already secured funding from an organization called PASSIP (Projet d’appui du Système de Santé à l’intérieur du Pays), and only needs to 20 refine the budget. The regional director there hopes to increase the number of days of the initial leadership dialogue to three days, based upon his observations and recommendations made about the first dialogue in Kankan. He believes the program can be launched in as little as two months, and that it will have approximately the same time frame as the one in Faranah. The regional directors of Mamou and Kindia plan to submit proposals for this program to GTZ and WHO, respectively. All participants expressed excitement and enthusiasm for replicating the program at the regional level. One participant pointed out that he had traveled 1350 km to attend the workshop in Kankan. As he said: “Je sais que ça peut amener des choses à mon pays. J’ai absolument confiance dans le changement que ça peut apporter. ” (“I know that this can bring something to my country. I have total confidence in the change it can bring about.”) Another participant, referring to his plan to launch the leadership program at his regional level, said: “Tant qu’on n’a pas la même vision, on aura toujours des difficultés à atteindre rapidement des résultats.” (“As long as we don’t share the same vision, we will always have difficulty achieving results quickly.”) And another said “Je suis prêt à mettre tout en oeuvre pour réaliser ce programme et ainsi impliquer mes collaborateurs dans l’amélioration de la santé de la population. ” (“I am ready to implement this program so that I can enroll my colleagues in this program in order to improve the health of the population.”) And still another said “Si on a de la chance d’assurer de la formation dans chaque région, on va changer la philosophie du système de la santé.” (“If we are lucky enough to have this training in every region, we will change the philosophy of the health system.”) 5. Conclusions Participants from the LCSP continue to implement the behavioral and attitudinal changes documented in the April/May 2003 evaluation report. They continue to strive to improve their listening skills, anger management, team-building, team participation, negotiation skills, and conflict resolution. Additionally, the participants reported a stronger collaboration between themselves, the formation of a support network, and that they seek advice and feedback from one another through that. They are using this network to join together and make positive changes in the health system. The participants are also very notably including their partners more and more often in the decisions they are making. To summarize, as the former Chief of Party of PRISM observed about the participants from the cohort with whom he collaborated: “They are much more aware of their actions, words, and impact on their team environment. They manage their communication more carefully. They have a better sense of the potential that comes with working as a team—promoting team work, gaining clarity in roles and responsibilities. They manage their tempers much better. When I witness this, I have to conclude that they develop their ability to understand the others’ perspective, where he is coming from.” 21 There are some behaviors that have not been implemented by some individual participants, as well, which are documented in the facilitators’ report. These behaviors include anger management, team integration, and managing superiors. The lack of implementation of these behaviors is likely due to the fact that behavior change is often a difficult and slow process. The lack of implementation of these behaviors is, however, recognized by the participants themselves in many cases. The program has inspired excitement and a feeling of being able to change that the participants want to share. The excitement and sense of empowerment were palpable in the regional workshops, and evident in some of the participants’ enthusiasm for becoming facilitators. The participants were almost preaching the virtues of the different aspects of leadership, of humility, of creating a clear vision, and of working in a team. They were also explaining how this can lead to change. As one participant said to the group during the workshop: “In the CTRS [the bi-annual meeting for the Regional Technical Committee of Health], we have made the same recommendations year after year. Maybe it’s because we are not analyzing the problems in the right way.” All of the participants interviewed want to see the program carried out at the regional level, and of those who are regional directors, all have intentions to implement the program in their regions. The follow-up by local facilitators is an important element in the program as a support for continued improvement as well as a way to measure progress. All of the participants interviewed valued the follow-up visits, though informal, for the feedback, advice, and inspiration the visits gave them. Many of the participants interviewed in March 2004 felt that the follow-up by the local facilitators has, however, been insufficient. Compared with the information gathered in April/May 2003, there is more evidence of the impact of this program on services that the participants attribute to the application of the new leadership skills they gained from the program. 6. Recommendations 6.1 Systematic program follow-up The key recommendation from this follow-up inquiry is the implementation of a systematic follow-up by the facilitators/ trainers with the participants. All of the seven participants interviewed in March 2004 said that the follow-up was helpful; five of the seven participants interviewed said that the follow-up by the local facilitators was insufficient (and one of the two who did not feel this way works with one of the facilitators in the same office). It is recommended that the follow-up be systematized with pre-determined indicators in order to continually measure progress or lack of progress by the participants. The information gathered could be used for self-evaluations by the participants, or internal program evaluations within the regions or at the national level. 22 Staffing and resources for the follow-up There are several challenges for a systematic follow-up system. The first, and the reason for which the program follow-up outlined at the April 2003 coaching workshop was not followed, is that the local facilitators have obligations to their full-time positions and are unable to make the time for systematic follow-up. As the program becomes decentralized, this is not likely to change, as the new facilitators/ trainers will be the regional directors and /or central level ministry staff, who are also very busy. It should be considered for future programs, if the resources are available, that there be staff with Level of Effort (LOE) dedicated to the program in order to have sufficient follow-up. It is recommended that if outside consultants are ever used for this purpose that they have an intimate knowledge of the program and/or have been participants in the program. It is very important that the participants have a trusting relationship established with the facilitators who are conducting the follow-up. In order to recognize and overcome this important staffing and organizational challenge within the program, it is recommended that the participants from the original cohort design a support mechanism for the program. As mentioned earlier in this report, one participant suggested holding a round-table discussion to determine indicators for monitoring participant progress. This idea could be taken a step further to create an advisory committee for the program made up of the original cohort of participants who will create a support mechanism for follow-up, especially as the program becomes decentralized. It is recommended that a two-day meeting be held with members of the original cohort. The purpose of this meeting would be to share stories of leadership experiences and challenges, and to design the support mechanism or strategy for the program, especially at the decentralized level. At this meeting, indicators would be determined, as well as a feasible system that will support and mentor both the members of the original cohort, and the new program participants at the decentralized level in their leadership development. Indicators and self-assessment The second challenge would be that, by implementing a set of fixed indicators, these follow-up visits may lose the support and counseling aspect that the participants value. Many of the participants interviewed, as well as the facilitators themselves, saw these visits as an opportunity to ask questions, get support, and seek advice from the facilitators. A key factor in this success may have been the informality with which the follow-up visits were conducted. With the development and use of indicators, the new facilitators/ trainers for the regional-level program will have to be careful not to slip into a “check-list” routine, seeking information about indicators of progress without giving the moral support and informal advice so greatly valued and utilized by the current cohort of participants. It is recommended that these follow-up visits be systematic without 23 becoming formal examinations of the participants and their current practices. The follow-up visits should be viewed as opportunities for support and self-improvement, and not simply for measurement, though the collection of data on pre-determined indicators would be equally useful for future programs and improvements. Therefore, it is recommended that measurement tools, such as the Work Climate Assessment, be promoted to be used as a self assessment with results reviewed with the mentoring facilitator during the support visit. This may help eliminate the tendency towards a “check-list” routine, it would give the participants an active role in the assessment of their growth as leaders, and it would create a starting point for the feedback from the facilitators conducting the follow-up. 6.2 Program Sustainability A critical mass of trained facilitators/ trainers is essential for the success of the program at the decentralized levels. This will not only provide ample facilitators if each non￾PRISM region is able to secure funding for a regional program, it will also create enough trained facilitators to help in the follow-up of the program. It is recommended that this program be continued at the regional level. In order to do this, it is recommended that a facilitator’s guide be created and distributed. The guide should contain all of the resources and tools that are used in the workshops (program materials such as the M&L Framework, the Vision Tree, etc) as well as the facilitators’ notes from both the Kankan and the Faranah initial regional dialogues, as well as outlines and guides for the following three dialogues in the program. This resource can be created by the “facilitators in training” who attended both the Kankan and Faranah regional workshops in collaboration with the two local facilitators of the LCSP. This guide will serve as resource and a confidence-builder for the original cohort members who will now be facilitating the new program and can be used to eventually train new facilitators if the program decentralizes further.