The impact of public health l

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Aug 4, 2011 - copied from printed or electronic sources, translated from foreign sources ..... staff, and among the staff or the health care team and the patient or patient's family. .... system-wide development, but most MOH managers are occupied with donor funded projects. .... The structure of the health services delivery id.
MASTER OF SCIENCE in Health Management MASTER in Gestione dei Servizi Sanitari Dissertation Title: The impact of public health leadership in Somalia the case study of Bosaso district

Name:ABDULKADIR ABDULLAHI YUSUF

Year:2018

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ABSTRACT

Introduction Background The objective of this study was to investigate public health leadership in Somalia case study in Bosaso district and project leadership could be developed based on a review of the literature. Little empirical studies have been conducted on trait theory or transformational leadership involving addressing the 8 themes and 6 key elements of leadership and management. Two out of six elements had two themes in each because these themes were closely related and integrated. The 8 themes were change management, organizational structure, styles of leadership, performance management, conflict resolution, total quality management and quality assurance. Objective: to evaluate the impact of public health leadership in Somalia case study Bosaso district Methods conducted from March to June 2018 the public health leadership workforce eight management and leadership occupation titles were used as job categories. The competencies were selected from the leadership and management domain of public health competencies for the Tier -3, leadership level. Study participants were asked to rank on a Likert scale of 1–8 the relevance of each competency to their current job category, with a rank of 1 being least important and a rank of 8 themes being most important. The instrument was administered in interview. Findings: The competency of most relevance to the highest executive function category was that of “interaction with interrelated systems.” For sub-agency level officers the competency of most relevance was “advocating for the role of public health.” The competency of most relevance to Program Directors/Managers or Administrators was “ensuring continuous quality improvement.” The variation between competencies by job category suggests there are distinct underlying relationships between the competencies by job category. Conclusion: Public health leadership in Somalia decline and disintegration, the Somalia Federal Government alongside international and domestic partners is beginning the process of rebuilding

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its national health system, this study has important implications for public health practitioners. One of the most significant implications of the study is related to workforce development.

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CONTENTS

Table of Contents Declaration............................................................................................................................... 7 1.0 Introduction ......................................................................................................................... 10 1.2 Aims of the study ................................................................................................................ 10 1.3 Research questions .............................................................................................................. 10 1.4 Justification ......................................................................................................................... 11 1.5 Significance ......................................................................................................................... 11 1.5.1 Scope and limitation of the study ..................................................................................... 11 1.0 CHAPTER ONE – LITERATURE REVIEW I...................................................................... 12 1.1 Traits of leadership .............................................................................................................. 13 1.2 Trait Theory of Leadership ................................................................................................. 13 1.3 Public health leadership model ........................................................................................... 14 2.0 CHAPTER TWO – LITERATURE REVIEW II ................................................................... 17 2.1 Conflict resolution ............................................................................................................... 17 2.2Prevention of conflict’s ........................................................................................................ 18 2.3 Management changes .......................................................................................................... 19 2.4 Performance management ................................................................................................... 20 2.5 Management Structure ........................................................................................................ 25

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2.6 Organizational Structure ..................................................................................................... 26 3.0 CHAPTER THREE – METHODOLOGY ............................................................................. 30 3.1 Research design ...................................................................................................................... 30 3.2 Case study ........................................................................................................................... 32 3.3 Study area ............................................................................................................................ 33 3.4 Research population ............................................................................................................ 33 3.4.1 Sample size....................................................................................................................... 33 3.4.2 Sampling procedure.......................................................................................................... 33 3.5 Data collection instruments ................................................................................................. 34 3.5.2 Instrument validity ........................................................................................................... 35 3.5.3 Instrument reliability ........................................................................................................ 35 3.6 Data Collection .................................................................................................................... 35 3.7 Data Analysis ...................................................................................................................... 36 3.8 Ethical considerations ......................................................................................................... 36 CHAPTER FOUR ......................................................................................................................... 38 TABLE 1

RESPONDENTS CHARACTRISTICS ................................................................ 40

Table: 2 Socio-demographic ..................................................................................................... 41 The key elements ....................................................................................................................... 43 4.4.7 Table 2 Key elements ....................................................................................................... 47 5.0 ANALYSIS ......................................................................................................................... 51 5.10. Discussion ........................................................................................................................ 57

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6.0 CONCLUDING REMARKS .................................................................................................. 63 6.1 Conclusion........................................................................................................................... 63 6.1.1 Recommendations ............................................................................................................ 65 6.1.2 BIBLIOGRAPHY ................................................................................................................ 67 6.1.3 APPENDIX .......................................................................................................................... 70 PROFILE OF RESPONDENTS ............................................................................................... 70

LIST OF ABBREVIATIONS MOH: Ministry of Health UNO: United nation Organization OAU: Organization of Africa Unit IPRB: International Population Reference Bureau PRB: Population Reference Bureau WHO: World Health Organization TAP: Training and production EPHS: essential package of health system CBFHWS: Community Based Female Health Workers SHRFHDP: Somali human resource for health development policy PF: policy formulation HAS: health sector analysis 6

PHCU: primary health care unit MCH: maternity and child health

Declaration I confirmed that the work reported in this thesis was carried out by the candidate under our supervision and submitted to the faculty of health science with our approval as the academic head of (ITUU) Head of academic Professor Kyriako’s kyvelosa SIGNATURE------------------------------------------------------------DATE------/---------------/------------/-------------------------------------

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ACKNOWLEDGEMENTS

I am grateful to all of those with whom I have had the pleasure to work during this and other related projects. Each of the members of my Dissertation Committee has provided me extensive personal and professional guidance and taught me a great deal about both scientific research and life in general. I would like to thank my supervisor Dr Kyriakos Kyveliosa general director of master of science in health management in University of thalematica unnituno from Italia Roma with Global Science University in Galkacyo Somalia supplementary support technological pole in online platform all professor who contributed higher education during academic activity and also I would like to mention his coordination untireless effort Professor abdullahi Fataho he was good person when he was coordinated the master of science in health management program more important to me in the pursuit of this project Minister of health in Puntland Somalia who permit interview of qualitative date from different mangers in health care system of Bosaso in other hand I would like to thank my dear wife Farhiya said Hussein and my children and all members of my family. I would like to thank my parents, whose love and guidance are with me in whatever I pursue. They are the ultimate role models. Most importantly, I wish to thank my loving and supportive wife, and my three wonderful children, Mohamed, Hibo and Huda, who provide unending inspiration.

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Dissertation Thesis

Statement of compliance with academic ethics and the avoidance of plagiarism

I honestly declare that this dissertation is entirely my own work and none of its part has been copied from printed or electronic sources, translated from foreign sources and reproduced from essays of other researchers or students. Wherever I have been based on ideas or other people texts I clearly declare it through the good use of references following academic ethics. (In the case that is proved that part of the essay does not constitute an original work, but a copy of an already published essay or from another source, the student will be expelled permanently from the postgraduate program).

Name and Surname (Capital letters): .Abdulkadir......................................................................................................................................

Date: ..........17.............../...6......./...2018......

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INTRODUCTION

1.0 Introduction Somalia’s health care system has suffered from inadequate funding, mismanagement, and poor planning and policy development ever since independence. As a result, the people’s health suffered. Currently, the health care system is obviously in crisis from the protracted civil war of more than a decade. The population has been growing annually at a rate of 2.8%, although it experienced high mortality rates during the civil war in the early 1990s. The health care needs were increasing while resources and enabling infrastructures were diminishing or ceased to function. The health status indicators rarely experienced any significant improvements (Worldbank, 2005). Many factors were attributed to this desperate situation, among the main factor is the leadership system in Somalia; this has caused a serious setback to the development of public health sector in Somalia, hence, the need to study the leadership system in Somalia Public health system. 1.2 Aims of the study To evaluate the impact of the public health leadership in Somalia the case study of Bosaso district in Puntland state

1.3 Research questions 1. Why are leadership traits and styles significant in managing healthcare service? 2. How do healthcare leaders resolve conflicts? 3. How do healthcare leaders manage changes in health care service? 4. How do healthcare leader manage performance of health care professionals? 5. Why is structuring organizations significant in managing health care service? 6. How do healthcare leader make their team work? 7. Why is quality assurance significant in managing healthcare service? 10

8. How do total quality management play a role in managing healthcare service?

1.4 Justification Evaluating the leadership system in Somalia will help to identify the leadership structure of Somalia, the prospect of the leadership system in Somalia and the challenges of leadership in public health issues in Somalia. Studying the leadership in Somalia public health will enable the researcher to recommend befitting solution to the problems of Somalia public health. In Somalia, the first and foremost challenge to the development of a sound health care plan is a strategic information and leadership management systems on the health care systems and its operations. The information on other related leadership management sectors is also justified to be important to be explored in this study. 1.5 Significance This study will help the potential researchers to have in depth knowledge about the leadership system in Somalia case study of Bosaso district It will help the policy makers, government and concerned agencies to identify the challenges of leadership system in Somalia It will enable the researcher to prescribe befitting recommendation which could help in overcoming the leadership problem in Somalia It will help the researcher in attaining some academic height as this is part of the required evaluation to achieve the degree

1.5.1 Scope and limitation of the study This study encompasses the leadership structure in Somalia. It takes into account how public health system in Somalia is been governed. The geographical scope will be within the geographical location of Puntland Somalia and the study will be done by going retrospective and prospective about leadership system in Somalia.

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1.0 CHAPTER ONE – LITERATURE REVIEW I

The leadership task is to ensure path, alignment and assurance within teams and organizations (Drath, McCauley, Palus, Van Velsor, O’Connor, McGuire, 2008). Direction ensures covenant and superiority among people in relation to what the organization is trying to achieve, consistent with vision, values and strategy. Alignment refers to effective coordination and integration of the work. Commitment is manifested by everyone in the institute taking responsibility and making it a personal priority to ensure the success of the union as a whole, rather than focusing only on their individual or immediate team’s success in isolation. good leadership must be demonstrate presentation skills and forward alliance with other organization Essential of health care in society, the topic is significant for scholars of Somalia in public health leadership this area because of the potential influence that can be made to educating patient care and the health of societies. a model of central factors that shape philosophy and climate in health care organizations, describes significant research and addresses issues such as: the definition of presentation in this context; links among environment, nation, and routine in public health leadership is an energetic ,motivated,rewerder,during the implementation of organization work (West, M.A., Topakas, A., and Dawson, J.F. (2014) Effective leaders in health services underscore frequently that safe, high quality, sympathetic care is the top priority. They ensure that the voice of patients is consistently heard at every level; patient experience, concerns, needs and feedback (optimistic and negative) are consistently attended to. They offer loyal, available, empathic, fair, polite, compassionate and empowering leadership. They promote participation and involvement as their core leadership approach. They ensure the staff ‘voice’ is encouraged, heard and acted on across the group and provide practical support for staff to innovate within safe limits.

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1.1 Traits of leadership Personality traits of leadership has been reemergence last two decades including the five main traits, cognitive abilities ,motives,values,social skills,expertize and problem solving skills 1.2 Trait Theory of Leadership The basic foundation of the trait theory of leadership is that leaders possess particular traits that differentiate them from other individuals The Trait Theory of Leadership involves determining the essential characteristics of leaders based on the characteristics of past successful and ineffective leaders, and using those findings to envisage the effectiveness of leaders. The trait approach identifies personality traits, such as extraversion, that often align with leader development and efficiency, The trait theory of public health leadership to day in Bosaso district is typically not used alone due to the fact that good leadership does not simply arise from inherit inborn traits without attention of motivation and creativity The Big Five model of personality describes personality in terms of five dimensions, openness, conscientiousness, extraversion, agreeableness, and neuroticism, known as OCEAN, Openness refers to being outgoing and interested in new practices. Thoroughness refers to being organized and hard-working. Extraversion, on this scale, refers to being outward and social. Agreeableness refers to being helpful and sympathetic. Neuroticism refers to the degree to which a person is emotionally stable. Each trait is expressed on a continuum, meaning that person can exhibit a presence of or lack of each trait. Studies have shown that the Big Five approach is consistent as a predictor for leadership Another study by Judge et al. found a 0.39 correlation between the Big Five Personality Traits and leadership success know days public health leadership in Somalia is not standardized due to low transparent and un suitable quality assurance (

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1.3 Public health leadership model Leadership

communication

Productive In health team Development

Heterogeneity

Coherent

1.4 Personality and leader effectiveness There bare originally major watercourse of investigation replicates a long intense magnetism with the behavior traits of those who become leaders. Today there are many obstacles personnel character from this broader leadership research indication we can identify core personality traits associated with leadership efficiency, including (Yukl, 2013): Great energy level and stress tolerance - They have high levels of strengths and can work effectively over long periods. They are also less affected by conflicts, crisis events and pressure, maintaining equilibrium more than others. They are able to think relatively calmly in crisis situations and communicate that calmness and confidence to others.

the aim of good management is to provide services to the community in not, insufficient, un equitable, and on sustainable manner.in case of Somalia there is disparities in health care system to day low experience lack of knowledge shortage of health service in urban area This can only be achieved if key resources for service provision, including human resources, finances, hardware and process aspects of care delivery are brought together at the point of service delivery and are carefully synchronized. Critical management considerations for assessment and planning, managing the care process, human resources, interacting with the community, and 14

managing information are covered in the Planning, Human Resources, Integration and Monitoring CURRENT PICTURE OF THE HEALTH WORKFORCE 1.4. 1 Training and Production During the first decade of the civil conflict, almost all public sector higher medical education and mid-level training institutions were destroyed, creating a huge and acute shortage of qualified health workforce. This challenging situation has led to the rise of a large number of private medical colleges and health professional training institutions and programmes, which were the only viable sources for workforce production. However, these honest efforts were made without the founding of regulatory bodies, for regulating customs, authorization standards and governance control measures.in public health leadership to day Although creditable efforts were followed through the international partners’ humanitarian health emergency support interventions, this assistance lacked any tangible formal investment in HRH pre-service training or any form of standardized in-service training through continuing professional development (CPD) programmes. This historical absence of public sector support action to address the severe shortage of qualified health workforce was further challenged by vast insecurity that prevailed at the time. This has severely constrained the delivery of quality health services and limited workforce productivity. The withdrawal of public sector training institutions was replaced by civil society efforts acting in the public interest, whose actions have led to the regeneration of the health training programmes in different geographical centers. However, despite these notable goodwill programmes, several serious challenges were encountered, which can be summarized as follows: Lack of Regulation: These privately owned and managed training institutes though producing similar workforce categories have not pursued any inter-institutional agreement of self-

Regulation or public sector authenticated standard curricula, regular teacher training programmes or accredited educational environment. Lack of Focus on Mid-level Professionals: The devastating majority of these training health programmes are elevated to the university level for the high demand and higher fees they offer. This has affected the recruitment of the crucial mid-level workforce categories, as these graduate 15

professionals have failed to benefit the underprivileged remote geographical areas. Graduates qualifying from these higher educational institutions regularly seek employment in the big urban cities and in the private urban based health sector, while a tangible proportion is getting lost to brain drain. Shortage of Faculty development Opportunities: There is a general paucity for training teachers as well as opportunities for public sector support interventions for capacity building and their continuing professional development by formally constituting teaching improvement courses through in-service training programmes Disparity between production and demand: the lack of coherent planning and coordination between these professional training institutions and the health authorities has created a major gap between the workforce production in terms of workforce types and quantities to be produced, and the priority health needs of the population. There is an absence or severe paucity of midlevel training programmes for key health workforce categories that are essential for the implementation of the EPHS programme such as Clinical Officers, X-ray Technicians, Anaesthesia Technicians, Optometrists, Mental Health Technicians, Qualified Midwives and Nurses, Mental Health technicians and physiotherapists. Similarly, there is a lack of Community Based Female Health Workers (CBFHWs) at Grass Root Level. In recent years, public sector health authorities contributed to health workforce training and development, often in partnership with the private non-for-profit sector.. illustrates the efforts made Puntland, Somaliland and South-Central Somalia. The Somali health sector has expressed a desire to articulate a workforce policy framework in which the key priority interventions were outlined. The development of this policy was the result of a series of consultations covering an initial phase of HRH situation analysis followed by discussions and considerations in the areas of HRH production; planning, deployment, utilization and management; HRH financing and retention mechanisms; HRH regulation, health information and research and M&E as well as the policy aspects related to HRH institutional framework. Accordingly, the HRH policy deliberates on series of interventions that will enable the health sector to minimally conform to the EPHS deployment norms and standards and subsequently achieve staffing norm levels, consistent with the minimum WHO threshold, set for key professional categories. Moreover, the policy clearly spells out the imperative of forging 16

collaborative partnerships that involve both Somali and international stakeholders. Through this policy, the health authorities have also reiterated their commitment to increase HRH budgetary allocations and explore local support through regional and local government ownership and participation, with the long term vision of significantly reducing dependence on HRH external financing. The Somali health authorities emphasize on the significance of HRH profiling and development in the health policy agenda, and scaling up workforce production, addressing both the numerical and capacity shortages that hinder progress towards the attainment of UHC, as well as the ambitions of attaining the post-2015 health related sustainable development goals.( The SOMALI HUMAN RESOURCES FOR HEALTH DEVELOPMENT POLICY 2016 -2021)

2.0 CHAPTER TWO – LITERATURE REVIEW II

2.1 Conflict resolution Supervision conflict in the workplace is a time-consuming but necessary task for the physician leader. Conflicts may exist between physicians, Nursing, Anesthesia between physicians and staff, and among the staff or the health care team and the patient or patient's family. The conflicts may range from divergences to major debates that may lead to hearing or forcefulness. Conflicts have an adverse effect on output, self-esteem, and patient care. They may result in high operative revenue and certainly limit staff gifts and hinder efficiency. Process is now readily available for those who feel that they are working in an unreceptive work environment. The aggressive environment may be the result of foul behavior by other employees, managers, or doctors. The misuse may take the form of a disparaging attitude, mimicry, off-color jokes, sexual irritation, or even physical violence. Societies have significantly decreased their tolerance of disorderly behavior. A group or society can now hold remote liability for overlooking an antagonistic work environment if it flops to act when a complaint is made. conflict arises first as normally conflict is human nature whether it arise from human 17

interest or it arise other things ,so the first step to follow when conflict arise is to know The causes of this conflict and deeply understand it, then you have to get acceptance those who need to solve their conflict when they accept to solve their conflict you have to get solution to their conflict and open for a negotiation so that there many ways to solve conflict but these main things that I can remember in health care system of Somalia Despite the recognized importance of collaborative working practices, only a small proportion of time is spent in true collaboration. Conflict can be a pervasive force within healthcare organizations and, as gaps in communication develop and are potentiated, failure in working practices can occur. The most common sources of conflict are recognized as the following: individualistic behavior within the organization, poor communication, organizational structures, and inter-individual or inter-group conflicts. Conflict usually develops from underlying latent issues (which implies the existence of antecedent conditions) and can progress to perceived conflict (where the issue becomes apparent) and subsequently to manifest conflict (the behavioral/action phase), with the last stage being conflict aftermath. The healthcare leader must adopt a suitable approach for handling conflict at all stages with the aim of creating a positive outcome for all involved. A leader can employ strategies such as competition, avoidance, compromise, accommodation, collaboration, bargaining/negotiation, mediation, facilitating communication, seeking consensus, and engendering vision to aid resolution of conflict.

2.2Prevention of conflict’s To preclude clashes, a professional code of conduct should be recognized, not only in the hospital but also as part of group repetition policies and medical staff by regulations. Powdered rules make it easier to correction, as they take personality out of the calculation. A disciplinary structure should be advanced, so that the instruments and the referral pattern to higher authority are well understood. Universal knowledge of this discipline passageway can often facilitate resolution at a lower level. Everyone needs to appreciate that there are firm limits on untimely conduct. Every health system have own policies to keep conflicts of health qualified and based on their activities to save life threatening condition in many patients

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The current education designed at perceptive the association among conflict management and decision making styles in the academy leaders. The model of the schoolwork included 100 heads of private and community sector degree universities of Somalia. We solve some issue stayed Conflict Management Account (Anis-ul-Haque, 2003) and Overall Decision Making Style Survey (Scott & Bruce, 1995). Several deterioration analyses exposed that integrative conflict management style was the significant predictor of rational decision making style. Leading and avoidant conflict management styles turned out to be the optimistic predictors of avoidant decision making style..( Journal of Behavioral Sciences, Vol. 24, No. 2, 2014 )

2.3 Management changes Managing change is about conduct the density of the course. And it is about appraising, development and employing procedures, devices and approaches and making sure that the change is valuable and significant. Managing change is a multipart, energetic and challenging method. It is never a choice between scientific or people-oriented solutions but a combination of all. Organizational reform almost public health leadership of Somalia is not exist unfortunately low infrastructure and transparent to day behavioral in health leadership is autratic Effective change has been categorized as releasing old manners, introducing new ones, and refreezing them. Change may be continuous, intermittent, sporadic, or rare. Predictable change allows time for groundwork, whereas volatile change is more problematic to respond to efficiently. Since changes in healthcare occur so rapidly, they are less likely to be predictable. Organizational reform is better for the continuous work how to measure the magnitude of economic status in health management system, The only sustainable reasonable advantage today is the ability to change, adjust, and evolve - and to do it better than the antagonism., Failure rates are associated to a number of different factors such as lack of vision and commitment from senior management, limited mixing with other systems and processes in the organization, and vague execution plans. If groups are to skill a greater level of success in their development efforts, managers and executives need to have a better framework for thinking about change and an understanding of the key issues which complement change management. Even if change is recognized, workers want to understand why change is happening and how they will be affected. 19

Layoffs or other organizational changes can lead to paranoia, confusion, anger and insecurities under the auspices of change (Oman Med J. 2007 Oct; 22) The governments of Puntland are currently working on a complete reform of their public administrations with a focus on increasing women’s participation as a key element of the post conflict Reconstruction and Development Programme (2008-2012). Despite years of civil war, famine and drought and the lack of basic infrastructure, the governments of Puntland have made some progress towards establishing a peaceful and safe environment, developing independent process and structure institutions, rules, and approaches that are now beginning to address their citizens’ basic needs. A focus of the state rebuilding reform process has been the development of a decentralized for health service delivery to the remote area which know days to be good reputation in health system of Puntland Somalia especially Bosaso district how to prioritize health needs from community villages in eight health centers located of Bosaso district there are many challenges exists in Puntland due to low resource allocation to health facilities poor knowledge of health professional lack of training and skills inadequate or shortage per doctor population and so on (post conflict and recon structure and development program 2008-2012) 2.4 Performance management The status of health care system for an economy is crucial due to the impact that the access to health care Bloom, 2003; Ramesh & Mirmirani, 2007). The ultimate goal to which societies expect Murray & Evans, 2003). Thus, the analysis of the performance of health systems in attaining this objective becomes of great importance for all political and managerial decisionmakers on the health care system. During the last two decades, many countries have introduced reforms aimed at improving health system performance (Collins et al., 1999). We have strategy goal first we selection employee qualified nurse and midwife they woks primary health care health unit up to health center and referral service after that we sure quality of place service like equipment’s which one who need replacement also we do knew buildings than our employee we give trains to reach our strategy goal most strategy goal is how to reduce morbidity and mortality pregnancy mother and children under five year that time we reach When we selected we look CV and we resend his university to sure his certificate it true or fraudulent if it true we add short list than we take exams and we build their capacity we do motivated their knowledge and skills to make promoted how can lead good communication and management 20

The performance of the health system in responding to the health needs of the people is poor. There is virtually no health information and health promotion programme. There is a severe shortage of qualified health staff, with just one doctor for 43,000 people. There are only 57 midwives working in the public sector. 500 Community Health Workers provide a limited service in rural areas. Coverage of public health services in rural areas, and for nomadic populations, is very limited; it is estimated that less than 15% of the rural population has access to any health provider. A skilled provider attends fewer than 20% of births. Consultation rates for children and adults are very low, with adults visiting a health facility once every ten years, and children visiting once every five years. Even functioning hospitals are underutilized. Management and planning of the health system is poorly developed. A central ministry and six Regional Health Teams are responsible for the health sector. A small planning unit is tasked with system-wide development, but most MOH managers are occupied with donor funded projects. There is no MOH planning and budgeting system. Therefore, the UN and donors, often with little or no involvement of or consultation with the MOH, decides programming and funding of the health sector.(Minister of health Puntland

Health sector strategic plane January 2013 –

December 2016 )

HRH POLICY FORMULATION The health sector HRH Policy substantiates the commitment of the health authorities to workforce development in which the related priorities, the strategic courses of action to pursue, and the operational goals to be achieved are clearly spelled out. The HRH policy also outlines the regulatory measures and legislation to be considered and the coordinating mechanism to pursue for its implementation. The policy is aimed at building a national consensus on the critical role of the workforce in scaling up the performance of the health system and encouraging health professionals and health sector stakeholders to rally around the HRH issues. Moreover, the HRH policy will 15 deliberate on the production, deployment and equitable distribution of the required numbers of qualified and motivated health workers who will effectively perform their functions at the right place and right time.

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HEALTH SECTOR ANALYSIS 2.1 Health System organization and Infrastructure 2.1.1 The Primary Health Unit (PHU) The Primary Health Care Units (PHUs) operate at the most peripheral level of the district health system network and are staffed by trained and remunerated Community Health Workers (CHWs). Each PHU is supported by a locally constituted Community Health Committee. The major role of the PHU is to provide basic promotive, preventive and simple curative services that include maternal, reproductive and neonatal health, child health, communicable disease surveillance and control, environmental health promotion, first aid and treatment of common illnesses. PHUs also promote nutrition education and the utilization vaccination services 2.1.2 Maternal and Child Health (MCH) centers MCH centers are located in urban and rural community centers and receive complementary support in terms of supplies, human recourse remuneration and logistic support from the government health partners operating in the different districts of Puntland [4]. These facilities carry out antenatal care services; assistance during labour and postnatal period; maternal and child nutrition promotion and care, as well as the delivery of child and maternal immunization services and the treatment of minor common diseases and conditions. In many areas the MCH centers are the only reliable facilities that provide MNCH care to the distantly located communities that have limited access to immediate referral support. The specialized nature of these facilities restricts the scope of the PHC service package that they could provide; hence - 6 the need to upgrade the most distantly located MCH centers to full-fledged health centers to broaden the range of their service delivery. 2.1.3 The Health Centre (HC) The HC is assigned to deliver key programmatic interventions as envisaged in the Essential Package of Health Services (EPHS). The HC offers a facility based service with maternity beds operated by a qualified midwife. Each HC is also staffed by a qualified nurse, auxiliary nurse and a community midwife. HCs also provide facility based vaccination and nutrition promotion services, as well as outreach services to the HC catchment area. Community Health Committees are expected to provide support to the management of the 22

HCs, assisting the health teams in improving service utilization and local resource mobilization and assist in addressing the operational and referral logistic gaps that are identified and communicated by these HCs. 2.1.4 Referral Health Centres/District Hospitals The third tier of the service delivery network is the referral Health Center or District Hospital that is connected with the MCH/HC facilities for referral support, training and supervision. Most district hospitals are not sufficiently equipped or have the qualified human resource cadre to attend to MNCH care and to other essential medical and surgical services. In addition to the six core functions set in the EPHS, Referral health centres/district hospitals carry out a range of medical and surgical services, and provide mental health care, treatment of chronic diseases, and dental and eye health. These levels of care carry out comprehensive emergency obstetric and newborn care, with the capacity to perform caesarean sections and reproductive health related surgical services. A district hospital has at least 8 beds maternity ward and an in-patient facility for at least 20 patients. However, some of the above outlined services are executed by accessing specialists through outreach visits performed by the regional team, although currently this relevant support is seldom accomplished. District hospitals are staffed by at least one medical doctor or clinical officer, two midwives, two qualified nurses, an officer for the Expanded Programme on Immunization (EPI) and a laboratory technician and a health/clinical officer. A community based Health Committee is established to provide the necessary support to improve hospital operations as well as to mobilize resources to fill the evolving operational gaps of this facility. The reality on the ground however, reflects a bleak picture with many district hospitals being poorly staffed and functioning at very low performance levels. 2.1.5 The Regional Hospital the regional hospitals provide reasonable levels of specialist care, although the service demand overwhelmingly exceeds the capacity and the resources that these hospitals require. Regional hospitals provide medical, surgical, gynecological and pediatric health care and other specialized services and are staffed by qualified nurses, midwives and doctors who are expected to conduct outreach clinics to RHCs/District Hospitals. In Puntland, the management and coordination of this health system network is directly operated by the Ministry of Health, although the operational support for a tangible number of these facilities is profoundly assisted by international health partners whose contribution is highly valued. The 23

regional EPI central cold chain and regional medical store are other key facilities instituted to support the health system network of the state. 2.1.6 The Private Sector The public health sector in Puntland is complemented by a thriving private health sector that ranges from the sale of pharmaceutical products though without having licenses regulating the importation and sale of these products. This sector along with it traditional medicine - 7 - component has significant impact on the population’s health care seeking behaviour ,Moreover, the is a rapidly increasing number of private clinics and hospitals predominantly located in urban areas, hence falling beyond the reach of the poor and vulnerable households of the community. The private sector however, can play a major role in the delivery of health care service in view of the expected significant increases in need and demand for health care services. The private health sector can also help to improve the scope, scale, quality, and efficiency of access to essential services, not only for the urban but also for the rural settings. From this perspective the government of Puntland is acknowledging the positive role of this sector in the delivery of health care services, with a strong desire to engage it as essential partner, while introducing appropriate oversight and regulatory mechanisms to stream line its operations.(Health policy of Puntland 2012-2017)

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2.5 Management Structure

The Somali health care system can be divided conveniently into three official sub sectors namely public, voluntary (Non Governmental Organisations) and private. The public sector comprises the Ministry of Health (MoH), Ministry of Local Government (MLG), and health services of other ministries and parastatals. The voluntary sub-sector consists of the mission health services and the health activities of what are popularly known as NGOs. The private sector includes the medical services provided directly by private health facilities and health professionals in private practices, also referred to as the private for profit sectors. There is also an unofficial sub sector comprising of institutions and providers over which the MOH has no control, i.e. traditional medicine consisting of herbalists, bone setter spiritual healers and other practitioners. The Public sector is the major provider of health services with a control of 58% of all health facilities, 42% of all beds and 530% of all health personnel. It is followed by the private sector and then the voluntary sector. The structure of the health services delivery id hierarchical in nature. The dispensaries and health centers provide the bulk of health services and form the first level of contact with the community. The district hospital form the next layer followed by the provincial hospitals. The both provide referral and outpatient services in addition to the requisite technical backstopping to facilities at the periphery. Somali National Hospital and Madina Hospital are at the apex as key referral, research and teaching facilities. (Minister of health of Somalia a heretical 2016)

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2.6 Organizational Structure The Ministry Of Health is headed by the Permanent Secretary who is the Accounting Officer and the Chief Executive. Directly under is the Director of Medical service who is in charge of all technical issues regarding health in the ministry. Administratively, the MOH is divided into three department comprising various divisions which are responsible for the various functions of the Ministry. The first step in any strategic transformation is to clarify the official assignment, visions, and aims. The ‘mission’ states the administration's characteristic purpose or reason for being. The idea represents what its leaders want the organization to accomplish when it is achieving the mission. Strategic goals are those overarching end results that the organization follows to complete its mission. (Organ Dev ,201,vol.29)

26

The organizational and management structure of the Somali health system comprises of four facility based health care provision levels and a community based programme, collectively aimed at providing the maximum coverage of health services to the population (figure1). These include the primary health care units (PHUs) located in the most peripheral geographical areas, covering a defined catchment area population with basic promotive, preventive and simple curative services. The PHU is operated by at least one community health worker (CHW), supported by the local leaders in the organization of health services delivery. PHU services are also reinforced by the health center (HC) outreach support, particularly in services related with

27

the expanded programme on immunization (EPI) and nutrition promotion and education.(Somali health policy Approved by the Health Advisory Board September 2014)

28

29

3.0 CHAPTER THREE – METHODOLOGY

CHAPTER III: RESEARCH METHODOLOGY 3.1 Research design Quantitative research designs emphasize fairness in measuring and describing phenomena (McMillan & Schumacher, 2010). As such, the research design exploits objectivity by using descriptive measurement, , construction and control. An significant sub-classification of quantitative design is experimental and non-experimental. The variance between the two has significant implications for the nature of the design, and the types of conclusions that can be drawn. Qualitative research designs, however, use methods that are distinct from those used in quantitative designs. While qualitative designs can be said to be just as systematic as quantitative designs, they underscore gathering data on naturally occurring occurrences. Most data gathered is in the form of words and the researcher must search and explore with a variety of methods, until a deep understanding is achieved. Qualitative research designs can be organized by: (1) focus on individual lived experience, as seen in phenomenology, case study grounded theory and some critical studies; and (2) a focus on society and culture, as defined by ethnography and some critical studies (McMillan & Schumacher, 2011). The study was adopt qualitative exploratory research design specially a descriptive survey design. A descriptive studies that may be defined as studies that describe the patterns of disease occurrence and other health-related conditions by person, place and time so according to research objectives this type of research design is important for this research Descriptive design focuses on formulation of objectives, designing the data collection instruments, selecting the sample, collecting the data, processing, analyzing and reporting the findings. In addition Kothari (2004) observed that research design is making research as efficient as possible hence yielding maximum information with minimal expenditure of effort, time and money. Again it’s a blue print that facilitates smooth functioning of all research operations. This research is a combination of both exploratory and descriptive research designs. Exploratory Research- It has conducted with the purpose of gaining better insight into a problem. Descriptive Research- The researcher has no control over the variables; he can only report what has happened & what is happening. 30

This design refers to a set of methods and procedures that describe variables. It contains review & fact verdict enquiry of different kinds. Descriptive studies portray the variables by answering who, what, and how questions (Babbie, 2002). Research can be defined as the systematic process of collecting and logically analyzing data for a given purpose (McMillan & Schumacher, 2010). However, this definition is generalized to some degree, since many methods are used to investigate a problem or question. Research methods (constituting a research methodology) are the ways in which one collects and analyses data. These methods have been developed for acquiring knowledge reliably and validly. A research methodology is systematic and purposeful, planned to yield data on a particular research problem (McMillan & Schumacher, 2010). Research problem with the introduction of the new education system in Somalia, outdated approaches to public health leadership to day in health care system are being challenged. Categorized, top-down attitudes are being set aside for a more democratic, disseminated form of leadership. In particular, there is a call for public health leadership in Bosaso district to take on situations of leadership in the today Somalia leadership is, however, outroratic leadership a relatively new concept to the public health leadership styles and traits in health care system . While the federal Government of Somalia for the Norms 37 and Standards for Educators (2000) calls for public health leadership to take up leadership locations within and beyond their daily routine basis – there is no discussion of how this should be done. Despite Studies conducted in South Africa focused on teachers’ understanding of the concept, and their readiness for teacher leadership (De Villiers and Pretorius, 2011). Other studies by Grant (2006, 2008) Singh (2007) and Khumalo and Grant (paper in progress) have investigated the enactment of teacher leadership, and barriers to teacher leadership.

Qualitative research Qualitative research is characterized by plans that take the subject’s perspective as central. Public health leadership to day will focus on interview one by one This method also pays significant attention to detailed surveillance in an attempt to produce a ‘rich’ and ‘deep’ explanation (Morrison, 2002). In qualitative research, detailed attention is given to the holistic picture in which the research topic is inserted. The fundamental idea is that investigators 31

can only make sense of the data collected if they are able to understand the data in a broader educational, social and historical context (Morrison, 2002). Qualitative research defies a simple definition (Merriam, 2009). There is also much misunderstanding over what organizes qualitative inquiry. One of the problems in doing this is that qualitative research is often defined by what it is not, namely, research that is not quantitative (Best & Kahn, 2006; Lichtman, 2006). This is a problem for two reasons: (1) some qualitative research results in some quantification; and (2) it represents a negative meaning – that qualitative research is only what quantitative research isn’t, rather than positively stating what it is (Best & Kahn, 2006). Unlike quantitative research designs, qualitative research designs can vary significantly, depending on the theoretical framework, philosophy, assumptions about the nature of knowledge and the field of study (McMillan & Schumacher, 2011), resulting in different definitions of what constitutes qualitative research.

3.2 Case study A case study refers to the study of the singular, the particular, the single (Simons, 2009). In the literature on case study, different authors refer to case study as a method, a strategy and a 42 approach. For the purposes of my research, I will be using Simons (2009) favorite for the term approach. This shows that the case study has a research intent and operational purpose which affects which methods are chosen to gather data. The primary purpose for choosing a case study is to explore the particularity of a single case, in this instance, public health leadership in Somalia development to day in health care system is an important kind of strategic documentary in federal government Simons (2009) defines a case study approximately as that process of conducting systematic, critical inquiry into a sensation of choice and producing understanding to contribute to cumulative public knowledge of the topic. In contrast, Thomas (2009) and Lichtman (2006) emphasize that a case study involves in-depth research into one case or a small set of cases. The ‘case’ that forms the basis of the examination is normally something that already exists (Descombe, 2007); it is a ‘naturally occurring’ wonder Yin (1994) cited in Descombe (2007). According to Merriam (1998), the qualitative case study can be defined as an intensive, holistic description and analysis of a single entity, occurrence, or social unit. Merriam’s (2009) 32

3.3 Study area Bosaso was previously known as Bandar Qasim, a name derived from a Somali trader of the same name who is said to have first settled in the area during the 14th century. It is believed that Qasim's favorite camel was called Bosaso, from which derived the current name of the town.

3.4 Research population

The target population for the study is mainly attacking the, some of communities in Bosaso specially public health leaders, who are lived in Bossaso district 3.4.1 Sample size However the purpose of sampling is to secure a representative group which was enable the study to gain its objectives This study selects 8 public health leaders interviewed and then their answers were video recorded and interpreted in written messages. 3.4.2 Sampling procedure A sample is a sub-set or part of the target population; sampling is a process of selecting subjects or cases to be included in the study of the representative of the target population (Mugenda and Mugenda, 1999) Sampling procedure is a process in which a number of individuals are selected for a study in such a way that the larger group from which these individuals were selected is represented by them. Purposive sampling is the most common sampling strategy. In this type of sampling, participants are selected or sought after based on pre-selected criteria based on the research question. This study may be attempting to collect data from public health leaders in Somalia. The sample size may be predetermined to provide additional insights. In qualitative studies is it critical that data collection and analysis are occurring simultaneously so that the researcher know

33

when the saturation point is reached. It is important to understand that the saturation point may occur prematurely. Generalization of research findings largely depends on the degree to which the sample, accessible population and the target population are similar characteristics. If the sample, the accessible population and the target population are similar characteristics, then generalization of the research findings can be made to the target population with confidence. So this research sampling procedure will be confidence because the entire sample size, accessible population and the target population are similar characteristics in Bosaso district because they have one language, one culture, one religion and also they live in same geographical area. our sample accessible population and the target population they are from Bosaso district(Mugenda and Mugenda, 1999)

3.5 Data collection instruments In this research the researcher try a comprehensive self-administered open ended questionnaires guide to be developed covering all aspects of the study variables designed covering demographic information of the respondents and consideration of the dependent variables and independent variables.

Video recorder will be used.

Primary Data: Creswell (1994) noted that, data

collection methods for primary data include: interview The researcher is using the most common method of data collection instrument that is interviewing the respondents we use self-administered questionnaires. The questions are: 1. Why are leadership traits and styles significant in managing healthcare service? 2. How do healthcare leaders resolve conflicts? 3. How do healthcare leaders manage changes in health care service? 4. How do healthcare leader manage performance of health care professionals? 5. Why is structuring organizations significant in managing health care service? 6. How do healthcare leader make their team work? 7. Why is quality assurance significant in managing healthcare service? 8. How does total quality management play a role in managing healthcare service?

34

3.5.2 Instrument validity An instrument used is valid in all reason if it procedures what it claims to measure, content validity of the questionnaires will be tested through pilot study (pretesting research instrument). The questionnaires are self-administered to the respondents in the pilot study. After filling them a discussion held with the respondent’s to find out if there are areas where the words used might have not been clear. Also the researchers try to make a consultations and debates that will also be done with the supervisor and lecturers in the line of study.

3.5.3 Instrument reliability

Reliability refers to the consistency that an instrument demonstrates when applied repeatedly under similar conditions. The reliability of the research instruments will be established by our research before analysis and consequent presentation. Achieved by testing the questions primarily from the supervisors. The split halves method used to test reliability. The major advantage of this approach is that it eliminates chance error due to differing test conditions 3.6 Data Collection The research design is qualitative descriptive design, chief data will be collected through a semi structured open ended questionnaires; the less important data collected through the use of both theoretical and observed literature available. Data collection will be implemented based on the objectives of the study that the researcher want to achieve, therefore the researcher will use appropriately data collection instrument in order to achieve identified research objectives and therefore get answers to the questions asked. The 8 respondents were used by video recorded. The video recorded interview was transcribed into written responses and thus used for data analysis.

35

3.7 Data Analysis The study made qualitative data; the research was descriptive nature with written reports which came from the data collected from the respondent interview session by playing and replaying the videos. Open ended written questions will be issued to public health leaders before the interview commences. Thus videos recorded as findings were easily understood and the outcomes and recommendation given by the respondents are transcribed without misunderstandings. The analysis divided into themes: 1. Leadership traits and styles 2. Conflict resolutions 3. Management of change 4. Performance management 5. Organizational structures 6. Team working 7. Quality assurance 8. Total quality management

3.8 Ethical considerations Ethical approval will be sought from the Uninettuno University informed consent was also sought from the respondents. This study involving human subjects in any ethical review the following points must be stated clearly for approval:•

The known benefits and risks or disadvantages for the subject in the study



Exact description of the information to be delivered to the subjects of the study and when it was communicated orally or in writing. The researcher consider the freedom of subjects to withdraw from the study



Indicate how the information obtained from participants in the studied kept confidential and private

36

37

CHAPTER FOUR – FINDINGS / ANALYSIS / DISCUSSION

CHAPTER- IV PRESENTATION, ANALYSIS AND INTERPRETATION OF DATA 4.1: OVERVIEW This chapter presents data collected, analysis and interpretation from the field. The data was collected using instruments like questionnaire, interview guide and documentation, which was highlighted under the methodology section. In this chapter, more emphasis has been placed on the interpretation of raw data in relation to the set objectives and the research question as set for the study.

The researchers distributed 8 questionnaires with at least 3 questions to different public health officers in Bossaso district to prepare them for the live video recorded interview. All the questionnaires were completed and the respondents answered the questions verbally. This means that questionnaires which have been completed represented the verbal response of the public health leaders and were video recorded live.

4.2 PROFILE OF RESPONDENTS Most of the respondents were qualified from inclusion criteria set. Above all, most of the respondents are citizens of Somalia working full time in public health services. Respondent #1: (1) 33 yo male (2) position finance manager and secretary of student affairs in university of health science (3) theme: conflict resolution

38

Respondent #2: (1) 27 yo male (2) position health academic office city college of Bosaso university (3) theme: quality assurance

Respondent #3: (1) 30 yo female (2) position hospital manager in Daryel hospital of bosaso (3) theme: leadership traits and styles

Respondent #4: (1) 29 yo male (2) position doctor of Biyo Kulule health center (3) theme: management of change

Respondent #5: (1) 35 yo male (2) position manager of Puntland Public Health Organization (PPHO) (3) theme: total quality management

Respondent #6: (1) 34 yo male (2) position Bossaso district health officer (3) theme: structuring organization

Respondent #7: (1) 36 yo female (2) position health care officer of Puntland in Bari region (3) theme: performance management

Respondent #8: (1) 28 yo male (2) position human resource manager (3) theme: team work

39

4.3 FINDINGS TABLE 1 Age

RESPONDENTS CHARACTRISTICS sex

Marital status

Educational

Position

Income

status 33

Male

Married

Master

Manager

$1200

27

Male

Married

degree

Academic

$800

30

Female

Married

Master

Manger

$1000

29

Male

Married

degree

manger

$1500

35

Male

Married

degree

Manger

$1600

34

Male

Married

degree

Officer

$1000

36

Female

Married

degree

Officer

$1200

28

Male

Married

degree

HRM

$800

40

Table: 2 Socio-demographic

41

demographic

25% 50%

50%

80%

manger

income

4.4 Data analysis 42

officer

master

In the interview they defined the 8 themes as the manner in which the organizations are interrelated to work together. A major advantage of the 8 themes is that it gives a focus on leadership and management. However, the researchers have analyzed that the 8 themes can be further synthesized in to 6 key elements that came from the results of the interview sessions.

The key elements Are found on the table below:

K

e

y

e

l

e

m

e

n

t

s

1

W

o

r

k

2

D

e

p

a

3

C

h

a

4

S

p

a

5

C e n t r a l i z a t i o n / d e c e n t r a l i z a t i o n .

6

F

o

r i

s

p

e

c

i

a

l

i

z

a

t

i

o

n

.

t

m

e

n

t

a

l

i

z

a

t

i

o

n

.

c

o

m

m

a

n

d

.

c

o

n

t

r

o

l

.

n

o

n

r

o

m

a

f f

l

i

z

a

t

i

o

n

.

4.4.1. Work specialization Question: what skills do you need for change? Answer: we provide key skills for effective change managers. Personal resilience, trust-building, coaching, forcing clarity, managing others’ uncertainly, organization, follow-through.

43

Theme: change management is the process, tools and technical to manage the people side of change to achieve the required of the organization outcome. And helps employee to understand, commit to, and accepts and embrace changes in their current organizational environment.

4.4.2. Departmentalization Question: how organizational structure affects organizational action? Answer: in two ways it provides the foundation on which standard operating procedures and routines rests. It determines which individuals get to participate in which decision –making processes, and thus to what extent their views shape the organizational action. Theme: organizational structure activates as task allocation, coordination, and supervision that are directed towards the achievement of organizational aims.

4.4.3 Chain of command Question: Why is important to have a flexible leader in your work? Answer: to improve work oriented tasks and people relationship together. Theme: flexible leaders are one of the styles of leadership. We interviewed them and said that they met conflict between their staff. This shows that flexible leaders is often needed at public health services to reduce conflicts and make the team work.

4.4.4 Span of control Question: how to select new employ select ensure their good performance? Answer: when we select we look CV and the resend his university to sure his certificate is true or fraudulent if it true we add short list then we take exams. 44

Theme: In the performance management one important question was giving appraisals to the staff series conflict case that led to sacking the staff

Question: may you describe conflict that you faced between you and one of your employee? Answer: something occur sometimes but we solve it excuse. Theme: Conflict resolution is away of preventing mistakes or defects and avoiding problems when delivering solutions or services to customers. This is summarized as mgt system for a customer focused organization that involves all employees in communicating and resolving conflicts.

4.4.5. Centralization/Decentralization Question: tell me about a time you faced an ethical dilemma affecting team working? Answer: in our organization I did not meet any ethical dilemma. Everyone work together as a team. They are ethically separated accordingly but centralized as one team. Theme: Team working can be learned but in many ways can also manifest itself naturally during ethical dilemma. That is why organizations are built with separate departments with centralized heads and directors to ensure each members of staff work with their own specialties to avoid dilemma of incapacity because they cannot function together with the other team members. Therefore in an organization, it is ethical that team members must be separated according to their capacity to perform, but centralized by an overall head.

4.4.6. Formalization Question: when do you practice the routine of quality assurance? Answer: we do practical audit every year to ensure full accreditation of our organization.

45

Theme: One of the important things about public health is the routine quality assurance for public health institutions through audits and accreditations. This shows a lot of improvement in terms of quality. Quality assurance is monitoring of the services, service-users, and employees to ensure adequate knowledge, capacity of skills and attitude is at par with other public health services.

Question: how do you achieve total quality? Answer: we keep the quality of the organization by communicating with our employees by asking for suggestions on the best possible services. In addition, the quality of items are annually checked and examined. Being polite to customers by greeting the service users or customers every time for example saying "thank you" is also a means of ensuring quality service for customer satisfaction.

In

addition, the service-users are given some gifts and free products such as vitamins and minerals hoping for them to have a good life. The right processes for quality is both for the service and the service-users. Theme: A total quality management is the integration of the quality process of the organization it is over all management that faction of the organization to achieve the goals and targets of the organization. It is important when we say total quality must be functioning and processing as the policy of the organization.

46

4.4.7 Table 2 Key elements 1-Work specialization

What

we

Personal

trust-

Forcing

Theme:

skills

do provide

resilience

building,

clarity,

change

coaching,

managing

manageme

you need key for

skills for

others’

nt is the

change

effective

uncertainl

process,

change

y,

tools

manager

organizati

technical

s

on,

to manage

follow-

the people

through

side

and

of

change to achieve the required of the organizati on outcome. Departmentalization

how

in

two It

and

organizati

ways

onal

provides

s

structure

the

individua

affects

foundati

ls get to views

organizati

on

onal

which

e

action

standard

which

operatin

decision

g

–making

procedur

processes

it determine to

Theme

what organizati

supervisio

which extent

on participat

47

thus Theme:

their

onal

n that are

structure

directed

activates

towards

shape the as

in organizati

task the

allocation

achieveme

onal

,

nt

action

coordinati organizati on

of

onal aims

es

and

routines rests Chain of command

Why

is to

Theme:

We

This

Often

flexible

interview

shows

needed at

to have a work

leaders

ed

flexible

are one of and

important

improve

oriented

them that

public

said flexible

health

leader in tasks and the styles that they leaders

services to

your

people

of

met

reduce

work

relations

leadershi

conflict

conflicts

hip

p

between

and make

their staff

the

together

team

work.

Span of control

how

to when we Theme:

select

select we In

new

look CV performa

conflict

employ

and

that

select

resend

managem

ensure

his

ent

the describe

the nce

their good universit

may you somethin

occur Conflict

sometime

resolution

you s but we is away of

faced

solve

one between

important

g

Theme:

you

and of

excuse

it preventing mistakes or defects

performa

y to sure question

one

and

nce

his

was

your

avoiding

certificat

giving

employee

problems

e is true appraisals

when

or

to

delivering

fraudule

staff

the

solutions

nt if it series

or services

true we conflict

to

48

add short case that list then led

customers

to

we take sacking exams

Centralization/Decent

tell

ralization

about

me in

the staff

our They are Theme:

a organizat ethically

time you ion I did separated faced

That

is Therefore

Team

why

in

working

organizati

organizati

an not meet according can

be ons

but learned

an

are on, it

is

ethical

any

ly

dilemma

ethical

centralize

affecting

dilemma

d as one many

team

.

team.

working

Everyon

also

centralize

e

manifest

d

together

itself

and

to

as a team

naturally

directors

capacity to

during

to ensure perform,

ethical

each

but

dilemma

members

centralized

work

but

built with ethical that in separate departme

ways can nts

of

team members

with must

be

separated

heads according their

staff by

an

work with overall their own head. specialtie s to avoid dilemma Formalization

when do we

do Theme:

This

you

practical

One

of shows

practice

audit

the

lot

49

Quality a assurance of is

we

keep

the quality of

the

the

every

routine of year

important to things

improvem monitorin ent

in g of the on of services,

quality

ensure

about

terms

assurance

full

public

quality.

accredita

health is

tion our

of the routine

organizati

service-

by

communic ating with

users, and our employee s

employees

to by asking

organizat quality

ensure

for

ion

assurance

adequate

suggestion

for public

knowledg

s on the

health

e

best

institutio

possible

ns

services.

through

In

audits

addition,

and

the quality

accreditat

of

ions

are

items

annually checked and examined

50

5.0 ANALYSIS 5.1. Introduction In discussion section it will clearly interpret and describe the 8 eight research questions which were: 1. Why are leadership traits and styles significant in managing healthcare service? 2. How do healthcare leaders resolve conflicts? 3. How do healthcare leaders manage changes in health care service? 4. How do healthcare leader manage performance of health care professionals? 5. Why is structuring organizations significant in managing health care service? 6. How do healthcare leader make their team work? 7. Why is quality assurance significant in managing healthcare service? 8. How do total quality management play a role in managing healthcare service? The main aim of this study was to find out experiences of health care leaders in leadership and management of health care service. 5.2. Strength of the study Qualitative exploratory study design was the most appropriate design since it is exploratory in nature (1). Its methodologies allow more in-depth understanding of a process or a phenomenon unlike quantitative research (1). Qualitative research looks at the real world in the actual context of the issues and provides insights into the problem or helps to develop ideas or hypotheses, qualitative Research is also used to uncover trends in thought and opinions, and dive deeper into the problem. (2)

5.3. Weakness of the study

51

Primarily, we had problems with data collection that was time consuming. As it was collected based on appointment dates fixed with individual respondents and issues of anonymity and confidentiality were present problems in this study since most of the health care workers as respondents were not comfortable with video recording. Therefore we need to eliminate those who refuse and find others. Lastly, some of the answers were in Somali language, therefore, we have to translate it to English before interpretation of the transcribed messages. Nevertheless, we were able to synthesize new knowledge on integrating the elements of leadership and management with the 8 themes.

5.4. Exploring work specialization with change management Doctor of Biyo kulule health center who was 29 years old male stated clearly and truthfully that they provide work specialization to their staffs and his organization gave them key skills for effective work. Other researchers agreed with our respondent's answer that personal resilience, trust-building, coaching, forcing clarity, managing others’ uncertainties were important in the management of change and work specialization (3). Therefore he concluded that these results to an employee who can change easily and specialize in their own fields of expertise. His answers were credible and reliable regardless of his age, gender and title. However, being a male medical doctor, his answers may have affected his personal points of view because Somali people believe that male leaders are more effective than female leaders because of their nomadic culture which males were the leaders of the community services. In addition, the setting is in Biyo Kulele, affected the answers because its most populated village in the city and its health center has a lot of workers.

5.5. Exploring departmentalization with organizational structure

52

Bosaso district health officer who was 34 years old male stated clearly and truthfully that they make departmentalization of health work in the district and made structures in District Health office like DHMIS department, PHC department, and then Nutrition department. Furthermore, he said that departmentalization determines which individuals get to participate in which decision making processes, and thus to what extent their views shape the organizational action. His answers were credible and reliable. However, being a male leader may have affected his answers because most health care leaders and even other social activities are male Somali people believe that male leaders are more effective than female leaders because of their nomadic culture which males were the leaders of the community services.

5.6. Exploring chain of command with leadership styles Daryel hospital manager who was 30 years old female stated clearly and truthfully that inside the the hospital, there is hierarchy and chain of command according to the style of leadership, which improves task orientation. Other researchers agreed that chain of command depends on leadership styles of the leaders and managers in designating tasks (4). However, being a female leader may have affected the answers, since leaders in Somalia are preferably males in order to ensure a concrete chain of command (4). According to the respondent, her leadership style in particular respondent was "flexible leadership" which may have also affected her answers. Flexible leadership are also democratic by nature, and hospital managers who are democratic or flexible may affect tasks orientation.

5.7. Exploring centralization with team working

53

Human resource manager of MOH Bari office who was 28 years old female stated clearly and truthfully that every staff work with their own centralized specialties with departments to avoid dilemma of incapacity. Other researchers agreed that being centralized having one head or director may ensure that team members will be working as a team (5). Her answers were credible and reliable regardless of her age and position. Human resource managers in Somalia must ensure that employees are distributed to a department and appoint a centralized department in order to ensure team working. Again being a female human resource manager may have affected the answer of the respondent since in Somalia leaders are usually males because Somali people believe that male leaders are more effective than female leaders because of their nomadic culture which males were the leaders of the community services.

5.8. Exploring span of control with performance management and conflict resolution A performance management system actions include developing clear job descriptions using an employee recruitment plan and providing effective new employee orientation, assign a mentor, and integrate your new employee into the organization and its culture (6). In addition, ongoing education and training will facilitate and reduce conflicts in the organization (7) that is why these two themes were integrated. Primary Health Care officer of Bari region who was 36 year old female stated clearly and truthfully that performance management is the key to leadership and management. Similarly finance managers and secretary of student affairs in university of health science stated truthfully that conflicts may come across in ay institution. Both their answers were credible and reliable regardless of their age, gender and position, as it seems that they are more experienced.

5.9. Exploring formalization with quality assurance and total quality management

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Quality assurance is a system that helps an organization to identify weaknesses and inconsistencies in the service or products and it’s a part of quality management which focuses on providing confidence that quality requirements will be fulfilled (8). Academic officer at city college of Bosaso university who was 27 years old male stated clearly and truthfully that they do practical audit every year to ensure full accreditation of his organization addressing quality assurance. On the other hand, a manager of Puntland Public Health Organization (PPHO) who was 35 years old stated clearly and truthfully that they manage the quality of the services of the organization. Total quality management was done by good communication with employees, asking for suggestions on the best possible services, customer care services, the quality of services are annually checked and examined. Their answers were credible and reliable regarding their age, gender and position supported by their years of experience in service.

Throughout this paper we have argued for the importance of leadership in management in modern healthcare. We tried to offer a general image on how the two affect all activities surrounding health services. Looking at the latest changes in the somalian healthcare system we expected to see a change at this level also, a change of approach, from the traditional legalistic view, to a more people oriented approach. More than this, we think that a comprehensive reform is impossible if only formal and legalistic aspects are considered as significant.

This article has presented a comprehensive theoretical framework for health promoting managerial work that supports capability to skill sustainable psychosocial work conditions in daily practice and during change. The leadership program, related to the theoretical framework, aims to support impact in practice, through focusing on more sustainable and health-promoting leadership that trusts on a greater use of reflexive assessments of the psychosocial risk management process, instead of traditional regulation approaches. The development of 55

sustainable working conditions, in practice, requires reflective management processes that manages the interactions between different levels in a work system, as these interactions have importance for function, well-being, and capability within all levels (individual, group, and organization) The key educational principles of dialog and exercises aim to support and strengthen such proactive handling through reflective management processes, to keep a focus on resources, and supporting the adaptation and application of the program’s evidence-based knowledge to practice in health care system to day Somalia public health leadership un ethical and do not know most managers how to respect the patients un able to talk and walk unfortunately lack of infrastructure of facilities from central government of Somalia since last 27 years after collapse siyadd barre regime know days really in Puntland we have many experience mangers but they did get off job training as well as on job training in case study of Bosaso district in Somalia we need organizational reform every 3 years at least know days we have many professional students graduated from unnituuno university and other institution more than 30 person who have knowledge and skills to manage referral hospitals in Puntland and Somalia

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5.10. Discussion The analysis of the competency framework in this preliminary study suggests that within LHDs there is distinct variation in the relevance of leadership competencies based on job category. Members of the highest executive function category, Health Officers, appear to place more relevance on competencies that engage in inter-organizational activities. Sub-agency level job categories, such as Department/Bureau Directors, and Program Administrators/Mangers rate competencies that facilitate intra-organizational functions, such as operations and quality improvement as the more relevant. The findings corroborate other studies, that suggest competency-based job descriptions benefit job function. Developing job descriptions that focus on inter-organizational competencies for the highest executive function category results in enhanced interaction with other organizations and thus builds an environment that allows LHDs to work with relevant partners to achieve the Public Health In the results was discussed systematically addressing the 8 themes and 6 key elements of leadership and management. Two out of six elements had two themes in each because these themes were closely related and integrated. The 8 themes were change management, organizational structure, styles of leadership, performance management, conflict resolution, total quality management and quality assurance. The results were reliable and valid because it was verified by the answers to the question. Evidences were available on video recordings and were used to interpret data. Collected data were checked and found that it was completed, after that it was organized in a systematic way in order to find out useful information of the lived experiences of Somali health care leaders in Bossaso district. In Somalia never developed a core health care services package nor gauged the extent of resources and infrastructure needed to deliver them. It could have saved wasted resources and eased its management burden if sound leadership had been practiced. As a result of poor leadership, the needs of the health care system and its effective operation were misconceptualized. Furthermore, the type and competencies of health manpower for the provision of a core health care services package, at different levels of delivery points, were never determined. Development of a national health plan with such attributes could have traced an efficient and progressive path for the Somali health care system. A prominent weakness of the Somali health care system was the lack of a strong regulatory body on drug importation and utilization Leadership management systems of the MOH lacked necessary infrastructure since funding’s, insurances, and equipment are not managed well enough as well as skilled manpower 57

is not available that could use such information for strategic planning and policy development. Some donor nations provided scholarships to MOH personnel for public health training, and the faculty of Medicine of the Somali National University started postgraduate training in public health in the early 1980s. However, most of those who completed their training either joined international organizations or sought better opportunities in the oil-rich Arabian countries in the Gulf. Thus, a massive brain drain in the 1980s hampered any planned progress in this area. International paradigms and resolutions have both positive and negative influences on the health care plans in developing countries, and Somalia is no exception (UNDP, 2001). Somalia’s health care system has suffered from inadequate funding, mismanagement, and poor planning and policy development ever since independence. As a result, the people’s health suffered. Currently, the health care system is obviously in crisis from the protracted civil war of more than a decade. The population has been growing annually at a rate of 2.8%, although it experienced high mortality rates during the civil war in the early 1990s. The health care needs were increasing while resources and enabling infrastructures were diminishing or ceased to function. The health status indicators rarely experienced any significant improvements evaluating the leadership system in Somalia will help to identify the leadership structure of Somalia, the prospect of the leadership system in Somalia and the challenges of leadership in public health issues in Somalia. Studying the leadership in Somalia public health will enable the researcher to recommend befitting solution to the problems of Somalia public health. In Somalia, the first and foremost challenge to the development of a sound health care plan is a strategic information and leadership management systems on the health care systems and its operations. The information on other related leadership management sectors is also justified to be important to be explored in this study. The leadership task is to ensure path, alignment and assurance within teams and organizations (Drath, McCauley, Palus, Van Velsor, O’Connor, McGuire, 2008). Direction ensures covenant and superiority among people in relation to what the organization is trying to achieve, consistent with vision, values and strategy. Alignment refers to effective coordination and integration of the work. Commitment is manifested by everyone in the institute taking responsibility and making it a personal priority to ensure the success of the union as a whole, rather than focusing only on

58

their individual or immediate team’s success in isolation. good leadership must be demonstrate presentation skills and forward alliance with other organization Essential of health care in society, the topic is significant for scholars of Somalia in public health leadership this area because of the potential influence that can be made to educating patient care and the health of societies. a model of central factors that shape philosophy and climate in health care organizations, describes significant research and addresses issues such as: the definition of presentation in this context; links among environment, nation, and routine in public health leadership is an energetic ,motivated,rewerder,during the implementation of organization work The basic foundation of the trait theory of leadership is that leaders possess particular traits that differentiate them from other individuals The Trait Theory of Leadership involves determining the essential characteristics of leaders based on the characteristics of past successful and ineffective leaders, and using those findings to envisage the effectiveness of leaders. The trait approach identifies personality traits, such as extraversion, that often align with leader development and efficiency, The trait theory of public health leadership to day in Bosaso district is typically not used alone due to the fact that good leadership does not simply arise from inherit inborn traits without attention of motivation and creativity The Big Five model of personality describes personality in terms of five dimensions, openness, conscientiousness, extraversion, agreeableness, and neuroticism, known as OCEAN, Openness refers to being outgoing and interested in new practices. Thoroughness refers to being organized and hard-working. Extraversion, on this scale, refers to being outward and social. Agreeableness refers to being helpful and sympathetic. Neuroticism refers to the degree to which a person is emotionally stable. Each trait is expressed on a continuum, meaning that person can exhibit a presence of or lack of each trait. Studies have shown that the Big Five approach is consistent as a predictor for leadership Another study by Judge et al. found a 0.39 correlation between the Big Five Personality Traits and leadership success know days public health leadership in Somalia is not standardized due to low transparent and un suitable quality assurance During the first decade of the civil conflict, almost all public sector higher medical education and mid-level training institutions were destroyed, creating a huge and acute shortage of qualified health workforce. This challenging situation has led to the rise of a large number of private medical colleges and health professional training institutions and programmes, which were the only viable sources for workforce production. However, these honest efforts were made without the founding of 59

regulatory bodies, for regulating customs, authorization standards and governance control measures.in public health leadership to day Although creditable efforts were followed through the international partners’ humanitarian health emergency support interventions, this assistance lacked any tangible formal investment in HRH pre-service training or any form of standardized in-service training through continuing professional development (CPD) programmes. This historical absence of public sector support action to address the severe shortage of qualified health workforce was further challenged by vast insecurity that prevailed at the time. This has severely constrained the delivery of quality health services and limited workforce productivity. The withdrawal of public sector training institutions was replaced by civil society efforts acting in the public interest, whose actions have led to the regeneration of the health training programmes in different geographical centers. However, despite these notable goodwill programmes, several serious challenges were encountered, which can be summarized as follows:

Supervision conflict in the workplace is a time-consuming but necessary task for the physician leader. Conflicts may exist between physicians, Nursing, Anesthesia between physicians and staff, and among the staff or the health care team and the patient or patient's family. The conflicts may range from divergences to major debates that may lead to hearing or forcefulness. Conflicts have an adverse effect on output, self-esteem, and patient care. They may result in high operative revenue and certainly limit staff gifts and hinder efficiency. Process is now readily available for those who feel that they are working in an unreceptive work environment. The aggressive environment may be the result of foul behavior by other employees, managers, or doctors. The misuse may take the form of a disparaging attitude, mimicry, off-color jokes, sexual irritation, or even physical violence. Societies have significantly decreased their tolerance of disorderly behavior. A group or society can now hold remote liability for overlooking an antagonistic work environment if it flops to act when a complaint is made. conflict arises first as normally conflict is human nature whether it arise from human interest or it arise other things ,so the first step to follow when conflict arise is to know The causes of this conflict and deeply understand it, then you have to get acceptance those who need to solve their conflict when they accept to solve their conflict you have to get solution to their

60

conflict and open for a negotiation so that there many ways to solve conflict but these main things that I can remember in health care system of Somalia Managing change is about conduct the density of the course. And it is about appraising, development and employing procedures, devices and approaches and making sure that the change is valuable and significant. Managing change is a multipart, energetic and challenging method. It is never a choice between scientific or people-oriented solutions but a combination of all. Organizational reform almost public health leadership of Somalia is not exist unfortunately low infrastructure and transparent to day behavioral in health leadership is autratic The status of health care system for an economy is crucial due to the impact that the access to health care Bloom, 2003; Ramesh & Mirmirani, 2007). The ultimate goal to which societies expect Murray & Evans, 2003). Thus, the analysis of the performance of health systems in attaining this objective becomes of great importance for all political and managerial decision-makers on the health care system. During the last two decades, many countries have introduced reforms aimed at improving health system performance (Collins et al., 1999). We have strategy goal first we selection employee qualified nurse and midwife they woks primary health care health unit up to health center and referral service after that we sure quality of place service like equipment’s which one who need replacement also we do knew buildings than our employee we give trains to reach our strategy goal most strategy goal is how to reduce morbidity and mortality pregnancy mother and children under five year that time we reach When we selected we look CV and we resend his university to sure his certificate it true or fraudulent if it true we add short list than we take exams and we build their capacity we do motivated their knowledge and skills to make promoted how can lead good communication and management

The organizational and

management structure of the Somali health system comprises of four facility based health care provision levels and a community based programme, collectively aimed at providing the maximum coverage of health services to the population (figure1). These include the primary health care units (PHUs) located in the most peripheral geographical areas, covering a defined catchment area population with basic promotive, preventive and simple curative services. The PHU is operated by at least one community health worker (CHW), supported by the local leaders in the organization of health services delivery. PHU services are also reinforced by the health center (HC) outreach support, particularly in services related with the expanded programme on

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immunization (EPI) and nutrition promotion and education.(Somali health policy Approved by the Health Advisory Board September 2014) Quantitative research designs emphasize fairness in measuring and describing phenomena (McMillan & Schumacher, 2010). As such, the research design exploits objectivity by using descriptive measurement, , construction and control. An significant sub-classification of quantitative design is experimental and non-experimental. The variance between the two has significant implications for the nature of the design, and the types of conclusions that can be drawn. Qualitative research designs, however, use methods that are distinct from those used in quantitative designs. While qualitative designs can be said to be just as systematic as quantitative designs, they underscore gathering data on naturally occurring occurrences. Most data gathered is in the form of words and the researcher must search and explore with a variety of methods, until a deep understanding is achieved. Qualitative research designs can be organized by: (1) focus on individual lived experience, as seen in phenomenology, case study grounded theory and some critical studies; and (2) a focus on society and culture, as defined by ethnography and some critical studies (McMillan & Schumacher, 2011).

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6.0 CONCLUDING REMARKS

6.1 Conclusion Public health leadership in Somalia decline and disintegration, the Somalia Federal Government alongside international and domestic partners is beginning the process of rebuilding its national health system. In this study, we aim to shed light on the current approaches to health system strengthening, as viewed by stakeholders closely involved in its development. Methods: Key informant interviews were undertaken with health and development professionals working within all three administrative regions of Somalia, as well as with Somali ministry of health officials, global health and policy specialists with interests in health system reconstruction in fragile states. A review of published and grey literature on Somalia, health systems, fragile and conflictaffected countries using PubMed and Relief web was also conducted. Despite we collected interview 8 themes of health care system of Somalia especially case study of bosaso district and achieve good command of leadership style Technical documents designed for Somali health system building by external development partners were also reviewed. Results: Key priorities identified by participants were, strengthening of local governance and management capacity, scaling-up efforts to structure a resilient health financing mechanism, engagement with the burgeoning and dynamic private sector, as well as investing in the appropriate human resources for health. Conclusions: The study found that there was widespread agreement among participants that health system strengthening through a coordinated system would improve longterm capacity in Somalia's health sector. Future research should focus on the evaluation of the modalities by which health system strengthening interventions are implemented, on neglected topics such as mental health within the Somali health system, as well as on population-level barriers

to

accessing

health

systems.

characteristics of respondents age above 30 years while the gender respondents was 75% after that who have married was 90% of respondents were educational status who have degree of health science in other hand their income generation was good 80% have special salaries eventually those who have master level 25% of respondents most of them their responsibilities 50% of respondents while duties of key elements work Specialization. Departmentization, chain of command, span of control, decentralization. Formulization Effective leadership of healthcare 63

professionals is critical for strengthening quality and integration of care, one of the respondents who was Hospital Manager in Bosaso stated that there should be a hierarchy and chain of command according to the style of leadership, which will improve task orientation. One of the respondents who was secretory of Health Science University stated that conflicts may come across in any institution but Effective conflict resolution planes and strategies are key to successful conflict management. Healthcare leaders manage changes in health care service by handling the complexity of the process. It is about evaluating, planning and implementing operations, tactics and strategies and making sure that the change is worthwhile and relevant. healthcare leader manage performance of health care professionals by developing clear job descriptions using an employee recruitment plan and providing effective new employee orientation, assign a mentor, and integrate your new employee into the organization and its culture. The way in which an organization is structured has a great impact on the style of management needed to optimize the organization. A mis-fit between management styles and the organizational structure will result in a poorly functioning organization or institution, even though all other assets for success might be present. Teamwork is essential in the provision of healthcare, thus the division of labor among health care professionals means that no single professional can deliver a complete episode of healthcare, there healthcare leaders organize and let them to work together. The term "quality assurance" means maintaining a high quality of health care by constantly measuring the effectiveness of the organizations that provide it. It is a part of quality management which focuses on providing confidence that quality requirements will be fulfilled. Total Quality Management (TQM) may have been the first quality oriented philosophy to transition into healthcare. The competency of most relevance to the highest executive function category was that of “interaction with interrelated systems.” For sub-agency level officers the competency of most relevance was “advocating for the role of public health.” The competency of most relevance to Program Directors/Managers or Administrators was “ensuring continuous quality improvement.” The variation between competencies by job category suggests there are distinct underlying relationships between the competencies by job category.

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6.1.1 Recommendations Leaders are a vital component of any organization so capacity development and training is necessary for an institution, organization and any other institution that is constantly evolving, such as healthcare. Effective strategies to train, develop health care leaders is necessary to attain well qualified health care leaders. Nominate a focal point at MoH to be in touch with WHO country office about processes of review. Collect and share all relevant documents on health system development, service provision, policies and strategies for health system strengthening, and most recent national health system policies and plans etc. Identify and arrange visit to health centers, hospitals, institutions in Somaliland in both rural and urban areas Accompany the mission and provide assistance in translation during interviews if needed, approaching selected health care providers and contribute in report writing Prepare list of stakeholders and managers to be interviewed including high level officials and make sure their availability during the mission. Organize one day workshop in Nairobi to present findings of the mission to national stakeholders.

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6.1.2 BIBLIOGRAPHY

Abdulkadir dallaf (2018) The impact of public health leadership in Somalia the case study of Bosaso district Uninettuno University Roma Italia

Anis-ul-Haque, A. , Bano, M. and Khan, J.Z. (2004), “Conflict management styles: private and public sector differences”, Journal of Behavioral Sciences, Vol. 15 No. 12, pp. 2534. [Google Scholar] Articles from Oman Medical Journal are provided here courtesy of Oman Med J. 2007 Oct; 22 Bloom, D.E., and Canning, D. (2007), “The Preston Curve 30 Years On: Still Sparking Fires,” International Journal of Epidemiology, Vol. 36, No.3, pp. 498-499. B.E.-Biomedical Engg, PGD-Quality Management, MS-Medical Software (1st sem)-MCIS, Manipal University Centers for Disease Control, “Population-Based Mortality Assessment—Baidoa and Afgoi, Somalia, 1992,” MMWR 41, no. 49 (1992): 913–917. CIA, Somalia—World Fact Book, 2005. Online at http://www.cia.gov/cia/publications/ fact book. Case study research is an investigation and analysis of a single or ... Case study research has been defined by the unit of analysis, the process of study, ... or social constructionist viewpoint of other authors (Merriam, 2009; Stake) Drath, McCauley, Palus, Van Velsor, O’Connor, McGuire, 2008 “Declaration of Alma-Ata.” International Conference on Primary Health Care, Alma Ata, U.S.S.R., 6–12 September 1978. Online at http://www.who.int/hpr/archive/docs/ almaata.html.

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Ethnography and some critical studies (McMillan & Schumacher, 2011). For the purpose of my study I have chosen to use a qualitative research design. Earl Babbie, best-selling author in the field, is joined by Lucia Benaquisto, experienced ... Nelson Education Limited, 2002 - Social sciences Faisal Talib, Zillur Rahman & Mohammed AzamQuarterly Published online: 04 Aug 2011 K.Shridhara Bhat, “Total quality management (text andcases)”,4nd edition. Himalaya publishing, India 2007, ch-1, 3,6, 8,9,17. Mugenda, O.M. and Mugenda, A.G. (1999) Research Methods Quantitative and Qualitative Approaches. Acts Press, Nairobi. World Bank, World Development Report. Investing in Health (Washington D.C.: Oxford University Press, 2015). West, M.A., Topakas, A., and Dawson, J.F. (2014). Climate and culture for health care performance. In B. Schneider and K. M. Barbera (eds.), The Oxford Handbook of Organisational Climate and Culture. (pp. 335- 359). Oxford: Oxford University Press. Weber, D. (2010). Transformational leadership and staff retention: an evidence review with implications for healthcare systems. Nursing Administration Quarterly, 34 (3), 246-258. Welch, C. E., & Grove, P. L. (1991). An overview of quality assurance. Medical Care, 29(8), AS8–AS28. Wikipediaorg. (2014). Health Care. Retrieved 19 August 2014, from http://en.wikipedia.org/wiki/Health_care Houle, D., & Fleece, J. (2012). Why one-third of hospitals

will

close

by

2020.

Retrieved

8

August

2014,

from

http://www.kevinmd.com/blog/2012/03/onethird-hospitals-close-2020.html West, MA & Lyubovnikova, J 2012, 'Real teams or pseudo teams? The changing landscape needs a better map' Industrial and Organizational Psychology, vol 5, no. 1, pp. 25-28. DOI: 10.1111/j.1754-9434.2011.01397.x Population Reference Bureau, “Country Profiles: Somalia,” 2005. Online at http:// www.prb.org/templateTop.cfm; WHO-EMRO, “Country Profiles: Somalia,” 2004. Online at 68

http://www.who.int; Earth Trends, “Population, Health, and Human WellBeing—Somalia,” 2003. Online at http://earthtrends.wri.org; and UNICEF, “End of Decade Multiple Cluster Primary data plays important role in problem definition,Research, Creswell (1994) stated that the descriptive method of research is to gather . Survey Technical Report for Somalia,” Nairobi, 2001. SA Journal of Education, Vol 31, No 4 (2011) ... Democracy in schools: are educators ready for teacher leadership? Elsabe de Villiers, Fanie Pretorius ... UNDP, “National Human Development Report—Somalia” (2001). UNFPA, “Somalia Country Paper” (2004). WHO (Draft), “Health Facilities Overview, Somalia” (2005). WHO, “Facts and Figures from the World Health Report.” The World Health Report, Geneva, 2015. Online at http://www.who.int/whr/en. ORGANIZATIONAL CHANGE AND DEVELOPMENT … ORGANIZATIONAL CHANGE AND DEVELOPMENT. Annual Review of Psychology Volume 50, 1999 OAU, “Health System Strengthening in Africa. Sustainable Access to Treatment and Care for the Achievement of the Millennium Development Goals.” Meeting of Experts, Addis Ababa, 10–12 October 2005.

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6.1.3 APPENDIX

PROFILE OF RESPONDENTS Most of the respondents were qualified from inclusion criteria set. Above all, most of the respondents are citizens of Somalia working full time in public health services. Respondent #1: (1) 33 years male (2) position finance manager and secretary of student affairs in university of health science (3) theme: conflict resolution

Respondent #2: (1) 27 years male (2) position health academic office city college of Bosaso university (3) theme: quality assurance

Respondent #3: (1) 30 yars female (2) position hospital manager in Daryel hospital of bosaso (3) theme: leadership traits and styles

Respondent #4: (1) 29 years male (2) position doctor of Biyo Kulule health center (3) theme: management of change

Respondent #5: (1) 35 years male (2) position manager of Puntland Public Health Organization (PPHO) (3) theme: total quality management

Respondent #6: (1) 34 years male (2) position Bossaso district health officer (3) theme: structuring organization 70

Respondent #7: (1) 36 years female (2) position health care officer of Puntland in Bari region (3) theme: performance management

Respondent #8: (1) 28 years male (2) position human resource manager (3) theme: team work

Open and questions about leadership and management 1. How can u explain leadership as manager? 9. Leader ship Skill can be learned but in many ways, leadership can also manifest itself naturally in other people

2. How do you see yourself as leader? a. To be leader I very happy because I have more experience and talent to work and manage to achieve my goals as leader

3. Why is the leadership important in health care? b. Help to work easily from top-down respectfully and benefit to get good quality service and improve morally of patient.

4. What would you describe your leadership styles? a. Autocratic styles

5. Why is important to have flexible of leadership in your work? a. To improve work orient and people orient together

6. How can you be good leader?

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b. To motivate worker and improve morally

Recommendations 1. To use universal leadership model to develop 2. To make team work 3. To motivate worker

Open end question of the focus: “Conflict Management” 1. How do you manage conflicts? Answer : Bismillah if conflict arises first as normally conflict is human nature whether it arise from human interest or it arise other things ,so the first step to follow when conflict arise is to know The casues of this conflict and deeply understand it, then you have to get acceptance those who need to solve their conflict when they accept to solve their conflict you have to get solution to their conflict and open for a negotiation so that there many ways to solve conflict but these main things that I can remember . Follow up questions a. Is it difficult?

Answer : As normal conflict is not easy but it needs tolerance or

patience b. Do you like managing conflicts?

Answer : Yes I like to manage conflict

2. Can you give one case on which you have dealt with conflict as a public health leader in your organization ? Answer : conflict occur sometimes but I did not meet with any conflict in our organization Follow up question: How did you resolve the issue? 3. Tell me about a time you faced an ethical dilemma? :in our organization I did not meet any ethical dilemma

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Answer

4. May you describe conflicts that you faced between you and one of your employee? Answer

:

something

occur

sometimes

but

we

solve

it

as

excuse

5.In general what is your message to us on how to solve a conflict? Answer :first to undertand any conflict deeply to solve or to manage it then you have to get acceptance for people in relation to this conflict

Said Farah Jama lecturer and member of top management of University of Health Sciences Bossaso Next question was : Can you give one case on which you have dealt with conflict as a public health leader in your organization ? Mr Said “conflict occur sometimes but I did not meet with any conflict in our organization” Third question was : Tell me about a time you faced an ethical dilemma? Mr Said answered “in our organization I did not meet any ethical dilemma” Fourth question was : May you describe conflicts that you faced between you and one of your employee? Mr Said answered “something occur sometimes but we solve it as excuse” Last question was : In general what is your message to us on how to solve a conflict? Mr Said’s final massege about conflict resolution “first to undertand any conflict deeply to solve or to manage it then you have to get acceptance for people in relation to this conflict”

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Open and end Questions about performance management

1: how to manage employees in your sector to achieved strategy goal ? We have strategy goal first we selection employee qualified nurse and midwife they woks primary health care health unit up to health centre and referral service after that we sure quality of place service like equipments which one who need replacement also we do knew buildings than our employee we give trains to reach our strategy goal most strategy goal is how to reduce morbidity and mortality pregnancy mother and children under five year that time we reach 74

---------------------------------------------------------------------------------------------------------------2:How to select new employees to sure their performance ? When we selected we look CV and we resend his university to sure his certificate it true or fraudulent if it true we add short list than we take exams ------------------------------------------------------------------------------------------------------------Follow up questions A: Which type to use in interview? We use traditional interview ---------------------------------------------B: are you make recruitment process? Yes we do screen -----------------------------3:- How do you like to receive feedback on your work? I like best one because I cant wok with out -------------------------------------------------------------------------------------------------------4: What can you do to improve your management and employee communication?

Staff training and we build their capacity we do motivated their knowledge we make promoted we can lead good communication and management ---------------------------------------------------------------------------------------------------------5: Do you give reward and appraisal ? Yes we give 75

Fallow up question Which reward you gives? We give certification also we do mentions ---------------------------------------------------------6:finaly what your recommendation to me how to reach good performance management ? 1:I recommend you to do best management your sector 2: try to continue your knowledge means learning more 3: you become flexible person, also mast be have good organizational behaviour 4: give training your employee 5 provide reward, if you do that you can reach good performance management and strategy goal

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Questions and answers 1. Question (1) What is the quality assurance? Why is it important? Answers 1. Quality assurance is a monitoring of a student’s knowledge capacity of skills and attitudes 2. QUESTIONS How do you assure quality in your department?

2. Answer Continuous assessments in attendance of the students and practical skills in their career of knowledge to upgrade in different departments 1-Health science like Nursing midwifery, public health, clinical officer, pharmacy, laboratory (3)When do you practice the routine of quality assurance? Answer 3-we do practical every year how to ensure students skills related in hospitals and health centers minimal supervision Questions (4)Tell us examples of a successful quality assurance which your company has achieved? Answer We achieved research in weekly develop by the students in different faculties and 8 patch graduated from university of Bosaso 77

(5)What is your final message regarding quality assurance? Answer 5-eventually quality rather than the quantity To increase quality assurance in practical skills which mandatory the future knowledge and technology education will be good advanced we need more concentration

Management change Question: what skills do you need for change? Answer: we provide key skills for effective change managers. Personal resilience, trust-building, coaching, forcing clarity, managing others’ uncertainly, organization, follow-through. Theme: change management is the process, tools and technical to manage the people side of change to achieve the required of the organization outcome. And helps employee to understand, commit to, and accepts and embrace changes in their current organizational environment.

Organizational structure Question: how organizational structure affects organizational action? Answer: in two ways it provides the foundation on which standard operating procedures and routines rests. It determines which individuals get to participate in which decision –making processes, and thus to what extent their views shape the organizational action. Theme: organizational structure activates as task allocation, coordination, and supervision that are directed towards the achievement of organizational aims.

Team work 78

Question: Why is important to have a flexible leader in your work? Answer: to improve work oriented tasks and people relationship together. Theme: flexible leaders are one of the styles of leadership. We interviewed them and said that they met conflict between their staff. This shows that flexible leaders is often needed at public health services to reduce conflicts and make the team work. Question: tell me about a time you faced an ethical dilemma affecting team working? Answer: in our organization I did not meet any ethical dilemma. Everyone work together as a team. They are ethically separated accordingly but centralized as one team. Theme: Team working can be learned but in many ways can also manifest itself naturally during ethical dilemma. That is why organizations are built with separate departments with centralized heads and directors to ensure each members of staff work with their own specialties to avoid dilemma of incapacity because they cannot function together with the other team members. Therefore in an organization, it is ethical that team members must be separated according to their capacity to perform, but centralized by an overall head.

Question: how do you achieve total quality? Answer: we keep the quality of the organization by communicating with our employees by asking for suggestions on the best possible services. In addition, the quality of items are annually checked and examined. Being polite to customers by greeting the service users or customers every time for example saying "thank you" is also a means of ensuring quality service for customer satisfaction.

In

addition, the service-users are given some gifts and free products such as vitamins and minerals hoping for them to have a good life. The right processes for quality is both for the service and the service-users.

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Theme: A total quality management is the integration of the quality process of the organization it is over all management that faction of the organization to achieve the goals and targets of the organization. It is important when we say total quality must be functioning and processing as the policy of the organization.

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