Seriously Implementing Health Capacity Strengthening Programs in Africa; Comment on 'Implementation of a Health Management Mentoring Program: Year-1 Evaluation of Its Impact on Health System Strengthening in Zambézia Province, Mozambique'

Faced with the challenges of healthcare reform, skills and new capabilities are needed to support the reform and it is of crucial importance in Africa where shortages affects the health system resilience. Edwards et al provides a good example of the challenge of implementing a mentoring program in one province in a sub-Saharan country. From this example, various aspects of strengthening the capacity of managers in healthcare are examined based on our experience in action-training in Africa, as mentoring shares many characteristics with action-training. What practical lessons can be drawn to promote the strengthening so that managers can better intervene in complex contexts? Deeper involvement of health authorities and more rigorous approaches are seriously desirable for the proper development of health capacity strengthening programs in Africa.

H ealthcare management capacity strengthening programs only recently have started addressing scientific evidence. This improvement follows the human resources (HR) for health progresses. 1 Often capacity strengthening programs are just an opportunity for the health managers to leave their office and go to the capital city for some upgrading session, usually very theoretical, with limited value added. 2

"No Health Without a Workforce"
properly prepared to tackle daily challenges. Consequently, capacity strengthening programs are needed to deliver new skills and competencies, which would compensate for both resources and health professional's shortages. 3 The paper by Edwards et al 4 provides a good example to better understand the challenges of implementing a mentoring program by evaluating the impact on the health system in one province in a sub-Saharan country: Mozambique. Facing the challenge of doing more with fewer resources, one needs to use good practices and evidence. The "mentorship" strategy is an approach that looks for improvements by mentoring the managers into using good practices and problem-solving. 5 Mentoring approaches share similarities with action-training. Today, most management approaches are based on management by objectives and on actionlearning. How well does "mentoring" work when there is shortage of resources and a large distance between managers? Edwards et al 4 show, in this particular context, that if properly organized it actually works.
An additional factor promoting change were the millennium development goals. These goals created a pressure to focus on specific targets bringing issues like healthcare management to the agenda. Hence, government's leadership (and resources) to promote millennium goals seriously was necessary. 6 Successful health reforms need to be supported by continuous interventions (with regular assessments and adjustments), whereas HR capacity strengthening plays a crucial role. 7 Concerning the case presented by Edwards et al, 4 the managers at Zambézia province, even being successful at this stage, need to be kept involved in a "mentoring program"; otherwise, or most will be lost. Besides the management, capacity strengthening on both the research and policy side is also needed if we wish to promote change and quality improvements. It would be easy to implement if we involve decision-makers already from the start. 8 Clearly more research is needed. In terms of methodologies, there is still room for improvement. Capacity strengthening interventions should benefit from implementation science and realistic review methodologies, which opens a new window of opportunity. 9,10 In the African context, healthcare reforms typically pursue improvements in basic access to healthcare services and make it as efficient as possible. Among the various strategies used, the main one is the strengthening of primary healthcare (PHC). The better the integration of services, 11 and adequate and balanced HR distribution, the better the service efficiency. 12 Recently, several international organizations led by World Health Organization (WHO) and the World Bank 12,13 joined the ambitious project of 'universal coverage in health, ' to improve the 'situation in which all citizens can use quality healthcare services they need, without major financial sacrifices to pay them. ' These objectives can be understood as if they were 'reforms, ' as its scope requires profound changes at different levels of the health system. The decentralization of management and new methods of service delivery, regulation, or training of providers are good examples. However, the success of these changes depends absolutely on the existence of an institutional and organizational environment to create favourable conditions for their implementation. Institutionally, it is fundamental to establish a legal framework to eliminate obstacles to the process of change. It may require the adoption of legislation to redefine the responsibilities and procedures of decision-making between the different levels of governance, review of legal definitions of tasks that can be performed by the various groups, or creating financial incentives and professional systems to stimulate the cooperation of providers. For instance, to be effective when adopting "mentoring" strategies, one needs to properly integrate it within the organization governance. At the organizational level, one needs to assure there are management capacities, access to agile information systems and autonomy in the allocation of resources. Institutional and organizational mechanisms are essential determinants of the success of health reform. In reality, there are individuals with skills, values, motivation and dedication that can make a difference at every level of policy formulation, planning, and management, and particularly, in the provision of services. New challenges and tasks corresponding to new needs of citizens require not only new skills, but also new ways of acquiring such skills. 14,15 Mentoring seems to provide good results in healthcare environments. It is important to understand (and further study) the behaviour of managers and other professionals, and the challenge of strengthening their capacities to enable them to tackle reform. It is particularly challenging for these professionals to be engaged confronting a complex context that continually changes, and often is not predictable. Unlike clinical area, managers cannot rely, to guide their decisions, on 'good practices' replicable in any context. There are 'good practices, ' ie, examples of management practices known (and with evidence) to favour the reform process, but they are always linked to a context, so often are not replicable. The challenge is fundamentally in the creation, strengthening and updating relevant skills to enable managers to cope with the transformation of healthcare processes and services demand. In our work with African Portuguese-speaking countries we have collaboratively developed several healthcare management programs. From specific one week to 1-year programs, we always include mentorship. 7,16 In defining capacity strengthening needs, several aspects were considered: (a) Programs must be focused on the reality: The organization of training in an African country has specific requirements; therefore, it is essential to coordinate with local entities and the team of trainers. 17 There is a great heterogeneity at various levels, from equipment to HR. 18 They suffer from specialized HR shortages and lack of equipment, or lack proper maintenance. A first reference African hospital is usually located in a rural area, supporting not only a population directly dependent on the hospital, but also health-centers in districts without hospital. Clinical teams are led by a group of nurses and general practitioners (who also do surgeries). Often, these physicians also take management responsibilities. (b) Consider typical service organization: African hospitals and health-centers usually provide a set of essential services: obstetrics and gynaecology; emergency and general surgery; internal medicine; basic diagnostics; supply of medicines and vaccines, which suffers from frequent stocks disruptions. 16 The literature shows that there are serious weaknesses with the referral system and often referred-patients do not reach the hospital, due to the lack of transportation, taxes and services weaknesses. 19 (c) Main healthcare management challenges: Most healthcare professionals have a high level of qualification, making it difficult, or impossible even, for the traditional hierarchical supervision. Being the hospital a very different organization, vertically and horizontally, its production is mainly located in the operating center (emergency, surgery, consultations, etc). In this case, support services primarily serve to assist the operations center; the techno-structure and hierarchy are part of the supporting architecture (eg, the head-nurse and the supervising nurse can be considered as techno-structure elements). 20 The size and scale issues are particularly complex in small states (Cape Verde, Guinea-Bissau, and São-Tomé and Principe). (d) Searching for quality and health gains: The dynamics of health services, especially in hospitals, require leadership and strong skills in management and clinical governance. Health management should also promote good use of instruments (planning, evaluation, etc) that allow support the decision on the allocation of resources (HR, technology, financial, etc) in line with the organization's objectives. It should increasingly focus on cost-effectiveness and quality (eg, Lean systems), and patient safety, with a growing desire to increase access and universality. Clinical management intersects routine administrative aspects of resources, which so far are the most expensive in the hospital, with a very different scientific knowledge and ethics. (e) Health professional development: The reorganization effort begins to manifest itself by a set of change attempts and integration of services. 21 This type of transformation requires change management and organizational development competencies. Organizational development is the way to develop and improve services. On the other hand, healthcare organizations must provide services that respond to the 'need' of individuals and populations, creating adequate access 'channels, ' so that the services can be provided. (f) The management of the interface with PHC. The hospital management cannot ignore the interface with the PHC. Ideally, integration between hospitals and PHC creates value that requires at least 4 conditions 22 : (1) The alignment of primary and secondary care activities; (2) The existence of an information system that enables the sharing of medical records to support the decision-making; (3) The coordination of care and clinical governance. An integrated organization can develop a type of planning that disaggregated operators cannot; and (4) The ability to enhance efficiency improvements. The development of capacity-strengthening programs, taking into consideration the above issues, allows listing a set of lessons: (a) Action-training. The context of action-training yielded good results on the training programs. From a theoretical point of view action-training programs provide activities related to the reality of work, 16 as they are focused on solving concrete problems. 23 On the other hand, it is necessary to consider innovation to allow finding 'innovative' alternatives to overcome existing bureaucratic obstacles in the health system. (b) Time. It is important to diagnose and have time to prepare the program, aligning it with the needs of managers. (c) Multidisciplinarity. A diversity of lecturers to support a multidisciplinary training is critical. It also requires a pedagogical effort to integrate contents and guide the various actors. (d) Monitoring. A constant monitoring, or mentoring, is necessary from the Ministry of Health (MoH): Often an action-training program itself is not enough. More government involvement is required. The challenge is to design and implement the right kind of strategies to create the environment that supports change.
(e) Technology. The technology and the Internet are fundamental supports for communication. All programs have sought to enhance the most use of technology for the benefit of the managers. The Internet is an important pedagogy support that allows more and better communication between participants and lecturers. In some countries, the health system evolved almost without plan; while in others there have been concerted efforts by governments and other partners to develop services tailored to the needs of populations. 24 The objectives of health systems are population health, response to expectations of populations, and fair financial contribution. Capacity strengthening should focus on manager's skills and attitudes. However, training interventions design are complex and demanding processes. The creation and implementation of action-training programs prove to be a good mechanism to enable health managers and help them face the difficulties inherent to reform. Training programs alone are not enough. It is always necessary to have other mechanisms, such as incentives and the close monitoring from government bodies.

Ethical issues
Not applicable.