Transcript STRATEGIC ALIGNMENT

ALIGNMENT OF STRATEGY :
LEARNING AS AN INSTRUMENT
OF IMPLEMENTATION
B.V.L.NARAYANA
Structure of presentation
•
•
•
•
•
•
•
•
Problem identification—trigger
Literature review– motivation for study
Methodology
The case
Findings
Discussion
Conclusion and Contribution
Limitation and future research avenues
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Problem identification--Trigger
• Disparity in distribution of mortality and morbidity
– Between developed and developing countries
– Between states in India
• Conditions preventable
• Proven cost effective interventions available
• Common health care programmes
• Why the disparity in India
• Reason : low usage of interventions
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COMPARISION OF HEALTH CARE INDICES
Developed
countries
Developing
countries
9
100
58
76
13
13
114
95
130
19
3
41
46
60.4
22.6
40
630
301
517
110
5
40
27
NA
NA
31
164
6.8
NA
NA
Full ANC %
97
65
50.7
96.5
16.7
Safe deliveries %
98
45
40.2
99.7
12.2
Children fully immunized %
90
60
43.5
80.8
20.1
NA
32
23.4
60.4
7.2
INDICATORS
IMR(/ 1000 live births)
<5 MR(/ 1000 live births)
UNDERWEIGHT %
MMR ( / Lakhs births)
Deaths due to TB( / Lakhs population)
Deaths due to AIDS(/ Lakhs population)
India
India
India
( average) (highest) (lowest)
INTERVENTIONS
Children breast fed %
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Source : National health profile 2006, NFHS 3(2005-06)
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Problem identification--Trigger
• India and other developing countries
– Investments and funding (Bajpai, Dholakia and Sachs 2006;
CMH 2001)
• Mediated through good governance (Wagstaff and
Claeson 2004 )
– Institutional factors (NCMH 2005; Wagstaff and Claeson 2004)
– Service delivery mechanisms ( Mavalankar 1999;
Seshadri rao 2001; Wagstaff and Claeson 2004)
Implementation is one of the key issues
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Literature review – Strategy implementation
• Neglected subject in research (Hutzschenreuter and
Kleindienst 2006; Hrebiniak and Joyce 2001)
– 21/991 articles looked at implementation
issues
– Extreme emphasis on formulation (Hutzschenreuter
and Kleindienst 2006)
– Non consideration of implementation variables
(Ginsberg and Venkatraman 1985)
– Lack of processual studies (Pettigrew et al 2002)
– lack of cumulation of theory
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Literature review –Strategic alignment
• Used for alignment of IT systems with
business strategy ( Henderson and Venkatraman 1999)
• Alternatively called as “Fit” (Chandler 1962)
• Researched as a static concept with poor
operationalisation (Venkatraman and Prescott 1990; Hrebiniak and
Joyce 2001)
• As bivariate relationships in cross
sectional studies ( Ginsberg and venkatraman 1985)
Call to use fit as a dynamic concept
And link to implementation
(Hrebiniak and Joyce 2001)
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Literature review --RBV
• Alignment between VRIN resources and
business activities (Barney 1991)
• RBV is static , must look at evolution of
resources( Priem and Butler 2001)
• Resource allocation process Model (Bower and
Gilbert 2005)
– Realized strategy is outcome of iterative
allocations of resources
– Is a strategy process implementation
framework
– Not linked process to performance
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Literature review -Learning
• Knowledge –resource with VRIN
characteristics (Grant 2003)
• Role of Knowledge in ensuring competitive
advantage is not clear (Amin and cohendet 2004)
• Learning not linked to implementation (Moingeon and
Edmondson 1996)
How does learning influence the process
of implementation
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Methodology
• Implementation –Non linear, dynamic
(Hrebiniak and Joyce 2001)
• Study aiming to answer “How” and “Why”
questions– Qualitative methods
• Requires processual study (Pettigrew 1997)
• Context – Public health care systems of
states
• Choice of programmes –(CGDEV2007)
RCH,NVBDCP,NBCP,RNTCP
• Embedded case study design and multiple
units of analysis (Yin 2003)
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Methodology
• Choice of units for study- purposeful
sampling (Patton 2002) Exemplar units
– State level– (NCMH 2005)
– District and field unit level
• Data collection:
– Retrospective histories from
Interviews of key informants
– Documents
• Data analysis
– Contextualizing strategies (Maxwell 1993)
• Case study, displays
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Methodology
• Formal approval for participation taken
• Field work driven by concurrent analysis
– Appropriateness of data collected
– Adequacy
– New insights arising from data
• Triangulation by
– Secondary documents
– Independent key informants
• Cases sent to liaison officer for verification of data
• Peer reviewed for reliability of analysis
• Study based on RCH programme implementation in
Tamil nadu
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The Case
• CONTEXT
• PROGRAMME OBJECTIVES (NHP2002)
– IMR of < 30/ 1000 live births
– MMR of <100/ Lakh live births
– Service utilization >75% at FRU level
• Tamil nadu achieved these in 2006
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The case
COMPARISON OF KEY INDICATORS FOR STATES IN
1999-2003
INDIA
2005
2005
2005
2003
2004
STATE NAME
LEB (M)
LEB(F)
BR
DR
IMR
MMR
TFR
Kerala
70.9
76
15
6.4
14
110
1.7
Tamil nadu
64.3
66.5
16.5
7.4
37
134
1.8
Andhra Pradesh
62.2
64.8
19.1
7.3
57
195
2.1
Himachal Pradesh
65.8
66.6
20
6.9
49
301
2.1
Maharashtra
65.2
67.6
19
6.7
36
149
2.2
Punjab
67.6
69.6
18.1
6.7
44
178
2.2
West Bengal
63.5
65
18.8
6.4
38
194
2.2
Karnataka
62.9
66.4
20.6
7.1
50
228
2.3
Orissa
58.6
58.7
22.3
9.5
75
358
2.7
Gujarat
62.5
64.6
23.7
7.1
54
172
2.8
India
61.8
63.5
23.8
7.6
58
301
2.9
Assam
57.8
58.3
25
8.7
68
490
2.9
Haryana
65
65.6
24.3
6.7
60
162
3
Madhya Pradesh
57.2
56.9
29.4
9
76
379
3.7
Rajasthan
60.7
61.8
28.6
7
68
445
3.7
Bihar
61.6
59.7
30.4
8.1
61
371
4.3
Uttar Pradesh
59.6
58.7
30.4
8.7
73
517
4.4
SOURCE
CENTRAL BUREAU OF HEALTH INTELLIGENCE
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GOI
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The Case
Prioritized based on states problems– Dr Jayanti consultant UNICEF
Time period
Objective
Programmes
Key Services of area of focus
Key Service
deliverer
1982-1996
Tackle child
mortality
Child survival and Safe
motherhood; Universal
immunization
programme; ORT
Immunization coverage,
Management of childhood
diseases, ART, ADD
VHN
Medical
officer
1996-2005
Tackle
maternal
mortality
Reproductive and child health
phase I and II
Maternal care, emphasis on
institutional deliveries,
management of high risk
pregnancy conditions like
gestational diabetes, AIDS and
anemia. MTP, new born care
and immunization
VHNs
Staff nurses
Medical
officers
Specialists
1996-2007
and
onward
Tackle neo
natal
mortality
Reproductive and child health
phase II and new born
care
Maternal care, emphasis on
institutional deliveries,
management of high risk
pregnancy conditions, high
risk babies; medical
termination of pregnancy
(MTP), immunization
VHNs, staff
nurses,
medical
officers,
specialis
ts
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The Case
• Identification of key resources
• “People link availability of doctors and medical services.
Availability of doctors for services is most important. In case
of staff nurses and ANMs, not just availability but they must
be skilled to provide services”. Dr Padmanabhan
• Identification of key resources linked to
– Service delivery
• Management of key resources
•
•
•
•
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Initiatives designed to ensure adequacy
Skill up gradation and development
Effectiveness and efficiency of services
Introduction of new services
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The Initiatives– Up gradation of infrastructure
Year
PHCs
SCs
1985-86
436
5860
1989-90
1386
8681
8681
1995-96
1417
8681
8681
2700
1996-97
1418
8682
10336
2700
2000-01
1410
8682
90
24
10593
2700
270
2004-05
1413
8682
241
120
10593
2896
723
2005-06
1415
8682
736
130
10593
3089
2208
2006-07
1417
8682
956
130
10593
3089
2878
2007-08
1417
8682
1156
205
10375
3266
3500
source
Policy notes of department of health and
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24*7 PHCs
Upgraded PHCs
VHN
MO
Staff nurse
family welfare
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The initiatives –Up gradation of infrastructure
NUMBER OF SEATS AVAILABLE EVERY YEAR
COURSE
2002-03
2003-04
2004-05
2005-06
2006-07
2007-08
Staff provided
MBBS
1515
1565
1565
1605
2055
2055
Medical
officers
POST GRADUATE
892
886
886
902
889
889
Specialists
NURSING
2340
3340
3340
3695
3700
3830
Staff nurses
PHARMACY
1736
1740
1740
1756
1997
2106
Pharmacists
Lab
LAB.TECHNOLOGY
2700
2700
2700
2700
2700
5000
ANM/VHN training
200
200
200
200
200*
200
* present capacity can be scaled up to
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technicians
ANM/VHN
400
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The Initiatives
• Facilitation of staff working
– Minimal vacancies
– VHN mobility
– Recognition and rewards– training
• Management of shortage of key staff
– Development of staff– posting of Staff nurses
– MOs trained in anesthesia
• Training and flow of skills
– System strengthened under DANIDA (1996-2002)
– Managerial and technical skills
• Strengthening of feed back and correction
systems
– verbal autopsies
– Vital events surveys
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The initiatives– Flow of Management skills
Initiative
Creator of
knowledge
Exchange
mechani
sms
Storage
plac
e
Transmission
mechani
sms
Retrieval and usage
by
Actions taken
Impact
Verbal autopsies
of
maternal
and child
deaths
UNICEF
Training of
trainers,
administ
rators
Pilot project
Administra
tors,
train
ing
instit
utes
Training
courses,
Documents
Medical officers and
staff, field
unit
administrator
s
Monitoring of
process,
analysis of
data
generated
Corrections in
service
delivery.
Rationalization
of
specialists
posting
Analysis of verbal
autopsies,
administrat
ors at head
quarters
Meetings,
docume
nts
Administra
tors
at
head
quar
ters
Documents
Administrators
Policy of posting
only at
referral units
Functional
referral
units
Functional
referral
transport
Administrators
Analysis of verbal
autopsies
Meetings,
docume
nts
Field level
admi
nistr
ators
Documents
Field level officers,
and
administrator
s
Management of
vehicles
Creation of
awareness in
public
Link with detection
of
emergencies
Reduced
morbidity
and
mortality
of mothers
and
children
Vital events
survey
DANIDA
Training of
trainers,
staff,
officers
Training
instit
utes,
Meetings,
docume
nts and
training
courses
Medical officers,
staff
Conduct of regular
field surveys
Validation of
field data,
better
inputs for
planning.
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Findings
• Focused approach
• Management of key Resources
• Initiatives designed in line with objectives of each
phase
– Phase I -- increase reach of services
– Phase II–
• strengthen feed back and monitoring systems
• Increase number of services
– Phase III— Further extension of services
• Consistent correction of processes based on feed
back
• Increase and align services in line with community
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Discussion
• Organisation is an arrangement of people for
facilitating achievement of some agreed
purpose (Selznick 1949)—
– Economic system which determines internal
availability of scarce resources
– Is an adaptive system reacting to environmental
influences
• Alignment of strategy– strategic change
necessitated by changing environment
and/or business opportunities
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Discussion—Service delivery systems
house to house
survey--CNAA
activity plan
district plan
feed back
state headquarters-Addl director FW
targets
District head
quarters--CDHO
, RCHO
primary health
centre-MO,LT,
FHS
sub centre
MMPW FHW
identification
of high risk
cases
village
--AWW
community
immunisation
initiatives
referrals to
PHC
capital
projects
services at
PHC level,
lab tests
facilities, equi
pment,staffing
FRUs
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FP
motivation
health
education
management of
complications
referrals to
FRU
services at
SC level
MCH
services
management of
high risk cases
special
clinics
specialist
services
institutional
services
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Discussion
• Key resources– have VRIN Characteristics
–
–
–
–
VALUABLE– multiple uses
RARE– Skills for designated services in them only
INIMITABLE– no alternatives
NON SUBSTITUTABLE– no substitutes
• Are crucial for achievement of objectives
• Learning -mechanism for correction and alignment of
processes linked to management of key resources
– Verbal autopsy systems, process monitoring
• Focus of the administrators– manage key resources
– Skill development
– Openness to suggestions
– Consistent development, monitoring and evaluation of
systems
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Strategy process and cognitive architecture
policy makers
planning
resource
allocation
Advocacy
personal
seleciton and
management
training
institutes
health policy
Staff and
Skills
medical and
nursing
colleges
initiatives and
concepts
field units
autonomous
initiatives
infrastrcuture
development
feedback and
monitoring
systems
community
international
and national
agencies
service
delivery
identificaiton
of issues
Strategic
Initiatives
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headquarters
administrators
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TENTATIVE OPERATIONAL FRAMEWORK
SERVICE/GOODS
DELIVERY CHAIN
LEARNING
Sensing, Monitoring,
Evaluation
Development
STRATEGIC
ALIGNMENT
RESOURCES
REQUIRED
CUSTOMER
NEEDS
STRATEGIC
RESOURCES
PERFORMANCE
MAINTAIN STRATEGIC
OTHER
RESOURCES
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RESOURCES
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Conclusion and Contributions
• Learning – instrument used in Achieving
strategic alignment
• Contributions
– Clarified role of learning in achieving performance
over time
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Limitations and Future Research
• Single case study based study
• Limited to context of health care and RCH
programme
• Needs further testing to validate frame work
• Can perhaps assist in development of an
integrated model of organisational learning
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THANK YOU
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