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The Government of Egypt has made tremendous strides over the last three decades in improving
the health of its citizens; but problem areas remain. Compared to many other Governorates
in Egypt, the health indicators for women and children in 2000 were poor in the Aswan
Governorate. For every 100,000 live births, 135 women died in childbirth. For every 1,000
live births, 27 infants died before their first birthday, and the family planning needs
of nearly one out of every five women were not being met. The primary issue in this situation
was not lack of funding, medicine, or technology; it was the lack of empowerment, inspiration,
and commitment among the frontline healthcare workers. Healthcare staff were not available
all of the time, patients were frustrated, and most seriously, those whose health was
most fragile were not getting prompt and adequate care. "I have been here since 7 o'clock in
the morning, I have my son and the papers and I cannot find anybody." The Aswan Health
Directorate recognized that the root cause of the problem was the lack of leadership
at all levels of the healthcare system. To help the Aswan Governorate address these concerns,
in 2002, USAID's Office of Population and Reproductive Health sponsored a Leadership
Development Program, co-led by Management Sciences for Health and Egypt's Ministry of
Health and Population. A new approach to leadership development was introduced in Aswan, one that
focused on teams of healthcare workers and not individuals. "The Leadership Development
Program is different from different programs in many aspects. It is a process over time.
It is learning in action. It is a process of attitude and behavior change. It is a combination
of workshops and team meetings in their workplaces to be in action and to implement activities
with their teams and with their communities to make a difference and to produce better
service results." The Leadership Development Program consisted of a series of one- and
two-day workshops spaced over a few months. In the workshops, teams learned leading and
managing practices and applied simple planning and management tools that could help them
succeed. Between workshops, the team used what they learned in their local settings:
scanning their environments to understand the health challenges in their communities,
and then planning and prioritizing the actions they needed to take to address the primary healthcare
challenges. The program was launched with ten teams of health personnel. They focused
on addressing needs in family planning, and maternal and child health and began showing
measureable results in the first year. At the end of one year, the funding for the program
was finished but the program participants decided to continue the Leadership Development
Program on their own, taking it to new teams and health facilities in the Aswan Governorate
using their own resources. "We didn't know anything about this program in the beginning,
and we didn't know anything about improving leadership skills. We didn't realize how important
this program was." "Before, everybody was working on their own. If I was responsible
for something, I was doing it without coordinating with other people." "People started to think
about how to improve, how to create things. In every workshop we used to just sit and
listen." "In the beginning of the training, the nurses used to come and sit like wooden
chairs, there were no comments, no discussion and this is something we were complaining
about in other training programs. But now, with this program there is a big difference.
The nurses have started to act, to discuss, and even to get up and give a presentation."
"Through this program we started to think, "What am I going to say?", "How am I going
to participate?", "What am I going to contribute in the coming team meeting?", "How can I become
aware of situations around me so that I can explain them in the meeting?". Then we started
to think, "What are the obstacles at the center, so that we can improve our services to women
and children?" We started to realize that we had capacities that weren't used. We started
to make requests for support from people who could help us." "After the leadership program,
things changed. Each of us had a separate responsibility. Work changed for us." "In
the beginning, when someone was absent, no one would take his place. But now, we all
care about the results that have to be reached every month." "We set a goal to increase our
service capacity, so that we could serve an additional twenty-percent for the family planning
needs of our community. The plan was to increase our ability to serve family planning needs
over six months, from being able to manage 7,500 family planning clients, to being able
to manage 9,000." The heart of the program is a tool called The Challenge Model. It is
used to clarify a team's mission, enable a shared and inspiring vision of the future
they, their colleagues, and their communities want to reach, and identify a measureable
result to move the team toward that vision. Teams analyze their service statistics to
understand their current situation. Then they analyze the causes of the gap between the
current situation and their desired measureable result. With this information, they develop
an action plan or work plan to align and mobilize facility, staff, and their communities to
take them from their current situation to their measureable result and ultimately to
their shared vision, evaluating their progress at the end of set periods of time. The results
speak for themselves. Seventy-five percent of the original ten health teams achieved
95% or more of their desired results, and 80% of the teams selected a new
challenge without being prompted. What differentiates this leadership development approach from
performance improvement and other quality improvement processes is the commitment that
comes among health personnel from creating a shared vision, owning the challenge, working
as a team to apply leadership practices to address the challenge, and taking on ever
greater challenges as they gain experience and confidence. "When we started the program,
we pursued our challenge to reduce unmet need for family planning and we exceeded our goals,
and we also increased the number of children that were vaccinated." "When a team takes
on a challenge, all of the organization's services get better—even though this team
tackles just one challenge—and that is the proof of success of Aswan."
"I think very highly of this center because I come here all the time and they take care of my children,
and the organization is very good." Each year the self-directed and self-supported Leadership
Development Program grew, expanding to new teams and health facilities throughout the
Aswan Governorate. After 3.5 years, all 185 health facilities in the Governorate
had participated in the Leadership Development Program using local resources and local facilitators.
"In the beginning of the training sessions, I learned what was required and I began to
survey all problems that we had." Dr. Waleed was part of the third generation of Leadership
Development Program and utilized the skills and tools he gained to successfully tackle
the growing healthcare challenge in his community. "One day, a woman came to us and she had her
daughter with her and when we examined her daughter, we found she had a heart palpitation.
The small girl had rheumatic heart disease and when the mother learned that she started
to cry." Dr. Waleed took on the challenge of finding a way to diagnose and treat rheumatic
heart disease among the area's children before it seriously impacted their health. "We started
with two villages that were near each other, and we made home visits." "You are going to
go the village house by house, exactly as you do with the vaccinations." The teams went
into the villages and scanned for symptoms of the disease. They discovered 14 undetected
cases of rheumatic heart disease. Through the efforts of each member of the team, the
disease's advancement in the children was halted before serious heart complications
emerged. "So everyone on the team has their own measurement to determine their success
and to be satisfied with; that is the difference between other training programs and the kind
of leadership development this program introduced." "Thank God all the health care indicators
have improved, and this is important in gauging the program's success, but I personally know
about the success that happens in the units, not through the statistics but through the
eyes of the people who are working there. When I look at the eyes of the worker, I know
from his or her eyes whether they have success or not."
"The leadership program positively affected all of us, everybody who trained in the program. First of all, in my private
life, I used to have obstacles and I didn't know how to overcome them, but after the beginning
of the leadership program I started to make goals to achieve every day."
The Aswan Health Directorate holds annual conferences for Leadership Development Program participants to share their achievements and
the lessons they have learned with other participating teams as well as with central Ministry of
Health and Population officials and local government leaders. "At first I was a participant,
and then I became a facilitator and was able to take the leadership program to other places."
"This project doesn't need money, it doesn't need equipment, it needs the human being,
and a human being in Aswan is a great resource." "Now we can overcome the obstacles that we
face, and now we hope that all the workers, not only those in Aswan, but in other governorates
will do the same things." The success of Aswan started small: from a few local ministry facilitators,
the program has expanded to 35 facilitators who are bringing the Leadership Development
Program to other governorates in Egypt using Ministry of Health resources. The program's
success has even led ministries of health from other countries to adopt its principles
and approaches to empower healthcare workers to lead and manage teams with their own resources.
"Leadership is a life program, it's not time. If you put the seeds of leadership in the
heart of anyone, it continues him and so I hope that the leadership program extends to
other governorates in Egypt. And in Aswan itself, I hope that leadership is not only
applied in the health sector but to other sectors, to education sector and to every
sector in Aswan. This program has a principle of success inside it and I know that this
program can succeed in other governorates and in other countries and I have a good example,
you know that Afghanistan came to Aswan last summer, and they trained in Leadership Development Program
in Aswan, and they went back to Afghanistan and did very good work there.
So we can move this program to many countries because it does not need a lot of money, it does not
need a very big fund, it can be applied in low resource countries
and so it can easily be applied and be moved to another country.The very important thing is that the poor
patients in Aswan now benefit from leadership in terms of good healthcare."
As a result of women having more access to family planning services, receiving more antenatal care and
childcare visits, and having more deliveries by trained medical staff, the healthcare outcomes
in Aswan have improved. "Neonatal mortality, infant mortality, children less than five
years decreased, maternal mortality decreased. All the indicators in Aswan now are very good
and I am proud of that."