The current study levels the performance capacity of the health system workforce towards integrated L+M+G practices. It also identifies predictors related with this performance capacity. These are done after developing and testing a four-factor measurement model.
This measurement model provided from a study done in Ethiopia can catch the attentions of the health system workforce at all levels, particularly in low and middle-income countries [4, 11, 12, 14]. In fact, the workforce in such countries are assigned to ensure UHC in an increasingly socially, politically, economically and technologically turbulent ecosystem[4, 5]. These turbulences might be overcome by empowering the health system workforce towards integrated L+M+G practices, using scientifically reliable and empirically scalable models.
This concept is supported by some studies, which report that capacitating the health system workforce with the 12-practice integrated L+M+G framework improves the Key Performance Indicators (KPIs) of health services[22-25]. Nevertheless, few other studies report that there exists significant duplications among the practices assembled in the 12-practice framework[22, 28]. This might emanate, on one hand, from the rhetoric that accounts these paths as separate[17, 18, 21], and on the other hand, from the lack of using statistically reasonable techniques in modeling the 12-practice framework.
Thus, the current study answers the existing gaps in modeling integrated leading-managing-and-governing practices, through three main actions. Firstly, these authors collected the data using the multi-item questionnaire that incorporates a representative number of items from the three none hostile paths. Secondly, they employed a statistically reasonable technique that is factor analysis with varimax rotation in extracting factors. Finally, they developed a measurement model by assembling these four factors together with the items rated and error variances observed.
In the meantime, to make this measurement model more meaningful, the four factors extracted (table 5) are labeled based on the contents that the factor loadings reflect[36-38]. The first factor is named as compliance with principles. The word compliance describes act of acquiescing with a set of rules and the term principle explains accepted rule of action. Thus, compliance with principles could be stated as ability to act with accepted set of rules. The second factor is labeled as strategic sensitivity. Here, strategic describes mindfulness about mission and vision and sensitivity refers to strong attention. Hence, strategic sensitivity might be operationalized as intensity of mindfulness towards mission and vision. Likewise, the third factor is termed as system building. System means group of interdependent components that form unified whole and building refers to improving interactions among the components. Therefore, system building might possibly referred as ongoing process of improving interaction among the components. The final factor is denoted as contextual thoughtfulness. The term contextual refers to state of exploring conditions regarding to the environment and the word thoughtfulness describes deliberate thinking before doing something. Accordingly, contextual thoughtfulness can be defined as deliberate thinking in exploring conditions regarding to the environment.
The measurement model is also tested for reliability and validity through the values of CR and AVE (table 6) respectively, which in general show that groups of items assembled in the model are nicely loaded. In addition to the CR, the reliability of the model is checked with the total variance explained (table 4), in that the value for the first factor is quite larger than the next factor . Similarly, the validity of the model that is the variance is due to the construct, but not due to the measurement error is reaffirmed with the correlation coefficients (table 2), besides the AVE. At this point, the correlations are significantly different from zero showing convergent validity, and the items are highly correlated with higher number of times within their own factor compared with the items of the other factors demonstrating divergent validity[39, 40, 42, 44].
Generally, the current measurement model is acceptable in that: all estimates sound well, all estimates are above .5, CR for all factors is above .7, the total variance for the first factor is quite larger, AVE for all factors is above .5, and items are highly correlated with higher number of times within their own factor.
As noted earlier, the current study levels the performance capacity of the health system workforce towards integrated L+M+G practices as low, moderate, high, and very high. This leveling base the categories that are indicated in the health system workforce performance appraisal guideline of Ethiopian.
Though limited in scope, some studies report that the health system workforce capacity towards leading or/and managing or/and governing practices improves the health service outcomes[1, 12, 22, 23, 26, 27]. Nevertheless, these studies would not report levels of capacity, as well as, the degree of considering the three paths in assessing it. These might be due to the belief that leadership, management and governance have been accounted for a small number of actors, perhaps only those who are legally authorized; and the dearth of representative integrated models respectively. These indicate that there should be a breakthrough that shows the importance of performing the three paths in an integrated way, using scientifically reliable and empirically scalable models, by recalling that the entire reason being human is leadership or ruler-ship regardless of situations and hierarchies.
The current study also models the relationship between the outcome variable and its predictors including socio-demographic characteristics, by employing ordinal logistic regression (table 7). Sex and responsibility, as well as, the six items treated as predictors such as: (1) look for best practices in the last 12 months; (2) match deeds to words; (3) set annual and strategic organizational plan; (4) allocate adequate resources for work; (5) develop a structure that provide accountability and authority; (6) provide appropriate feedback, are significantly related. Whereas, age, educational level and service year are appeared insignificant.
Though, few literatures hypothesize determinants (measuring items) for each of leadership, management and governance separately[18, 20, 46], yet, how they are correlated and modeled, even within the respective path, have not been tested and reported.
Regarding to leadership, among many contributors, Richard Denny in his book reports 12 determinants: level of organizing details, the stand of the people to do what they would ask another to do, expectation of what people paid for, perception towards colleagues, level of creativity, self-perception, indulgence, level of loyalty, leadership approach, title and expertise, environment, and common sense.
Likewise, Henri Fayol reports about 14 determinant principles of management: division of work, authority and responsibility, discipline, unity of command, unity of direction, subordination of individual interest, remuneration, the degree of centralization, scalar chain, order, equity, stability of tenure of personnel, initiative and esprit de corps.
Moreover, a synthesis paper on effective governance for health revealed 10 determinants of governance: leadership, corruption, management, transparency, accountability, systems to manage data, participation of key stakeholder, political context, check and balance strategy, and financial resources.
The above exemplifications clearly show that one path is even accounted as determinant for the other path. For instance, leadership and management are mentioned as determinants of governance. Additionally, regardless of the level of specificity, most-perhaps-all of the characteristics mentioned as determinants in one path have a twin concept in the other paths. For example, common sense, unity of direction, and participation of stakeholder are similar concepts, but mentioned as determinants of different paths. This is the other reason, in that the current study develops and tests the above mentioned four-factor measurement model, considering representative items from each path.
Moreover, other than used as hypotheses, the report of the above and the like literatures would be helpless. Particularly, when people or organizations need to develop capacity building policies and strategies based on socio-demographic characteristics, in which their relationships with the outcome variable are nevertheless modeled. Hence, to illustrate the gap and provide a founding information, the current study models the relationships between the outcome variable and its predictors, particularly socio-demographic characteristics. For instance, being male workforce has a higher performance capacity towards integrated L+M+G practices compared with female workforce (table 7). This deviation might be arose from that, limited number of females are legally authorized to lead, manage and govern organizations, mainly in developing countries including Ethiopia. In such countries, this has a historical trend, in which breaking it and bringing adequate number of females to the stage is a troublesome investment. However, almost 50% of the participants in this study are females, which might indicate that considerable number of the workforce in the health facilities are females. Thus, whatever reasons people have, without empowering half of the segment of the workforce towards integrated L+M+G practices, getting organizations to the intended stage would be rather impossible.
The other significantly associated predictors (most at P = .000) as indicated in table 7 are the six items that are trimmed from factor analysis, and fitted to ordinal logistic regression analysis. This implies that, in scheming capacity building policies and strategies, as well as, designing further research, nesting them within the biologically plausible factor would be more meaningful. For example, among the six items that are significantly related with the outcome variable in the current study: item 1 can be captured by contextual thoughtfulness; item 2 can be enclosed within strategic sensitivity; items 3, 4 and 5 can be nested within system building; and item 6 can be contained by compliance with principles.
Away from all the implications, the dearth of available literatures that either develop or test integrated measurement model, level the performance capacity of the health system workforce towards integrated L+M+G practices and identify predictors, particularly socio-demographic characteristics that affect it, had limited the depth of our discussion.