Strategic Alignment : Learning As an Instrument of Implementation

Strategic Alignment : Learning As an Instrument of Implementation

ALIGNMENT OF STRATEGY : LEARNING AS AN INSTRUMENT OF IMPLEMENTATION B.V.L.NARAYANA Structure of presentation Problem identificationtrigger Literature review motivation for study Methodology The case Findings Discussion Conclusion and Contribution Limitation and future research avenues 02/26/20 2 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 02/26/20 3 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 % 02/26/20 Source : National health profile 2006, NFHS 3(2005-06) 4 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 02/26/20 5 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 02/26/20 6 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) 02/26/20 7 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 02/26/20 8 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 02/26/20 9 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) 02/26/20 10 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 02/26/20 11 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 02/26/20 12 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 02/26/20 13 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 02/26/20 GOI 14 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 02/26/20 15 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 02/26/20 Initiatives designed to ensure adequacy Skill up gradation and development Effectiveness and efficiency of services Introduction of new services 16 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 02/26/20 24*7 PHCs Upgraded PHCs VHN MO Staff nurse family welfare 17 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 02/26/20 technicians ANM/VHN 400 18 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 02/26/20 19 The initiatives Flow of Management skills Initiative Creator of knowledge Exchange mechani sms Storage place 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, documen ts 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, documen ts 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. 02/26/20 20 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

needs02/26/20 21 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 02/26/20 22 DiscussionService delivery systems activity plan district plan state headquarters-Addl director FW targets District head quarters--CDHO , RCHO house to house survey--CNAA feed back 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 02/26/20 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 23 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 02/26/20 24 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 02/26/20 headquarters administrators 25 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

02/26/20 RESOURCES 26 Conclusion and Contributions Learning instrument used in Achieving strategic alignment Contributions Clarified role of learning in achieving performance over time 02/26/20 27 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 02/26/20 28 THANK YOU 02/26/20 29

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