Management System and Performance of the Catholic Organization for Health in Cameroon: An Integrative Literature Review

Management System and Performance of the Catholic Organization for Health in Cameroon: An Integrative Literature Review

Eugénie Yvette NGA EBOLO^1*, Benjamin Alexandre NKOUM²

¹Inf; MGHS; PhD student in Public Health, School of Health Sciences, Catholic University of Central Africa
²PhD in Educational Sciences; Professor, Director of the Doctoral Training Unit of the School of Health Sciences, Catholic University of Central Africa

Received Date: June 21, 2022; Accepted Date: June 29, 2022; Published Date: July 05, 2022;
^*Corresponding author: Eugénie Yvette NGA EBOLO. Inf; MGHS; PhD student in Public Health, School of Health Sciences, Catholic University of Central Africa. Email: yvebolo14@gmail.com

Citation: EBOLO E Y N, NKOUM B A (2022) Management System and Performance of the Catholic Organization for Health in Cameroon: An Integrative Literature Review. Adv Pub Health Com Trop Med: APCTM-169.

DOI: 10.37722/APHCTM.2022302

Abstract
In many developing countries, poor health systems are one of the main barriers to accessing essential care. However, poor countries are not the only ones experiencing problems related to their health systems. In some high-income countries, a significant proportion of the population does not have access to health care because social protection systems are not always equitable. This literature review, conducted on the basis of thirty-five (35) selected studies and whose objective was to draw up a state of knowledge on the audit of the management system of a health system, revealed that the exercise of the audit of the management system of a health system is not simple and that its practice requires the appropriation of basic tools that the actors involved must master. In addition, the idea of evaluating a health organization is nourished by the principle of optimizing its performance from an effective management perspective. Given the legitimate divergences that may exist, in terms of approaches and objectives, it is up to the researcher to choose the precise form of evaluation tool/procedure that would best achieve the intended objective. Also, as part of this research work, the model of the "self-assessment grid according to the ISO 9001: 2015 standard", would be a suitable tool for the audit of the management system of the Catholic Health Organization in Cameroon, subject to its ecological validation. Based on this tool, the present doctoral research would be structured around the following research question: what is the place of auditing in the management system of the Catholic Health Organization in Cameroon?

Keywords: Audit; Health System; Management System; Performance

Introduction
Over the years, health care systems are gradually improved and have become more and more, complex structures where qualified peoples are needed to efficiently manage the different sectors involved.

In many developing countries, poor health care systems are one of the major obstacles to having access to essential medical care. However, poor countries are not only the ones facing health care system issues as a large part of the population of some rich countries are unable to get access to medical care because the social protection systems are not equal. In other countries, we can see that the money spent in care systems has increased because of the inefficient use of resources (WHO, 2019). An observation which implies a paradigm shift in the management and functioning, funding and distribution of resources as well as accountability frameworks and public health care system actions (Vainieri et al., 2020).

The World Health Organization (WHO) Human Resources for Health Strategy to 2030, adopted by Member States at the World Health Assembly in May 2016, recognized the need to strengthen the capacity of institutions at the subnational, national and international levels and to take the necessary steps to ensure that they effectively exercise governance of human resources for health actions (WHO, 2016). According to the WHO, health staff are at the core of the health care system and remain the major element we need to work on in order to reach the expected outcomes (Nxumalo and co., 2018b). Although all these elements are important for the smooth functioning of the system, « health systems cannot function without a health workforce; improving the coverage of health services and realizing the right to the highest attainable standard of health depend on the presence, accessibility, acceptability and quality of health personnel » (WHO 2016,p.8).

However, being a good health and/or medico-social staff, general practitioner, pharmacist or nurse, does not necessary mean that you are a good manager. You are not born a manager, rather you become. It requires new abilities such as human resources management, team leadership as well as economic and financial management of the structure, department and pharmacy (Benoit, 2019). Being in charge of the health care system performance is a permanent challenge. In fact, the health care system faces coordination issues of its components concerning an efficient mobilization of resources allocated to it, like taking into consideration the quality of service for service users and/or communities. Management practices are expanding and there are also many people/stakeholders involved in management at health organizations. Also, it is difficult to get knowledge and abilities considering these challenges (Louazel et al., 2020). That’s why it is important to set up Management System Performance (MSP), where one of the main components is the performance assessment of all the participants in the management system for its improvement. (Nxumalo et al., 2018a).

With this in mind, an exploratory survey conducted in April 2021 among the coordination team of the OCASC (Catholic Organization for Health in Cameroon) reports on: problem of supply of medicines, medical consumables, equipment and logistical means; difficulty in having the information necessary for decision-making; problem of instability and lack of human resources; and the problem of the financial accessibility of users to health services, in particular a considerable burden related to the care of the indigent, borne by the health facilities of the OCASC network.

Elements that all reveal a number of shortcomings in the management of this health subsystem, particularly in the field of Human Resources Management (HRM), financial management, the Health Information System (SIS) and the supply of medicines/consumables/medical materials and equipment- and which require a careful examination of the management system of this organization, before considering any reform action.

Also, the central question that underlies this literature search work is the following: What is the state of knowledge on the audit of the management system of a health system? Its objective is to draw up a state of knowledge on the audit of the management system of a health system, and in a specific way:

Describe the process of auditing the management system of a health system;
Highlight the place of a management system audit in a health system;
Establish the relationship between the management system and the performance of a health system.

Method
The method consisted of an integrative literature review as outcomes and/or recommendations and combinations from several sources (Arbour, 2013). Therefore, assertive data approbations (narrative, systematic and meta-analytic), empirical studies, theoretical articles (experts’ points of views), reading of reports (WHO’s report, Minister of Public Health etc…) have been considered at the same level to respond to the main question.

Literature research has been conducted in order to identify all the available studies related to the topic through WHO data bases (Hinari, PubMed, Global Heath, Google Scholar, …) and grey literature. An example of a research/research equation, bringing together different key concepts and other synonyms in English, have been formulated with the help of Boolean operators (AND, OR) as follow:

((« Management system » OR « administration system » OR « governance system » OR « direction system ») AND (Performance OR efficiency OR cost-effectiveness)) AND (« Health system » OR « Health organization ») AND (Audit OR Examination OR evaluation OR assessment OR review OR diagnosis)).

The introduction of this equation in the digital databases has produced 1462 references, that is 467 corresponding to the inclusive criteria (English or French language studies for ten (10) years and from health management). After some studies which have been selected twice, or not having relevant interest on this research have been removed, we ended up with a final sample of thirty-five (35) studies submitted to our analysis and discussion of this literature review. Among this final sample, we have 29 integral texts and 6 summaries. The obtained outcomes/ the outcomes (books, articles, reports) have been classified in a virtual library by the software Zoreto.

The selection of the documents with this different element /structures has been summarized in the following flux diagram-PRISMA.

Outcomes
The thirty-five (35) studies selected have been carried out from 2012 to 2021 in 16 countries and three (3) region members of the WHO. These studies have been done by: (42.86%) of an empirical study; a systematic review (37.14%), a theoretical study (14.29%) and PhD thesis (5.71%) as seen in the table below.

Years Study	2012	2013	2014	2015	2016	2017	2018	2019	2020	2021	Total
Empirical study					03		01	04	05	02	15
Theoretical article		02						01	01	01	05
Systematic review	01		02	02		01		02	05		13
PhD thesis								01	01		02
Total	01	02	02	02	03	01	01	08	12	03	35

Table: Summary table of studies per type and per year.

Management system audit process of the health care system

Management system audit process of health systems can be defined as a set of combined activities for a good implementation of the system management in the health system. Its goal is to check if the system goes in line with the requirements of its own mission and the efficient implementation of disposition in order to reach the goals set. It is about the diagnostic assessment process of the general performance of the management team by an objective and complete inspection of the organizational structure, staff, plans and politics, operation, as well as the use of physical facilities and various resources (human, financial, material and others) (Jonquières, 2020).

According to the NF EN ISO 9001: 2015, the management system audit process can be an organization of the components of the system depending on the cycle PDCA (Plan, Do, Check, Act), based on Deming’s wheel. The idea is to repeat four 4 phases: plan, do, check, act when we have not reached the results expected. (Danièle, 2018).

Plan: set up the plan, select a topic, set measurable goals and choose the method to achieve the goals.
Do: implement the plan, inform the staff and train them, when necessary, implement the method adopted.
CHECK: check the results, going through the results obtained by checking if the work has been done according to the method specified at the first stage, if the processes set up comply with the expected results and the requirements of the quality are the same than the expected value targets.
Act: improve/act: start corrective action or continue to maintain the results obtained.

Thus, if the work is not in line with the rules established, corrective actions shall be taken. In case of any problem, we need to see where it comes from and take adequate action to avoid it again. Scale up the systems and working methods (Danièle, 2018).

The use of a number of instruments and/or devices to check if the actions undertaken by the organization are in line with the goals set are required for the implementation of the system (Hassani & Moussali, 2020).

Example: Self-evaluation scale according to ISO 9001 standard 2015.

This instrument helps to evaluate the gap between the real practise of quality management system as well as requirements and recommendations of international standard. Therefore, the department considers it as an instrument that assists health care management to highlight all the improving actions to be carried out. The programme based on the evaluation plan of the management system, as mentioned in the PDCA plan, can be used as guideline for an internal, external or self-evaluation audit.

Generally, many actions and good briefs help to immediately get the results needed by the auditor for the reset of the programme. It is on Excel format with various windows: Opinion expert (4 rating levels: good, acceptable, to be upgraded and poor); Whole outcomes; Outcomes per chapter (Qualiblog.fr, 2015).

The importance of the management system audit in the health system

Audit management system is a core part of the supervision and management of an institution and it is considered as either internal or external, first, second or third audit. The audit management system helps the top management team to get crucial components of the current management system “health condition” (Jonquières, 2020). In a broader point of view, it is a critical assessment of the organization’s management to improve efficiency and performance (« Management Audit », 2020).

In the public health sector more than other sectors, assessment cannot be separate to the action undertaken and its approach involves the knowledge of some basic notions with specific questions. Its goal is to: prove by using comparative methods, the supposed efficiency of some response strategies (assessment research) and check the performances given by doing the said response strategies (Lajarge, 2017). In this perspective, the management system audit is an important activity for any health system. The responses proposed by the auditor aims to promote the increase of outcomes and improve health care service in general, they also contribute more specifically to empower management teams in functioning (Liberatti et al., 2019).

To improve health system performance, some assessments need to be done especially of its management system to check if the goals set have been achieved. Once the assessment has been done, decisions must be taken in order to pass a policy, set priorities, ensure key stakeholders’ participation, take adequate measures for the capacity building management of the health care system management and the health care system in general (WHO and al.,2019).

Management audit is a key element for a better management system. It helps the management team of a health organisation to successfully carry out their works and to achieve the goals set to ensure continuous improvement (Benchehida, 2020). After putting in place the management system, “assessment” is a crucial moment in the continuous improvement process and a good opportunity to do a critical assessment of the whole system. Made on a regular basis by the management team involved, the health organization’s management assessment specifies actions to be carried out to achieve and adjust a policy as well as goals. Furthermore, it helps to make useful adjustments to improve the management system. Data analysis of management system assessment is a specific action which helps the manager to adjust its strategy with a view to permanently place the organization in a continuous improvement dynamic. It is a fundamental tool in the improvement of health care management system performances (Friderich, 2019).

The connection between health care management system and health care system performance.

Organizational management is a process through which a company is organized for a proper and efficient development. In a globalization context, health organizational management is characterized as a complicated perspective where a permanent improvement of its performances is needed (Nkoum & Socpa, 2015).

A study carried out in 36 rural districts and 226 health centres in Ethiopia reveals that health centers with a management capacity above the median have significantly better performance on the summary score of the key performance indicator (73% versus 60%, respectively), statistically significant p-value (p <0.01) and also higher KPI synthesis scores (70% versus 62%). In addition, the managerial capacity of these health centres has been significantly tied in with a good performance (Fetene et al., 2019). At the same time, the analysis of the relationship between managers’ competences and the organizational performance in the public health care system enables us to see that managerial competences are positively linked to the organizational performance and play a key role on all the performances. Therefore, once the good connection between the management team perception competences and performances have been taken into consideration, the margin was statistically significant with a gain of < 05. An increase of 1 point on the managerial competences perception has been combined to the increase of the 0.628 global net result (Vainieri et al., 2019).

A study regarding the connections between instabilities characterizing the managerial competence of the manager and the organizational performance, reveals that the organizational performance when it has been well known by a commercial performance (Y2) is perfectly and significantly connected to the threshold of 1 % with X1 (manager efficiency) and X4 (strategy for client satisfaction). This performance is also perfectly connected to the threshold of 5% with X6 (manager professional conscience). Concerning explanatory variables which are different from each other, there is firstly a positive and significant relation at the threshold of 1% between the manager efficiency (X1) and the strategies for client’s satisfaction) and secondly, the capacities of the manager to be creative (X2), flexible (X5) and professional (X6). Therefore, it becomes a must for all companies to identify, train and keep all those who might be efficiently and effectively able to achieve its goal (Boubakary et al., 2020).

Another study reveals that there is a poor and significant relationship at the threshold of 10% between the managerial strategy and organizational performance when it is assessed by the economic output. Therefore, the organizational performance goes down when the managerial strategies set by the managers are poor. A poor and significant relationship has also been observed between managers’ flexibility and organizational performance at the threshold of 5% when it is impeded by the economic output. With this result, we notice that the output goes down when managers are not flexible. Emphasis is put on the ability of companies to adjust themselves to the development. With the rising of a competitive environment, a globalization of thoughts and communication, it is now urgent and even important for health organizations to achieve their flexibility (Tagne et al., 2021).

Moreover, the results of an analysis of the linear regression carried out during this study (Boubakary et al., 2020) which aims to try research hypothesis written between the variable to be explained (organizational performance) and different explanatory variables, shows that the success of a company comes from the exploitation of a single factor that they have (key strategy and competency resources). Its role is to identify, convince those who have them, develop and promote them through adequate strategies with a view to make its stay for long (Tagne et al., 2021).

For a health care system, output is the ability to put together available resources in order to improve the health system, to develop its ability to consider the population expectations and reduce the unequal financing of the system. In addition, when it concerns the health system improvement, the development of managerial competencies has a significative impact on the health system management. Health care system performance and system management are closely related (ISO, 2016).

Discussion
The audit management system process analysis shows several approaches in literature justifying the need of a reference framework to form/model the elements of the system and set the dimensions to be assessed (Vrijens et al., 2014). It also exits different performance models which can be strongly generalized because they are only pertinent in their context. None of the tools used for an audit process were considered good because sometimes they used indicators which were not really representing the audit process, a high level of reluctance/ignorance in the theory leading to the absence of specific contextual details. Information which could have come from another level in some studies have been left out, because there was a way out, samples were taken on purpose, with only informants who probably owned the data needed to examine management abilities of health managers Tetui et al., 2016). It is also very important to note that these tools are constantly upgrading due to the increasing of management systems standards as well as cultural and technologies changes, leading therefore to the need to always update them (Jonquières, 2020). On the other hand, it is noted that management audit is not easy and the person in charge needs to master the basic tools to do it. In that way, the assessment of the health system performance has proved to be a challenging task since it is difficult to come out with an agreement on what people consider to be part of the performance and what we have to assess, because the word performance is a vast and abstract concept (Tagne et al., 2020).

Regarding the place of the management system audit in the health system, the documentary review brings out that the management system audit is a crucial component in improving services in the health care system. A poor health care system derives sometimes from the tension between the stronger demand for good health care system as well as financial and material constraints in the health system, the assessment of the effectiveness of the health system management is crucial to its survival and is itself a difficult issue (« Améliorer la performance des systèmes de santé », 2018). The assessment of the management system of health systems remains difficult especially because of the lack of clarity in objectives by the authorities who always bring out constant approaches and update indicators. In addition to the diversity of the stakeholders involved in the performance assessment, one of the obstacles is also the lack of consideration and the absence of means test gathered in the process which were needed to achieve the expected results. That makes us believe that despite the development of the initiative in the performance measure of health systems, they are still in the experimental stage and more needs to be done to take advantage of their full potential (Sebai, 2015). Moreover, the gap between rich countries and poor countries in the assessment process of health systems management abilities, reveals the importance of the environment and the national wealth and the importance to look at other components which will promote the assessments of good elements depending on each country (OMS, 2020). As the word performance has several meanings and functions by the choice of criteria helping us to assess the managerial practices or the activities of the whole health system (Nkoum, 2020).

Concerning the relationship between the management system and health performance system, most of the studies selected have made a close connection between health system management and health system performance without forgetting the importance of the management ability in the health sector which is increasingly being recognized. However, some studies with lowest samples cannot be generalized, that makes the assessment more approximative than comprehensive. For example, mitigated data on health results and health service access related to the decentralization. Those data are a thread on the management qualities and political process which can encourage or be an obstacle to the performance improvement (Witter et al., 2019). At the global level, the acquisition of skills in management and organizational performance has emerged in the efforts to improve local health systems as well as health results of people and the populations. Considering the results of the different studies, especially in terms of management capacity building in order to improve health system performance, we can say that much needs to be done. A limited managerial autonomy as well as the obstruction in managers responsibilities and abilities to take decisions happen because of the inconsistent political ideas by the authorities in charge which are sometimes out-of-date, outdated legal frameworks and long administrative procedures. Internal challenges and restricted managerial, operational and financial strategy in healthcare institutions, make financial and general performance difficult (Duran et al., 2019). Performance assessment derives from the tension between the stronger demand for good health care systems as well as financial and material constraints in the health system, the performance assessment of the health system management is crucial to its survival and is itself a difficult issue (« Améliorer la performance des systèmes de santé », 2018).

Conclusion
In an ever-changing world, the evaluation of a health management system is an initiative that is no longer to be demonstrated, as it establishes a framework that allows for a re-examination of the functioning of the system, in order to identify areas of weakness that may require corrective action.

This literature review, conducted on the basis of thirty-five (35) selected studies and whose objective was to draw up a state of knowledge on the audit of the management system of a health system, revealed that the exercise of auditing the management system of a health system is not simple and that its practice requires the appropriation of basic tools that the actors involved must master. Tools in perpetual evolution due to the multiplicity of reference systems of management systems and technological innovations (Jonquières, 2020). The purpose, mission, vision and values of the organization to be audited are all elements to be taken into consideration, in order to identify the specific points on which action is needed, in order to contribute to its achievement of the sustainable development goals in terms of health. Given the legitimate divergences that may exist, in terms of approaches and objectives, it is up to the researcher to choose the precise form of evaluation tool/device that would best achieve the intended objective. Also, as part of this research work, we think that the model of the "self-assessment grid according to the ISO 9001: 2015 standard", would be a suitable tool for the audit of the management system of the Catholic Health Organization in Cameroon, subject to its ecological validation, because it was developed for a company and not a health system. Based on this tool, the present doctoral research would be structured around the following research question: what is the place of audit in the management system of the Catholic Organization for Health in Cameroon?

References