“You feel you are participating in change.”
As CEO of Pelonomi Hospital in Bloemfontein, the capital city of the Free State Province of South Africa, Dr. Marcus Molokomme is at two front lines: providing daily care in one of country’s largest cities, and moving South Africa toward wide-reaching goals around HIV, reproductive health and overall access to healthcare services.
In 2014, Molokomme was a member of the first class of ASELPH Fellows (Albertina Sisulu Executive Leadership Programme in Health), South Africa’s premiere health leadership training program. The initiative is a partnership among organizations in both South Africa and the U.S., including the University of Pretoria, University of Fort Hare, Harvard School of Public Health, and South Africa Partners in collaboration with the South African National Department of Health. Funding for ASELPH is provided by The Atlantic Philanthropies, the Elma South Africa Foundation, and USAID.
The overarching goal of ASELPH is far-reaching: to strengthen the country’s ability to meet its health transformation challenges, particularly at the district level.
At the individual level, ASELPH gives health managers an opportunity to learn from each other, benchmark goals against best practices, and develop the networks and resources that will help their organizations thrive. Molokomme spoke to SA Partners about some of the highlights of the experience.
Tell us about some of the things that stood out about the program — what did you learn that you’ve been able to use at your hospital?
The biggest idea is the whole concept of management versus leadership. In one of the first ASELPH modules, Professor Nancy Kane of Harvard University focused on how to analyze your structures — be it a hospital, or a district, or a health facility or a department —and look at how people view management versus leadership. Many of us used these terms interchangeably and that module put it clearly for me what the key competencies of each are.
We did an exercise that I was so fascinated by that a week later, I called a meeting of all the managers at the hospital to do the same exercise. I cut out little colorful cards, and I asked people to write on one card what they believed the key competencies of a manager should be and on another card the same with leadership.
The key points of management that they listed were implementation, monitoring and evaluation. For leadership, the top points were forecasting and benchmarking. It was interesting to see that what we as ASELPH Fellows found during Professor Kane’s class was the very same thing that I found at my hospital.
So the concepts of monitoring and evaluating resonated with both the Fellows and with your hospital staff?
Yes. You can lead people all you want, but the problem will be that, while you find a lot of meetings in hospitals, there’s no implementation, no monitoring and evaluation.
That problem is bigger than any one institution. In South Africa, we are starting to appreciate that implementation, monitoring, and evaluation are our biggest dilemmas as a country. South Africa has the best policies, health-wise, on crime, on social cohesion, on everything, but when it comes to implementation, monitoring is a problem.
We are finding that we as a hospital are just an extension of the problems that we see nationally. So one of the key competencies that I have learned is to be able to look at a situation analytically on the basis of management and leadership and then be able to direct people in the right direction — usually based on what they have decided themselves. People want more than anything to be motivated.
You were part of the first group of ASELPH Fellows. What was the peer interaction like?
There is comradeship in the class. In the selection process, they managed to pick people who can be cohesive as Fellows. Nobody arrived just to defend the status quo. That can be a problem with some of us health managers — we are so beaten up by our environment, from politicians to the media, that we become so defensive. I think this program allows you to leave your defenses outside, to say that we have a need to improve ourselves as managers. To get the most out of the program, you have to be able to come in and say, “I have a problem.” You must allow the faculty and your colleagues to assist you.
This program came at the right time. ASELPH comes as a motivator to health managers, because development in government services is not really a priority. HIV and housing are the main priorities, but developing a CEO is not something that comes naturally in government in South Africa.
I found that while there is a certain level of commonality in the challenges that the Fellows face, our approaches are different. For instance, one of my colleagues from Kwazulu-Natal is running a tertiary hospital similar to mine. Even though it is a smaller in terms of numbers, we are funded similarly so we are able to benchmark on a number of things. We visited each other’s facilities and on a weekly basis we exchange ideas and tools on challenges that we face.
Another colleague, from Limpopo, another province further north, has been promoted to run a health district. The challenges are not the same, but in health, even though the problems might be different, the root cause is probably similar. So I have been able to benchmark a lot with them as well.
In terms of looking at other health programs as models, what has been most useful to you?
One of the key things that stands out is Human Resources for Health [HRH] management. In the past, all of us have just accepted this concept that HRH management is an administrative clerical function. We come up with all these national targets like Millennium Development Goals, but nobody asks, “What do we need to achieve these goals? Do we have the money for it?”
That leaves us with benchmarking with other countries. For the longest of times, as South Africans we always thought that South Africa is one of the richest countries in Africa, so there is not much to learn from anywhere else. I think many of us have suffered for that. But now I tend to look at what is Ethiopia doing, how is Nigeria doing, how is Ghana doing, how is Tunisia doing.
Like for clinical associates, we look mostly to the Tunisian clinical associates’ model for their rural health plan. ASELPH engaged us in analyzing our district health plans and what we knew about HRH, and all of us found interesting gaps and how we were just focused on numbers and standards.
Really, nobody has looked at the specific needs of the townships as we adopt World Health Organization norms and standards. The ASELPH lecturers always encourage us to apply our minds more and look at our dynamics in South Africa. In the final analysis, we should be able to customize concepts and standards to suit our needs. In a country like South Africa, which has the biggest gap between the rich and the poor, and which has public and private health care sectors that are running in different directions, we need to find the South African model that will work.
If you go to Germany and the U.K., they have taken 120 years just to say yes, universal health coverage is done. So the things we are looking at in South Africa, and the time frame we are looking at, are very ambitious.
You grew up in apartheid South Africa and the township political structure. It must be a powerful feeling to be part of the generation of leaders who are bringing change to the country.
ASELPH draws its name from Albertina Sisulu, who was part of a legendary family of important activists. When I was a young boy, she and her husband Walter Sisulu were township metaphors for struggle and hardship. So when this program was introduced I was highly motivated because I could identify with the name it was associated with.
When you are just a practitioner worried about the bottom line and the next patient, you don’t get to appreciate the bigger environment that you are operating within. It’s like you come in, you bow your head, you see a patient, and when you lift up your head, it’s 6pm and time to go home.
ASELPH targets the way we look at the concept of NHI (National Health Insurance) and universal coverage and delivery of health services. Being part of this program, you feel you are participating in change. You are doing your little bit, your little contribution towards the betterment of the health care system in South Africa. That’s an ongoing motivation.
What kind of continuing relationship do you have with other ASELPH Fellows?
We are planning on having a forum outside the formal ASELPH programs and our own network, which we have already created. We can now share experience and solutions in almost real time because of the technology.
You know, we got to attend such a professional class that engages in debates that are well informed and academically based. The issue is how do we take that back to our institutions. Because if our institutions were to behave like we do in these classes, we would far out-perform any private sector health system. Maybe that is the challenge.