APPNA SEHAT: CHANGE MANAGEMENT (B)

Dr Shafique-ur-Rahman became Chief Executive Officer (CEO) of APPNA SEHAT, a

health sector NGO, in 2002. A year passed before he was finally able to buy-in support
from the Chairman and Board of Directors regarding the policy of the institution to phase
out existing health units. However, the implementation stage involved multiple decisions
regarding the policy of relieving 225 employees of 45 existing units, while maintaining the
morale of the current workforce. Dr Shafique had to ensure transparent organizational and
procedural justice in the laying-off process due to strong opposition from a former
contender for his post. Moreover, a large number of employees had appealed to him on
economic and social grounds to reconsider his decision of phasing out the units. In such a
politicized environment any miscalculation on his part could jeopardize his career and the
future of the organization.

BACKGROUND

APPNA SEHAT was formed in 1989 as a subsidiary of Association of Pakistani

Physicians of North America (APPNA-USA). This forum, established to organize
Pakistani physicians in America as a community, had a membership base of more than
4,000 doctors. APPNA-USA generated funds from its membership. The idea of
philanthropic intervention originated from APPNA-USA, and its first activity in Pakistan
APPNA SEHAT Pakistan was initiated. The objective of this organization was to improve
health conditions in rural Pakistan through social organization, awareness and capacity
building of rural households. The idea was inspired by a study aimed at evaluating current
health conditions in Pakistan. This study identified that the focus of health related efforts
was on curative measures rather than on preventive measures. To adopt preventive
measures, APPNA launched this program of Scientific Educational Health Administrative
Training (SEHAT1).

This organization followed a model of organizing and training local stakeholders,

primarily in preventive health, along with manageable curative measures at grassroots
level. Further, sustainable arrangements were worked out in consultation with local
stakeholders to phase out mature units and move on to the next area. This phasing out
policy would enable APPNA SEHAT to broaden its base of beneficiaries within its limited
resources.

1
Sehat means health in Urdu

This case was written by Muhammad Nadeem Dogar to serve as a basis for class discussion rather than to
illustrate either effective or ineffective handling of an administrative situation. This material may not be
reproduced in any form without the prior written consent of the Lahore University of Management Sciences.
Certain identifying information may have been disguised to protect confidentiality. This research was
conducted by LUMS-McGill Social Enterprise Development Centre and was funded by CIDA.

© 2007 Lahore University of Management Sciences

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APPNA SEHAT selected four districts of Pakistan, Mardan, Murree, Sahiwal and Badin to
establish its regions. Each region was managed by a regional director who worked under
the CEO based in Islamabad. The CEO was appointed by the Board of Directors of
APPNA-USA (see Exhibit 1 for the organization structure).

Regional directors were required to be doctors with an MBBS degree so that they could
implement APPNA SEHAT interventions effectively. Mostly regional directors had been
managing their regions for the last ten years. One of the regional directors, who had been a
contender for Dr Shafique’s position, was very influential in his region. Dr Shafique had
known him for several years and knew his strengths and weaknesses. This director was
vehemently opposed to the current policy of phasing out mature units, and mobilized
support within the organization against its implementation.

PROGRAM

The APPNA SEHAT program was based on its philosophy of self reliance while striving
to achieve objectives of reducing the morbidity and mortality rate among marginalized
populations.

Philosophy

APPNA SEHAT adopted an approach of self-reliance by mobilizing and utilizing local

resources at an optimum level. The philosophy rested on two principles: APPNA SEHAT
should not create any dependence for local Health Markaz2 in terms of funds generation
and technical assistance. In addition to the first activity APPNA SEHAT should create
awareness, and mobilize local resources to ensure financial and technical sustainability of
these projects.

Objectives

APPNA SEHAT had established the following goals:

1. To reduce the morbidity and mortality rate among households which were at
greater risk
2. To improve child and mother health by creating awareness through preventive
measures
3. To establish linkages among different service delivery organizations to maximize
synergies

Interventions

Details of APPNA SEHAT’s seven interventions are shown in Exhibit 2.

APPNA SEHAT’S POLICY

As per organizational policy, a unit was expected to achieve a certain level of improved
health and development indicators within three years of its establishment, after which it
was to be phased out of the active program. The objective of this policy was to cover a
maximum number of households through expansion within limited resources. As soon as

2
Health Markaz means a health centre
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units were phased out financial inputs would be withdrawn. However, technical assistance
would remain available to ensure sustainability and knowledge transfer through on-going
capacity building of local people. There were 45 units that needed to be phased out across
four regions; 14 in Murree, 12 in Mardan, 13 in Sahiwal and 6 in Badin.

While studying the policy documents, Dr Shafique realized that these documents just
mentioned phasing out time period and indicators but did not provide any guidance
regarding the phasing out and other employee-related issues. Further, he saw that there
was no record of letters and directives issued by his predecessors.

The current organizational strategy, structure, systems, staff, skills, style and superordinate
goals were as follows:

Strategy

The organization claimed a strategy of leveraging indigenous resources through smart

organization and mobilization of resources by adopting a participatory management style
that ensured proper involvement of key stakeholders (organization, employees, local
communities and direct beneficiaries).

Structure

APPNA SEHAT followed a centralized (bureaucratic) structure in which the main

organizational matters regarding policy and practices were managed by the head office.
The CEO gave directions to the regional directors on a unilateral basis, and the top-down
approach was normally followed (see Exhibit 1). The head office maintained a central
position by retaining financial and monitoring systems (see Exhibit 3). Further, regional
offices also had a highly structured hierarchy (see Exhibit 4). However, the system
regarding strategy and style also depended on personal priorities and values of individuals.
Task-oriented leaders used a bureaucratic approach, and relationship-oriented leaders
adopted a more personal approach.

Systems

Systems were designed to facilitate a centralized management style where regions set
goals and objectives in consultation with the head office. The organization had developed
a computerized monitoring system that provided monthly updates regarding regional
activities. Health indicators were well defined, therefore, detailed and comprehensive
updates were available. Standardized budgets were provided to regions regardless of their
specific activities and operations to ensure uniformity among regions.

Human resources were allocated according to a standard staff allocation among all four
regions. A core staff consisting of a regional supervisor, a training coordinator and social
organizer, an administrative officer, and a finance officer were placed in all four regions.
However, unit staff comprising five people was hired on the basis of the number of units.
For example, Murree had 14 units; they had the same number of core staff but there were
70 employees (5 employees per unit). In the case of Badin, the number of regional staff
was the same as for Murree, but there were 30 employees for the six units.

An internal monitoring system, placed in Islamabad, ensured proper utilization of

organizational resources. However, positions in this area mostly remained vacant, since
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according to organizational sources, no suitable candidates were available. This was

because this position required persons with specialized skills who demanded a salary
higher than the organization could afford to pay. Under the circumstances the current CEO
was doing this additional work.

The organization had no policy or procedures regarding lay-off of employees with

reference to phasing out and did not provide any guidance regarding termination notice
period, incentives and other benefits.

There was no operational manual that provided direction and guidance to organizational
employees regarding their role and responsibilities and organizational expectations.

Staff

According to the current CEO, “We are fortunate to have a team of very committed and
hardworking members. We don’t believe in monitoring; rather we facilitate each other and
do self evaluations”. The employees were motivated to serve marginalized segments of
society through primary health care programs. Normally the staff was recruited locally to
develop a sense of ownership and responsibility among the employees. The local staff was
accountable to the local community. The sense of accountability led to a sense of
responsibility, but it could also lead to alliances and coalitions that might lead to both
positive as well as negative organizational power politics. The roles and responsibilities
were well defined at the regional level. However, there was a certain degree of overlap
between the regional director and the regional supervisor (see Exhibit 5 for
Responsibilities of Regional Director and Regional Supervisor).

Skills

The staff was well equipped with technical skills in the field of health through in-house
training and development programs. APPNA SEHAT also trained them in hygienic
working practices particularly during delivery. The regional staff was selected based on
relevant degrees/diplomas and work experience requirements (see Exhibit 5). The unit
staff comprised one male and two female health assistants, and two traditional health
attendants. The minimum qualification for health assistants was matric. They were trained
in the areas of health related activities such as vaccination and advisory services to mother
and child. Further, they were given training in communication and presentation skills to
ensure effective dissemination of information. A traditional health attendant had to be a
practicing traditional birth attendant and to have good rapport among the community.
Their credibility within the community played a critical role in their acceptance by the
people.

These employees however, lacked management skills. The emphasis on health-related

activities had overshadowed this area, particularly interpersonal skills. The employees
were more task-oriented than relation oriented.

Style

Though APPNA SEHAT claimed a participatory decision making approach, the leadership
style depended upon the preferred style of the top leadership, which was followed by
organizational employees. This flexibility provided both opportunities and challenges. A
bureaucratic style could create problems for self-motivated employees and a participative
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management style could create problems for employees who preferred to get guidance
from the top.

Superordinate Goals

To achieve its mission of serving marginalized segments of society through provision of

primary health care services, values of trust, commitment, and transparency were shared
across the organization. Openness in organizational matters was expected to ensure
transparency and fairness through due process based on merit.

THE CURRENT SITUATION

Dr Shafique’s analysis regarding organizational strengths and weaknesses made him

optimistic of achieving the objectives of the organization because of the dedicated staff.
However, the absence of an operational manual, and guidelines regarding phasing out and
coalition building created confusion. Terminating 225 employees before addressing the
issue of appropriate systems and procedures for termination of services would create
problems for the organization. It could lower the morale of the remaining employees, and
the CEO might lose his position if he mishandled an important issue such as this. Dr
Shafique felt that he needed to set priorities in terms of changes, since at this stage it
would be very difficult to restructure the whole organization. However, organizational
analysis convinced him that it was important to bring changes in more than one area to
bring alignment between organizational structure, systems, staff and superordinate goals.

ISSUES

The first issue was regarding the scope and level of change. Dr Shafique was wondering
whether he should go for large scale changes or for incremental changes.

The second issue concerned procedural matters for the termination of employees.
Furthermore, a decision was needed whether all 45 units would be phased out at the same
time or whether they should be phased out gradually.

Thirdly, he was also considering how to communicate the restructuring to the organization
and to the affected staff in a manner that would minimize politics, and possibly motivate
employees by manifesting the responsible attitude of the organization towards its
employees.

Finally he had to decide from which region he should start. If he started with regions other
than his own service region Sahiwal, he would be accused of favoring his region.
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Exhibit 1
APPNA SEHAT: CHANGE MANAGEMENT (B)

Organization Structure

Board of Directors APPNA – USA

Chairman APPNA SEHAT

CEO

Regional Directors (4)

Regional Supervisor

Social Organizer Training Coordinator

Unit Level Staff (5)

Male Health Assistant (1)

Female Health Assistant (2)
Traditional Health Attendant (2)

Note: Unit level staff was recruited for three years only

Source: Organization records

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Exhibit 2 (p. 1 of 2)
APPNA SEHAT: CHANGE MANAGEMENT (B)

Interventions

Baseline Household Surveys to assess health and other related needs of the entire
population of the unit to be included in the program.

Health Education through primary healthcare household visits

Community Organization: Formation and functioning of:

i. Men and Women Health Committees in each unit

ii. Health Boards at regional levels ensuring representation from each
unit

Maternal Care: Educating communities on the importance and provision of:

i. Immunization against tetanus for women of reproductive age (15-45

years)
ii. Antenatal care for pregnant women to identify at-risk pregnancies
iii. Referrals for identified high-risk cases
iv. Safe deliveries by training birth attendants
v. Postnatal care after delivery
vi. Child spacing opportunities

Child Care

i. Education of parents on the importance and provision of

immunization for children under five against tuberculosis,
diphtheria, pertussis, tetanus, poliomyelitis and measles
ii. Control of diarrheal disease by educating communities on the
importance of Oral Rehydration Therapy (ORT) in diarrhea,
recognition of signs of dehydration, and preparation and
administration of home-made ORS by mixing salt and sugar in
water
iii. Education on the importance and
provision of regular growth monitoring of
children under five to identify and correct
malnourishment
iv. Education on the importance of, and
provision of, counseling for expectant and
nursing mothers on appropriate breast-
feeding
v. Nutrition education for mothers on how to obtain a balanced diet
out of a routine diet
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Exhibit 2 (p. 2 of 2)
APPNA SEHAT: CHANGE MANAGEMENT (B)

Establishment of Sehat Markaz: Establishment of community owned and

managed Sehat Markaz in each unit, or one Markaz in two units that could act as:

i. First referral facility for identified high-risk cases

ii. Resource generation to support field staff
iii. Appropriate birth centre
iv. Curative facility to treat basic illnesses
v. Child spacing promotion centre

Others

i. Educating the community on the importance of identifying and

obtaining potable water, and the advantages of proper disposal of
waste
ii. Educating communities on the importance of observing personal
hygiene practices
iii. Preventing Iodine Deficiency Disorders through utilization of
iodized salt
iv. Training in first aid procedures
v. Preventing hepatitis through health education
vi. Preventing tuberculosis through health education

Source: Organization records

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Exhibit 3
APPNA SEHAT: CHANGE MANAGEMENT (B)

Head Office Structure

CEO

Manager Manager Assistant to Monitoring

Finance Administration CEO Officer

Source: Organization records

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Exhibit 4
APPNA SEHAT: CHANGE MANAGEMENT (B)

Regional Structure

Regional Director

Regional Supervisor

Social Organizer Training Coordinator

Unit Level Staff (5)

Male Health Assistant (1)

Female Health Assistant (2)
Traditional Health Attendant (2)

Note: Unit level staff was recruited only for three years

Source: Organization records

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Exhibit 5
APPNA SEHAT: CHANGE MANAGEMENT (B)

Responsibilities of Regional Director (RD) and Regional Supervisor (RS)

Sr. Responsibilities of RD Responsibilities of RS

No.
1 Coordination with HO
2 Facilitation of regional staff
3 Monitoring of regional staff
4 Preparation of reports for HO
Facilitation of regional staff
Monitoring of regional staff
Preparation of reports for RD
Collection of field data

Minimum qualification of:

Regional Director MBBS (qualified doctor)

Regional Supervisor FA (12th grade)

Training Coordinator BA and Diploma in Lady Health Worker (graduate)

Social Organizer BA (graduate)

Admin Officer FA (12th grade)

Finance Assistant Diploma in Finance

Source: Organization records