Results Based Financing is a relatively new
strategy that has the potential to reform the health sector with system-wide
effect on service delivery, leadership and governance, human resource, health
management information systems, medicines and health technology. Strengthening
health systems consequently improves accountability, efficiency and equity.
This was recognized by the Mid Term Review of the Health Sector Strategic Plan
III, which recommend instituting
performance management systems through a pay for performance/Results Based
Financing strategy. RBF brought many
changes within Health facilities, the way of doing thing definitely change to the current implementing
regions (Tabora, Mwanza, Kigoma, Geita, Simiyu, Shinyanga, Kagera and Pwani)
since started in 2015 as pilot in Kishapu – Shinyanga).
Organization is made up of people and form to achieve collective goals,
an organization should be prepared with any occurrence of changes that may arise
in the working environment.
introduced the decentralization of its health systems in the 1990’s through
Health Sector Reforms in order to provide opportunities for community AND
management at lower level to participate in health services delivery
effectively. In this reform (change) a decentralized health system organized around three functional levels:
Council (primary level), regional (secondary level) and referral hospitals
(tertiary level). Under this system, the council have full mandate for
planning, implementation, monitoring and evaluation of health services. (Frumence G & et el 2014).
this reform, several programs and initiatives developed by Government and
Development Partners for example launched of Results Based Financing (RBF)
under Tanzania Strengthening Primary Health Care for Results Program (SPHC4RP)
supported by World Bank (World
Bank 2014). Health sector reforms emphasized on Organisational Change as
measurement force to change and shape the value of public health facilities
well-being and success, the behind of this, is to manage public primary health
facilities just like private one. Bradley and Parker (2006) argued that;
private organization should be managed more like private organization and this
will be considered public organization reflect private organization culture by
looking more on external issue instead if internal matters.
Results Based Financing
interventions have recently gained significant momentum, especially in
Sub-Saharan Africa. RBF as a cash payment or non-monetary transfer made to a
national or sub-national government, manager, provider, payer or consumer of
health services after predefined results
have been attained and verified. The system of receiving payment is
conditional on measurable actions being undertaken, this is contrary to the
regions where RBF program not yet started (URT, 2015).
Change is inevitable because every individual and
organization experiences change, some of change may be mainly in response to
external circumstance (Reactive change) while other type of change may be
undertaken because the individual or organization has decided to change
(Proactive change). (N.A.Saleem, 2011).
Organisational Change in Government organizations help
to determines the public service orientation and service delivery, and is
affected by how employees are treated. Tanzania introduced RBF Program for the
purpose of to strengthening the health system and to accelerate the achievement
of universal health coverage (WHO, 2010); the reasons behind of this program is
to strengthen public health service delivery by shaping health service provider
in the way of accomplishing targeted indicators as planned (URT, 2015). This
also was supported by (Dunphy 1996, Czarniawska & Joerges 1996), thus;
organisational change mainly appears when there is failure of attaining desired
objective/target hence this cause plan of change and then implementations,
which later brought unexpected outcome.
2.0 OBJECTIVE OF THE STUDY
The main purpose of this Desk
review paper is to explain the general the concept of the Organisational Change;
Factors influence Organisational Change, Process in Organisational Change, Resistance
for Change, and How Managers Overcome Resistance for Change AND Theory for Change.
OF THE STUDY
This is Desk
review, whereby different books concerned Organisational Change was referred
and also the documents such as Results Based Financing Toolkit (2014), Tanzania
Results Based Financing Operational Manual (2015) and Tanzania Results Based
Financing Design Document (2015) was also reviewed.
The empirical literature review of
this paper provides detailed information what other studies said concerning Organisational
Change with the reflection on Government Organisations or Institutions
4.1 Factors Influence
Organisational Change (Source)
The implementation of the RBF system
as new strategy in Tanzania was adopted to face many challenges facing health
service delivery, some of these challenges were due to weak managerial process
in the health facilities and other driven from external source. This was
supported by Spector (2011) by highlighting that;
Organisational Change may
originate from inside or outside the organization therefore Organisational
Change can thus be because by external or internal factors/forces.
These are the factors occur within
the organization and may necessitate change; such change is required because of
two reason these are change in managerial personnel and deficiency in existing
organization practices, low performance or morale, re-allocation of
These are factors outside the organization
some of them are technological factors, competition factors, government
actions, environment factors, changing domestic and global economies, changes
in social cultural values (Markovic, 2008)
major challenges facing health services delivery was based on internal factors
especially poor management of resources available hence facilitate for change.
4.2 Organisational Change Process
According to C.B Gupta (2012), there are three steps in change process
(Lewin’s Model) which can be apply by managers to implement changes, these are
unfreezing, moving and refreezing. This is sometimes called as three steps for
successful organisational changes
Unfreezing implies breaking down the existing
ways of doing things so as the people are ready to accept new alternatives. This
stage is about getting ready to change from the current conform zone.
Moving is the step whereby people become receptive to
change, the proposed change is introduced in a systematic manner and learning
takes place during this phase and moving towards new way of being. Support is
very important in this stage, and it can be in form of training, coaching and
expecting mistakes as a part of the process.
Refreezing is where by change is made a
permanent part of organizations life. At this stage new practice are accepted
and change is stabilized. That is to say in any organisation there is a need to
ensure that there is a critical role of ensuring that employee to prepared to
change and more toward changes, as well becoming stable to coup with the
Also, Kotler (2008), describes also the process of change by going
through eight steps that people need to work and otherwise; There are sometimes known as eight step model for transforming organization;
Step 1 Determine the urgency of change
Step 2 Form a strong nucleus, leading change
Step 3 Create a new vision
Step 4 Notify all new vision
Step 5 Empower others to act on the vision
Step 6 Create a short term wins
Step 7 Maintain state or emergency
Step 8 Anchoring changes in corporate culture (strengthen change).
However, the above stages mainly make connection on changing people’s
behaviour and not system, strategy or culture of the organisation. Therefore, RBF
initiative was applied in order to break down existing ways of doing things in
health facilities whereby now quality and quantity indicators supposed to be
attained in order for the facilities receive incentive funds for day-to-day
running cost and general development of the centre.
4.3 Resistance to Change
Managers and employees often resist changes being introduced by their
organization due to various reasons, according to C.B Gupta (2012), resistance
to change is depending upon how members perceive the changes in the
organization, major forces for resistance are due to individual, as well as
organizational. Individual sources include: -fear of economic loss, status quo,
fear of unknown, peer pressure and social displacement while organizational
sources are, organizational structure, resource constraints, sunk cost, and
threat to power and influence.
Resistance to change is an emotional response to imagined threats to the
changes introduced in the organization, it is nature for employee to resist
changes, and it could be at individual or organizational levels (Kinicki and
Williams, 2013). Manager should decide on how to overcome to resistance to
change in an organization.
4.4 Overcoming to Resistance
to Change in Operating RBF Program
To overcome resistance to change can be made both for individual, group
and organization level, through effort at both levels may be easy to overcome
resistance since people react differently at individual level and at group
level. Therefore, effort is required at both levels.
According to L. M. Prasad (2007), techniques that can be used to
overcome resistance to change are: education and communication, participation
and involvement, commitment, leadership, these are effort at individual level,
group contact, group dynamics training for change, these are the effort at
group level. Also this was supported by (Anderson, 2011; Harvey, 2010), there
were number of technical approaches which can be applied to overcome resistance
to change which include the following: participation and involvement,
facilitation and support, education and communication, negotiation and
agreement, manipulation and co-optation, and explicit and implicit coercion.
Hospital Management Team responsible to manage changes in a way that
employees take positive manner the whole process of change in an organization.
Manager played the role by enabling changes to take place by making people
understand reason for change, when is to be introduced in the organization and
how the changes will be beneficial to all. Since manager Played the important
role to the organization the following technique were to overcome resistance to
change these are: –
data in electronic way instead of paper work through District Health
Information System (DHIS2) – managers use education as technique to overcome
resistance to change, the management conducted training to all employees in all
department in the hospital to adopt change on the use of computer system as the
means of storing data, employees taught new skills this help them to develop
new relationship and attitudes, during training they manage to show how the use
of computer will simplify work
and make easy way of preparing report monthly and quarterly.
use participatory and involvement to bring people who are likely to resist the
change through continuous dialogue. The aim of this process is to encourage
people to say what they feel about the various aspect of change to air out
their views about the change. This process decrease resistance to change due to
personal involvement hence led the acceptance of change in the organization.
use his leadership style and his personal quality to get consent and willing
support of the people. A hospital was successfully with strong leadership
qualities that created the environment that people were willing to change.
this method is where manager use force to people to accept change for example
termination, demotion, and transfers this method is very risky approach this
method was not applied at Hospitals due to the reason that manager had high
qualities to influence people and become willing to change.
of the aspects emphasized in RBF is the quality of data in the system of
district health information system (DHIS2) because through mentioned system
generation of invoice done for approval and final disbursement of funds
according to fulfilled indicators. Shifted from paper work record keeping to
electronic one brought resistance from employee due fear to lose their post. Weick & Quinn (1999) suggested that, both that change starts with
failures to adapt, once individual or the system as whole fear to adjust with
coming innovation; it is the beginning of changes.
and Marshock (2011) provides ways that will allow successful organisational
To create a
feeling of urgency reflects the creation of a strong ground to manage the
effort to change, workers must understand the need for change, those who unity
for it are called champion of change.
To provide a precise guidance; it includes those
activities that people must do together especially for those who are eager
To determine vision, leaders must be able to
anticipate future and provide innovations, adapt to the changing conditions
To share vision, workers must be able to commit
to the work with equal solutions.
To give authority to the workers to act in the
line with the vision;
which will make workers to work in accordance to
the vision in a shared manner
To plan short term gains;is important to
determine the awards and benefits of the organizational change for the
workers which will help to decrease resistance of workers and increase
tendency to embrace a change.
To executive more changes by reinforcing the improvement,
a leader must be able to notice or detect the
possible outcomes of an organizational change and monitor the change.
To institutionalize new approaches;
is important to prevent inactivity and loss of
energy and excitement in the workers of the organization and it allows the
institutionalize of the changes.
That’s why they have a duty to ensure that they
recognize those barriers and appreciate them by finding proper ways of
solving them, and those entire barriers are so relevant to education institution
5.0 THEORETICAL LITERATURE REVIEW
5.1 Definition of Terms
Results-Based Financing has
been defined as “a cash payment or non-monetary transfer made to a
national or sub-national government, manager, provider, payer or consumer of
health services after predefined results have been attained and verified.
Payment is conditional on measurable actions being undertaken” (URT,
Organisational Change is the adjustment of work
environment in an organization; it implies a new equilibrium between different
components of the organization technology, structural arrangement, job design,
and people (Prasad, 2007).
Organisational Change Implies planned adjustment in
existing organizational system. Also it is adjustment of structure relationship
and role of people in organization (Gupta, 2012).
5.2 Theory for Change
5.2.1 Resistance to change Theory by Lewin’s
Kurt Lewin (1951) developed the thought of force-field analysis by looking behaviour
within organization as a dynamic and not as a static balance of forces working
in opposite directions within the organization. Lewins believes that, any
change brought by current situation or condition of the organisation and this
cause force to change or resist to change. These forces may originate in the
internal or external environment in the Health Facilities or in the behaviour
of the Facilities in-charge.
Health Facilities in-charge supposed to make extra
effort in initiating change in the organisation while making sure of reducing resistance
to change. Health Facilities in-charge supposed to look condition in the
hospital as an equilibrium that is the result of driving forces and resisting
forces working against each other. Assessment of potential changes and
resistance and attempt to change must be done in order to balance the forces so
that there will be movement toward a desired condition.
There are three ways Health Facilities in-charge can
do this: increasing the driving forces, reducing the resisting forces, or
considering new driving forces.
Lewin points out that increasing one set of forces without decreasing
the other set of forces will increase tension and conflict in the organization.
Reducing the other set of forces may reduce the amount of tension. Although
increasing driving forces is sometimes effective, it is usually better to
reduce the resisting forces because increasing driving forces often tends to be
offset by increased resistance. Put another way, when we push people, they are
likely to push back. Forces for change and resistance to change; these are the
types of situations that Health Facilities in-charge face and must work with on
a daily basis when attempting to effect change.
Moreover, change involves a sequence
of organizational processes that occurs over time. Lewin suggests this process
typically requires three steps: unfreezing, moving, and refreezing. which can be apply by managers to
implement changes; Unfreezing
implies breaking down the existing ways of doing things so as the people are
ready to accept new alternatives. Moving
is the step whereby people become receptive to change, the proposed change is
introduced in a systematic manner and learning takes place during this phase. Refreezing is where by change is made a
permanent part of organizations life. At this stage new practice are accepted
and change is stabilized. However, RBF initiative was applied in order to break
down existing ways of doing things in health facilities whereby now quality and
quantity indicators supposed to be attained in order for the facilities receive
incentive funds for day-to-day running cost.
is inevitable because every individual and organization experience change,
change it implies a new equilibrium between different components of the
organization structure, and technology. Changing process need a competence
manager AND to influence change in an organization was successful due to the
leadership style with the competence manager who has the abilities and
qualities to influence change also the use of technique to overcome resistance
to change all these facilitate positive changes in the hospital.
RBF initiative there are many improvements in the provision of health services
especially reduction of maternal death, generally there is a great improvement
and achievement in the hospital due to the change which has taken place.
& McCalman (2000) suggested that, adapting changes in an organizations
requires competent team with managerial talents, also have a well-developed
leadership attribute which in serious moments moves things from a stoppage,
communication is considered being very important by offering support and giving
them the necessary feelings that success is guaranteed, stimulating them,
connecting with one another and making their staff enthusiastic.
Management should be open and explain to the employees the need for
change, also should explain how change will be beneficial to all, not only that
but manager should create the environment for the change to take place Example
procure of enough computers to all department so as to make equipment available
for the employees to do their work in a comfortable way hence successful to the
However participatory and involvement of employees to the changing
process it is very important so as to overcome resistance to change, on-going
training is also important since change is the process therefore there is a
need for the manager to provide on-going training to the employees so as to
increase their skill and knowledge in the use of computer.