Table Of ContentCOPYRIGHT AND CITATION CONSIDERATIONS FOR THIS THESIS/ DISSERTATION
o Attribution — You must give appropriate credit, provide a link to the license, and indicate if
changes were made. You may do so in any reasonable manner, but not in any way that
suggests the licensor endorses you or your use.
o NonCommercial — You may not use the material for commercial purposes.
o ShareAlike — If you remix, transform, or build upon the material, you must distribute your
contributions under the same license as the original.
How to cite this thesis
Surname, Initial(s). (2012) Title of the thesis or dissertation. PhD. (Chemistry)/ M.Sc. (Physics)/
M.A. (Philosophy)/M.Com. (Finance) etc. [Unpublished]: University of Johannesburg. Retrieved
from: https://ujdigispace.uj.ac.za (Accessed: Date).
A HEALTHCARE MANAGEMENT CONTROL MODEL FOR
EFFECTIVE PERFORMANCE
OF THE SOUTH AFRICAN PUBLIC HEALTHCARE SYSTEM
By
Boniface Okanga
A THESIS SUBMITTED IN ACCORDANCE WITH
REQUIREMENTS FOR THE DEGREE OF
PHILOSOPHIAE DOCTOR (PhD)
IN
BUSINESS MANAGEMENT
at the
DEPARTMENT OF BUSINESS MANAGEMENT
FACULTY OF MANAGEMENT
UNIVERSITY OF JOHANNESBURG, KINGSWAY CAMPUS,
AUCKLAND PARK, JOHANNESBURG, SOUTH AFRICA
Supervisor: Dr Adri Drotskie
Co-Supervisor: Prof Stephen Kruger
February 2014
i
ABSTRACT
Ever since Anthony (1965) in a seminal paper titled: “Planning and Control Systems” initiated
the debate on the nexus between management control systems and the improvement on the
organisational performance, the contentious issue in the debates which have been raging in the
st
21 century has not been centred on whether management control influences the organisational
performance, but on the key constructs that determine the effectiveness of a management control
model. In effect, different theorists and organisational practitioners have interpreted the
predictors of effective management control differently. It is not questionable that these different
debates and interpretations have resulted in a plethora of different and competing management
control theories which have so far proved effective for measuring and improving the
performance of most of the modern organisations.
However, the fundamental argument in this thesis is that considering the pace of the evolution
that the modern organisations are undergoing and the specific management control related
challenges that continue to mar the effective performance of the modern South African public
healthcare system, an analysis of the existing management control theories reveals a nemesis
anchored on a total lack of appropriate coherent management control model which can be
adopted for improving activities’ control in the South African public healthcare system.
In a bid to develop an alternative management control theory which can be used for remedying
such practical and conceptual limitations, the study posits in its overriding research hypothesis
that the effective application of the a priori multidimensional healthcare management control
model in Figure 1.1 would significantly influence the successful monitoring and evaluation of
the activities in the South African public healthcare system.
It is also part of the proposition in the overriding research hypothesis that the effectiveness of the
a priori multidimensional healthcare management control model in Figure 1.1 is predicted by the
four constructs that include; considering the essential healthcare management control
prerequisites, setting the appropriate healthcare performance standards, the use of a balanced
combination of healthcare management control techniques, and the application of the appropriate
healthcare corrective and improvement measures.
Despite the fact that the evaluation of discrete management control theories and literatures
confirmed that it is ubiquitous in the modern organisational practices that the effectiveness of a
management control model is influenced by these four constructs, the study also applied
confirmatory factor analysis as a quantitative research technique to determine the overall fitness
of the a priori multidimensional healthcare management control model in Figure 1.1. A general
interpretation of the results of confirmatory factor analysis indicated that the a priori
ii
multidimensional healthcare management control model in Figure 1.1 perfectly reproduces the
observed 416 sample data. This sample data comprised of public healthcare managers and
officials who were drawn through multistage sampling from a target population of 4 776 public
healthcare managers and primary healthcare facility coordinators in South Africa.
In addition to confirmatory factor analysis, the thesis also used structured interviews as the main
qualitative research technique to enhance the detailed evaluation of how management controls
are accomplished in the South African public healthcare system and the additional constructs and
variables that could be used in the modification of the model in Figure 1.1. The thematic analysis
of the qualitative data collected from 50 interviewed public healthcare officials and managers in
the Gauteng and Mpumalanga Provinces indicated certain constructs and variables which were
per se distinct from the four constructs in the healthcare management control model in Figure
1.1.
However, the interpretation and comparison of the results of confirmatory factor analysis with
the key interview findings yielded conclusions which are at tandem with the ratiocination in the
overriding hypothesis that the effectiveness of a healthcare management control model is
measured by the four constructs in Figure 1.1.
While drawing from these final findings, it was recommended that the South African public
healthcare system must adopt the postulated healthcare management control model in Figure 1.1
as the measure for improving the monitoring and evaluation of its activities so as to not only
achieve the desired level of performance, but also the outlined strategic public healthcare
objectives and goals.
In other words, it is argued that the use of the postulated healthcare management control model
in Figure 1.1 would provide a turn around strategy for the reason that the resulting significant
improvement in the monitoring and evaluation of the activities’ accomplishment would
significantly influence the general improvement in the performance of the South African public
healthcare system, and subsequently the enhanced ability to achieve the outlined strategic public
healthcare goals and objectives.
The thesis concludes with the suggestion that, other than in the healthcare sector, further research
can explore how the postulated management control model in Figure 1.1 can be used to improve
process efficiency, resources’ optimisation and competitiveness across different organisations.
Keywords: Management Control Model, Public Healthcare System, Prerequisites,
Standards, Techniques, Corrective and Improvement Measures, and Monitoring
and Evaluation.
iii
DECLARATION
I, BONIFACE OKANGA state under oath that the Doctoral Thesis titled: “A
Healthcare Management Control Model for Effective Performance of the
South African Public Healthcare System”, is my original piece of work.
I further state that the research was accomplished professionally within the prescribed University
of Johannesburg’s academic process and the South African Department of Public Health’s
research ethical standards.
I also state that this thesis has never been submitted in whole or in any part to any other
institution, college or university, other than the University of Johannesburg.
Boniface Okanga
(A PhD Candidate: University of Johannesburg)
Signature……………………………………………………………………………………………
Date----------------------------------Month of…………………………………………………..2014
iv
ACKNOWLEDGEMENTS
I would like to thank my academic supervisor Dr Adri Drotskie for the professional guidance
that made the successful completion of this study possible. There are no precise words that can
be used to describe and express appreciation for Dr Adri’s technical input in this research.
The technical support, expertise and all the sophisticated skills which were provided by Prof
Stephen Kruger cannot pass without being noticed. Professor Kruger I owe you a lot. God bless
you.
The distinguished University of Johannesburg’s academics and professors; Prof Cecile
Nieuwenhuizen, Dr Geoff Goldman, Dr Whity Linde and Prof Deon De Bruyn who constituted
the colloquium panel which I attended, your advice and suggestions, subsequently translated into
the core assets that enabled the successful accomplishment of this study possible. Thank you and
God bless.
The Department of Health officials who made the primary data collection possible, you are
saluted.
I would also like to thank my family, mum Jacinta Adoto, father Tom Adoto, brothers: Adupa
Godfrey and Okullu Freddie, and sisters Eunice Akello and Clara Among. Your prayers, support
and well wishes were significant towards enabling the successful accomplishment of my studies,
and may the Almighty bless all of you.
The late sisters Jennifer Tikke and Diana Alupu, you have gone to your place of rest. But I know
you have always been with me. This thesis is dedicated to all of you. Rest in Peace.
I would also like to thank my wife Grace Okanga and sons Denning-Anton Okanga and Nixxon-
Persha Okanga for the prayers and understanding during my studies.
Finally, I would like to thank the ALMIGHTY GOD, the Creator of both the seen and unseen,
heaven and earth for entrusting me with the necessary wisdom and intellect that made this study
successful.
v
TABLE OF CONTENTS
No. Page
1 ABSTRACT ii
2 DECLARATION iv
3 ACKNOWLEDGEMENTS v
4 TABLE OF CONTENTS vi
5 LIST OF FIGURES ix
6 LIST OF TABLES xi
7 LIST OF ACRONYMS xii
CHAPTER 1: INTRODUCTION AND MOTIVATION OF THE RESEARCH
1.1 INTRODUCTION 1
1.2 OVERVIEW: RESEARCH BACKGROUND INFORMATION 3
1.3 THEORIES ON STRATEGIC MANAGEMENT CONTROL 13
1.3.1 The Strategic Management Control Prerequisites 14
1.3.2 The Organisational Performance Standards 18
1.3.3 The Strategic Management Control Techniques 20
1.3.4 The Strategic Corrective and Improvement Measures 24
1.4 THE RESEARCH PROBLEM STATEMENT 29
1.5 RESEARCH PURPOSE/PRIMARY RESEARCH OBJECTIVE 30
1.5.1 Secondary Research Objectives 31
1.6 RESEARCH QUESTIONS 31
1.7 RESEARCH HYPOTHESES 32
1.8 OVERVIEW: RESEARCH DESIGN AND METHODOLOGY 32
1.8.1 Quantitative Research-Confirmatory Factor Analysis 33
1.8.2 Qualitative Research-Structured Interviews 38
1.9 IMPORTANCE AND SIGNIFICANCE OF THE RESEARCH 40
1.10 THE DEFINITION OF KEY KEY CONCEPTS 42
1.11 OVERVIEW AND STRUCTURE OF THE RESEARCH REPORT 44
1.12 CONCLUSION 45
CHAPTER 2:THEORIES ON STRATEGIC MANAGEMENT CONTROL
2.1 INTRODUCTION 47
2.2 THE NOTION OF STRATEGIC MANAGEMENT CONTROL 47
2.3 The STRATEGIC MANAGEMENT CONTROL PREREQUISITES 52
2.3.1 The Four-Traditional Management Control Prerequisites 52
2.3.1.1 An Effective Organisational Strategic Plan 52
2.3.1.2 Supporting Organisational Structures 55
2.3.1.3 Supporting Organisational Rules and Regulations 58
2.3.1.4 Supporting Organisational Leadership Style 61
2.3.2 The Three- Modern Management Control Prerequisites 64
2.3.2.1 The use of Employee Empowerment 64
2.3.2.2 Supporting Organisational Information Systems 68
2.3.2.3 Supporting Organisational Communication Mechanisms 70
2.3.3 Concluding Remarks: The Strategic Management Control Prerequisites 72
2.4 THE ORGANISATIONAL PERFORMANCE STANDARDS 73
vi
2.4.1 Critical Areas for Setting the Performance Standards 75
2.4.2 Concluding Remarks:Organisational Performance Standards 77
2.5 STRATEGIC MANAGEMENT CONTROL TECHNIQUES 78
2.5.1 The Feed-Forward Management Control Techniques 79
2.5.2 The Concurrent Management Control Techniques 81
2.5.3 The Feedback Management Control Techniques 85
2.5.4 Concluding Remarks: Strategic Management Control Techniques 88
2.6 THE CORRECTIVE AND IMPROVEMENT MEASURES 89
2.6.1 Six-Sigma as a Performance Improvement Measure 89
2.6.2 The use of Total Quality Management (TQM) 91
2.6.3 The use of Business Process Re-engineering (BPR) 92
2.6.4 The Accompanying Change Management Strategies 93
2.6.5 Concluding Remarks: The Corrective and Improvement Measures 94
2.7 CONCLUDING REMARKS: THEORIES ON STRATEGIC MANAGEMENT 95
CONTROL
2.8 A PERSPECTIVE OF MANAGEMENT CONTROL IN THE SOUTH AFRICAN 97
PUBLIC HEALTHCARE SYSTEM
2.8.1 The Healthcare Management Control Prerequisites 97
2.8.2 The Healthcare Performance Standards 100
2.8.3 The Healthcare Management Control Techniques 102
2.8.4 The Healthcare Corrective and Improvement Measures 106
2.9 THE CONCEPTUALISATION OF MANAGEMENT CONTROL SYSTEMS IN 107
THE SOUTH AFRICAN PUBLIC HEALTHCARE SYSTEM
2.10 CONCLUSION 111
CHAPTER 3: RESEARCH DESIGN AND METHODOLOGY
3.1 INTRODUCTION 112
3.2 RESEARCH PARADIGM AND PHILIOSOPHY 112
3.2.1 QUANTITATIVE RESEARCH-CONFIRMATORY FACTOR ANALYSIS 115
3.2.1.1 Step 1: Model Specification 115
3.2.1.2 Step 2: Target Population and Sample Size Determination 121
3.2.1.3 Step 3: Questionnaire Design and Data Collection Process 129
3.2.1.4 Step 4: Calculation of Estimates and Interpretations of the Indices 131
3.2.1.5 Quantitative Measures for Validity and Reliability 133
3.2.2 QUALITATIVE RESEARCH - STRUCTURED INTERVIEWS 135
3.2.2.1 Target Population and Sampling 136
3.2.2.2 Questionnaire Design and Data Collection Process 137
3.2.2.3 The Analysis of the Interview Findings 138
3.2.2.4 Credibility, Dependability and Transferability 139
3.3 RESEARCH ETHICAL CONSIDERATIONS 141
3.4 CONCLUSION 142
CHAPTER 4: FINDINGS, INTERPRETATIONS AND DISCUSSIONS
4.1 INTRODUCTION 144
4.2 MODEL FITNESS: CONFIRMATORY FACTOR ANALYSIS 147
4.2.1 Research Hypothesis 1: Healthcare Management Control Prerequisites 148
4.2.2 Research Hypothesis 2: Healthcare Performance Standards 161
4.2.3 Research Hypothesis 3: Healthcare Management Control Techniques 170
vii
4.2.4 Research Hypothesis 4: Healthcare Corrective and Improvement Measures 179
4.2.5 CONCLUSION: RESULTS OF CONFIRMATORY FACTOR ANALYSIS AND 189
MANAGEMENT IMPLICATIONS
4.3 INTERPRETATIONS AND DISCUSSIONS OF THE INTERVIEW FINDINGS 193
4.3.1 RESEARCH QUESTION 1: MANAGEMENT CONTROL PREREQUISITES 195
4.3.1.1 The Four Pillars for Healthcare Management Control Systems 195
4.3.1.2 The Four Contextual Factors for Healthcare Management Control Systems 206
4.3.1.3 The Three Contingent Factors for Healthcare Management Control Systems 222
4.3.1.4 The Strategic Healthcare Goals and Objectives 233
4.3.2 RESEARCH QUESTION 2: HEALTHCARE STANDARDS 243
4.3.2.1 The Quantifiable Healthcare Standards 243
4.3.2.2 The Non- Quantifiable Healthcare Standards 253
4.3.3 RESEARCH QUESTION 3: MANAGEMENT CONTROL TECHNIQUES 265
4.3.4 RESEARCH QUESTION 4: IMPROVEMENT MEASURES 276
4.4 THE INTEGRATION OF THE RESULTS OF CONFIRMATORY FACTOR 281
ANALYSIS WITH INTERVIEW FINDINGS:MANAGEMENT IMPLICATIONS
4.5 CONCLUSION 289
CHAPTER 5: SUMMARY, CONCLUSIONS AND RECOMMENDATIONS
5.1 INTRODUCTION 291
5.2 SUMMARY:BACKGROUND AND THE METHODOLOGICAL PROCESSES 292
5.3 THE FOUR KEY RESEARCH FINDINGS 296
5.3.1 Key Research Finding 1: Healthcare Management Control Prerequisites 296
5.3.2 Key Research Finding 2: Healthcare Performance Standards 298
5.3.3 Key Research Finding 3: Healthcare Management Control Techniques 301
5.3.4 Key Research Finding 4: Healthcare Corrective and Improvement Measures 304
5.4 CONCLUSION: THE FOUR KEY RESEARCH FINDINGS 306
5.5 RECOMMENDATIONS 310
5.6 LIMITATIONS OF THE RESEARCH 324
5.7 AREA FOR FURTHER RESEARCH 325
1 LIST OF REFERENCES 326
2 Appendix 1: The Five-Point Likert Scale Questionnaire 339
3 Appendix 2: The Structure Interview Questionnaire 344
4 Appendix 3: Approval Letters and Ethical Clearance 349
viii
LIST OF FIGURES
No. Titles of Figures Page
Figure 1.1 A Healthcare Management Control Model 1
Figure 1.2 The WHO Health Systems Framework 7
Figure 3.2 Step 1 Healthcare Management Control Prerequisites 117
Figure 3.3 Step 2 Healthcare Performance Standards 118
Figure 3.4 Step 3 Healthcare Management Control Techniques 119
Figure 3.5 Step 4 Corrective and Improvement Management Measures 120
Figure 4.2 The Framework of Key Themes from the Interview Findings 147
Figure 4.4 Standardised Regression Weights (Factor Loadings) and Square d Multiple 158
Correlation Coefficient ( ): Healthcare Management Control Prerequisites
Figure 4.6 Standardised Regression Weights (Factor Loadings) and Squared Multiple 168
Correlation Coefficient ( ): Healthcare Performance Standards
Figure 4.8 Standardised Regression Weights (Factor Loadings) and Squared Multiple 177
Correlation Coefficient ( ): Healthcare Management Control Techniques
Figure 4.10 Standardised Regression Weights (Factor Loadings) and Squared Multiple 187
Correlation Coefficients ( ): Corrective and Improvement Measures
Figure 4.11 Pillar 1: Political Support, Cooperation and Collaboration 197
Figure 4.12 Pillar 2: Principles of Good Governance 200
Figure 4.13 Pillar 3: Availability of Sufficient Resources 202
Figure 4.14 Pillar 4: A Department for Monitoring and Evaluation 204
Figure 4.15 Positive Effects of Contextual Factor 1: Public Healthcare Strategic Plan 209
Figure 4.16 Limitations of Contextual Factor 1: Public Healthcare Strategic Plan 210
Figure 4.17 Positive Effects of Contextual Factor 2: Organisational Structures 212
Figure 4.18 The Limitations of Contextual Factor 2: Organisational Structures 213
Figure 4.19 Positive Effects of Contextual Factor 3: Rules and Regulations 216
Figure 4.20 Limitations of Contextual Factor 4: Leadership Styles 218
Figure 4.21 Positive Effects of Contextual Factor 4: Leadership Styles 220
Figure 4.22 Positive Effects of Contingent Factor 1: Information System 225
Figure 4.23 Limitations of Contingent Factor 1: Information System 226
Figure 4.24 Positive Effects of Contingent Factor 2:Communication Mechanisms 228
Figure 4.25 Limitations of Contingent Factor 2: Communication Mechanisms 229
Figure 4.26 Positive Effects of Contingent Factor 3: Employee Empowerment 230
Figure 4.27 Limitations of Contingent Factor 3: Employee Empowerment 231
Figure 4.28 Strategic Leadership and Better Health Outcomes 236
Figure 4.29 Implementation of a National Health Insurance System 238
ix
