Manager's Guide_Problem-Solving

8/7/2019 Manager's Guide_Problem-Solving

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THE PHC MAP SERIES OF MODULES. GUIDESAND REFERENCE MATERIALSEach module includes:o a User's guideo a Facilitator's guide. computer programsModule 1 Assessing information needsModule 2 Assessing community health needs and coverageModule 3 Planning and assessing health worker activitiesModule 4 Surveillance of morbidity and mortalityModule 5 Monitoring and evaluating programmesModule 6 Assessing the quality of serviceModule 7 Assessing the quality of managementModule 8 Cost.analysisModule 9 Sustainability analysisManager's guides and referenceso Better management: 100 tipso Problem-solving. Computerso The computerised PRICOR thesaurusProduction Managers:

Design & Layout:Desktop Publishing:

First Printing:Second Printing:

Ronald Wilson, Aga Khan Foundation, Geneva, andThongchai Sapanuchart, Somboon Vacharotai Foundation,BangkokHelene Sackstein, FranceMarilyn J. Murphy, Suracha Suntarasut, Somboon Vacha-rotai Foundation, Bangkok, Thailand and Atthapon Tanoi,Dept. of Medical Sciences, ThailandIn 1993 by Thai Wattana Panich, Bangkok, Thailandln 7997 by Veteran Organization Printing Co.,Ltd, Thailand

Published by the Aga Khan Foundation USA, Suite 700,1901 L Street N.W., V\hshingtonDC, USA. Additional copies are available at the Somboon \lacharotai Foundation, 101Boromratchonanee Road, Glingchan, Bangkok 10170, Thaland Fax. (662) 44'&.66f,2


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ISBN : 1-882839-19-6Library of Congress Catalog Number :93-70732


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i, :.i'tit*iiliiiit-\.ii!F.ii.{ ;ii:,:,ri*An overviw of PHC MAP

The maln purpose of the Prlmary Health Care Management Advance-ment Programme (PHC MAP) is to help PHC management teams collect,process and analyse useful management information.Initiated by the Aga Khan,Foundatior\ PHC MAP is a collaborative programme ofthe Aga Khan Health Network'and PRICOR'. An a


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uManagers can easily adapt these tools to fit local conditions. Both new andexperienced programmers can use them. Govemment and NGO managers,management teams, and communities can all use the modules to gatherinformation that fits their rreeds. Each module explains how to collect, process

and interpret PHC-specific information that managers can use to improveplanning and monitoring. The modules include User's guides, sample datacollecting and data processing instruments, optional computer programs, andFacilitator's guides, for those who want to hold training workshops.The health and management services included in PHC MAP are listedbelow.

HEALTH SERVICES MANAGEMENTSERVICESGENERALPHC household visitsHealth educationMATERNAL CAREAntenatal careSafe deliveryPostnatal careFamily planningCHILD CABEBreast feedingGrowth monitoringNutrition educationlmmunizationAcute respiratory infectionDiarrhoeal disease controlOral rehydration therapy

OTHER HEAI.IH CAREWater supply, hygiene andsanitationSchool healthChildhood disabilitiesAccidents and injuriesSexually transmitted diseasesHIV/AIDSMalariaTuberculosis'Iieatment of minor ailmentsChronic, non-communicablediseases

PlanningPersonnel management'IiainingSupervisionFinancial managementLogistics managementInformation managementCommunity organisation

Several Manager's guides supplement these modules. These are: Bettermanagement:7}}tips,a helpful hints book describing elfectlve ways to helpmanagers improve what they do;Problem-soluing a guide to help managersdeal with common problems; Computers, a guidebook providing usefulhints on buying and operating computers, printers, other hardware andsoftware; and The computerised PRICOR thesourus, a compendium ofPHC indicators.

Health and management services


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The Primary Health Care Management AdvancementProgramme has been funded by the Aga Khan FoundationCanada, the Commission of the European Communities, theAga Khan Foundation U.S.A., the Aga Khan Foundation'shead office in Geneva, the Rockefeller Foundation, theCanadian International Development Agency, Alberta Aid,and the United States Agency for International Develop-ment under two matching grants to AKF USA. The first ofthese grants was "Strengthening the Management, Monitor-ing and Evaluation of PHC Programs in Selected Countriesof Asia and Africa" (cooperative agreement no. OTR-0158-4-00-8161-00, 1988-1991); and the second was "strength-ening the Effectiveness, Management and Sustainability ofPHC,zMother and Child Survival Programs in Asia andAfrica" (cooperative agreement no. PCD-0158-A-00-II02-00, 1991-1994). The development of Modules 6 and 7 waspartially funded through in-kind contributions from thePrimary Health Care Operations Research project (PRICOR)of the Center for Human Services under its cooperativeagreement with USAID (DSPE-6920-A-00-1048-00).This support is gratefully acknowledged. The views andopinions expressed in the PHC MAP materials are those ofthe authors and do not necessarily reflect those of thedonors.All PHC MAP material (written and computer files) is inthe public domain and may be freely copied and distributedto others.

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ContentsINTRODUCTIONCommon problems in primary health care .Community organisation ..Information, education, and communicationInformation systems and record-keepingPersonnel and training . . .. .. .LogisticsSupervisionMANAGEMENT FUNCTIONS: Community organisation " " " 6Information,education and communication ' ' ' '13Information systems and record-keeping " " "2LPersonnel andtraining.... '"""28Logistics ''""34Supervision ' "35PROBLEM-SOLVINGPROCESS ....42Sa"p It ldentify, select and define the problemStep 2: Learn lverything about the eiisting pronlem ' ' ' ' ' ' '45Step 3: Determineihe blsic causes of the problem " '45SaA 4t ldentify all possible solutions " "46Step 5: Choose and implement a solution ' ' " '47Step 6: Implementing iuality improvement solutions ' ' " ' "47REFERENCES ..... ".51

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ACRONYMS AND ABBREVIATIONS


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AcknowledgementsThe idea for this guide came from PHC managers, who requested asupplement to the PHC MAP modules that would provide practical

suggestions for solving problems. Jack Reynolds developed the design forthe guide, contributed the first examples, and oversaw the project through-out. Gael Murphy compiled the first draft from material prepared by anumber of URC/CHS staff. Maria Francisco and Neeraj Kak prepared arevised draft, which was reviewed by participants at the Internationalconference on the management and sustainability of PHC programmes, inMay L992. They worked on revisions together with Martine Hilton tocomplete the final draft. special thanks are due to Pierre Claquin of theAga Khan Foundation, Geneva, for his support and interest; severalparticipants of the 1992PHC MAP conference including Peter Mabongaand Jeddah Katimo (Mombasa PHC Programme, Mombasa, Kenya), andMjay Moses (Aga Khan Health services,lndia)for their suggestions on howto improve the guide; and Julia Friend for conducting the backgroundresearch.we wish to thank all of the managers, consultants and others withfirst-hand PHC experience who generously contributed their experiencesand guided us to other sources. The material for the problem-solvingprocess is based on previous material developed by URC/GHS'S pRICoRand Quality Assurance projects.

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Introduction"There are no problems, only opportunities."

As a member of a primary health care (PHC) management team, youprobably encounter a number of problems that demand innovative thinkingand flexibility. Many of these managerial problems will be identifiedthrough the tools and techniques in the PHC MAP modules. The moduleswill also help you identify most of the solutions, as well. Many will beobvious, but sometimes it may be a real challenge to identify an effectivesolution that will work in your situation.As the PHC MAP modules were being reviewed and tested, many PHCmanagement teams asked for guidelines for problem-solving. This prob-lem-solving guide is our response to those requests.The guide has two principal sections. The first is a compendium ofcommon problems and solutions that come from PHC managers. These areideas and strategies that they implemented and which worked. We havearranged them under six management headings:. communityorganisation. information, education and communication. information systems and record-keeping. personnelo logistics. supervision

Each topic is first described briefly, together with some key lessonslearned. Then a common problem is described, followed by one or moresuggested solutions and some examples from field experience around theworld. Several problems are presented for each topic, and as mentioned,several solutions are usually presented for each problem. Altogether, thereare 29 problems discussed in this guide. The following table shows howthey are distributed across management topics, and the specific servicesProblem-solving; introduction


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2

General Immunisatlon ORT Famtlyplanning Growthmonitoring BreastfeedingnutritionCommunityorganisation

L,2,3 4Information,education,communication

5 6 7 8,9,10 II,L2Inlormationsptems and reordkeeping

13,14,15 16 L7 18

Personnel andtralning t9 20,2rLogistics 22 23Superuision 24,25.26 27 29,29

from which the examples were drawn. obviously, the problems and solu-tions described could apply to a number of services.Numbers in the chart correspond to the number assigned to eachproblem in this guide. A summary listing of these problems is at thebeginning of the next section.The suggestions and solutions presented in this guide come from anumber of sources, including operations research studiel, pHC consultantsand teachers, case studies, articles, and trial-and-error experience of pHCmanagers. Numbers in superscript refer to the sources of the information,which are listed in the References at the end of the guide.The second section describes a general approach that managers canuse to analyse problems, identify root causes, and develop appropriatesolutions to address these causes. This section builds on'thl'probl.-identification and analysis process embodied in the pHC MAp Modules. Italso includes some simple tools that you and your team can use, such asbrainstorming, nominal group techniques, cause-effect analysis, flowcharts,and fishbone diagrams.

.ln presenting these problems, suggestions and practical solutions, it isour.hope that programme managers, outreach, clinic and hospital-basedhealth care providers and planners will be able to use the suggestions offeredas a "springboard" for their own ideas, inspiring them to d-velop appropri-ate solutions to their own problems.

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:l.iitfiii!!.!.W!i.#, -P#i1.ffi'! i tii:i!':':*it:!iiii'iCommon problems in primary health care

The following list summarises the problems discussed in this guide,arranged according to the six management functions described in theIntrodluction. Thii list is followed by an in-depth discussion of eachproblem, suggested solutions, and examples from PHC managers'organisation

Even though project interventions are acceptable toindividualcommunity members, they do not want tojoin in activities that would support those interven-iions, since they perceive that they will enjoy thesame benefits whether or not they themselves par-ticipate.Patients tend to bypass peripheral health units andseek care directly at the hospital outpatient depart-ment.Utilisation and support of health programmes arelow.Family planning activities are hindered by a.lack oftuppotf from influential village members who holdnegative impressions of family planning based onreports from dissatisfied clients.

CommunitYProblem 1:

Problem 2:

Problem 3:Problem 4:



Information, education and communicationParents do not recognise the need for immunization'Despite high recognition of ORT among mothers,key messages about preparation and administrationare not being conveYed to mothers.Family planning messages are not wellreceivedbecause of strong religious influences.Heavy case loads limit the opportunities for educa-tion in the health centre.

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Information systems and record-keeping

Problem 9:

Problem 1O:Problem 11:

Problem 12:


Problem 15:Problem 16:Problem 17:

Problem 18:

Personnel and training

Mothers are not alert to changes in their children'sweights that may signal the initial stages of malnu-trition.Mothers do not recognise the importance or utilityof growth monitoring.Health workers have difficulty convincing mothersof the importance of breast feeding. Efforts are oftenundermined by perceptions and media messagesthat bottle feeding is "modern" and "better."Supplementary feeding programmes do not rein-force behaviour change or independence.Referring providers do not learn from their referrals.Semi-literate CHW's cannot easily record and reportinformation, identify needed information, or usehealth records to determine major health problemsand the families allected by each.Record-keeping and reporting requirements aretime-consuming.Poor record-keeping by field workers.Performance records show wide variations amongfield workers. For example, in the same period oftime, some recruit over 100 family planning adopt-ers, while others recruit fewer than 20.CHW's involved in growth monitoring programmeslack interpretative skills and the supportive technicalstandards needed to properly respond to questions.They are not able to record weights correctly onchart and have difficulty counseling mothers effec-tively.

High attrition rates among CHW'S who suffer froma general lack of motivation and lncentive to do theirwork, and often do not feel appreciated by thecommunity.Problem 19:

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LogisticsProblem22zProblem 23:

SupervisionProblem 24:Problem 25:

Problem 26:Problem 272


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Family planning workers are not accepted by thecommunity.There are not enough health workers to provideelfective coverage. The programme is not having astrong impact on family planning acceptance, or onreductions in fertility.

Refrigerator records show storage temperatures areabove those required for vaccines.Weighing data are often inaccurate because of suchfactors as using inappropriate scales (such as bath-room scales). Scales are not calibrated before eachweighing session, and are not set to 0 before eachweighing; children are rarely fully undressed whenweighed. Age reporting as well as growth plottingare often inaccurate.

Ineffective and infrequent supervision of CHW's.Staff have a limited amount of time to performduties. Coverage, and hence prevalence of familyplanning use, for example, suffer as a result.'lbo many tasks are assigned to CHWs. Tasks do nothave a clear priority.Opportunities for immunization are often missed,even when a child does make contact with a healthfacility that is prepared to vaccinate.Lack of supervisory control in growth monitoringand counselling activities.Lack of organisation in growth monitoring/supple-mental feeding projects.

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Management function: Com-munityorganisationcommunity organisation addresses the processes and institutionsthrough which community members organise for participation in healthpromotion, including involvement in the decisions related to the planning,financing, construction, operation, and maintenance of a projeci. It emiphasises the group process for learning and collective action, and is incontrast to the rapid installation approach in which groups outside thecommunity make the majority of decisions related to the project. Thebenefits of this group process are not confined to improved pHc projectperformance or reduction in mortality and morbidity rates. The commu-nities learn togrRlv lessons that they have learned to other developmentopportunities. ^"Programmes must involve the community in health activities to ensurethat services reflect community needs and desires. In the process, it canalso provide individuals with organisational and planning skills that theycan apply to other development areas. As a management function, theprocess of community organising will vary quite extensively from oneprogramme to another, and from one community to another.Participation in health activities is a natural outgrowth of efforts atcommunity organisation. Throughout the modules, "community participa-tion" has been defined as the involvement of the community inthe design,planning, promotion, or delivery of health enhancing activities (see Module7, p-11). This definition can be expanded to include not only the contribu-tions made to establish and sustain services, but also the acceptance andutilisation of services.Successful programmes have found that the first and most essentialstep in initiating health programmes is to establish a positive rapport withthe intended beneficiaries, keeping in mind that prior negative experienceswith the lpalth system may predispose individuals to reject new pro-grammes."" Increasingly, programmeg are understanding the need forcommunity participation at all levels of planning, implementation, andevaluation in order to have successful projects and outcomes. The more acommunity feels a sense of ownership of project activities, the more likelythat project will be successful.

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Problem l:7

Even though project interventions are acceptableto individualcommunity members, they do not wantto join in activities that would support those inter-ventions, since they perceive that they will enjoy thesame benefits whether or not they themselves par-ticipate.Don't expect people to join voluntarily in healthactivities that benefit the community as a whole.Develop or point out appropriate incentive(s) foreither community leaders, residents, or organisationmembers. Incentives could include such things asmonetary pay, prestige, power, extra privileges, betterhealth, and increased economic productivity.

Suggestion A:

For example, a water sanitation project might expect that every familyin a village would benefit if each built a latrine, ending pollution of thevillage water supply. But no family is likely to build a latrine by itself, andthe effect on water quality would be too small. In fact, each family has anincentive not to build a latrine. An individual family is best off if everyoneelse builds one, while it retains old waste disposal practices. Such a familyis a "free rider" -- it gets the benefits of cleaner water without having tobear the costs of providing it. If the latrine is seen as a source.of prestigefor the household, more households may aspire to having one."Example: The Indonesia Rural tvVater Supply Project installed 100 gravity watersupply systems, and a few rainwater catchment systems. The implementing agencywasCARE-USA, whose development strategy stresses community involvement andfits well with Indonesia's national philosophy of selFhelp. CARE employed andtrained Indonesian project workers who lived in the village during the constructionphase, and participated in village life to draw political, religious, and other leadersinto the planning and implementing activities. In each village, the details ofimplementation were set by a subgroup of the village community enduranceinstitution (VCEI), a voluntary civic body found in most Indonesian communities.By tying water project responsibilities to the indigenous organisation, projectworkers encouraged the VCEI subgroup to organise neighborhoods and involve.villagers in the project. In addition, the VCEI subgroups enjoyed added prestige andpower. The success of the CARE community participation approach is explainedlargely by this strategy of using existing decision-making infrastructures, rather thancreating a mechanism which would compete for human resources and power.'"



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Problem 2:

Suggestion A:

Patients tend to bypass peripheral health units andseek care directly at the hospital outpatient depart-ment.Offer outpatient consultations only to patients whoare referred by a health centre or CHW linked tothat hospital.

Example In the Bwamanda Health ZoneinZaire,the zone hospitalpractised thispolicy. It had no general non-referral dispensary, for patients from the town inwhich the holpital was located, a separate health centre was provided 0.5 km fromthe hospital.34Example At the village health centre in a Somali project, priority was given topatients who had &en relerred by CHW's. This enhanced the cHws importancein the eyes of the community, and served as a valuable teaching tool for CHW's ontheir referrals.r

Problem 3: Utilisation and support of health programmes arelow.Suggestion A: Public displays, such as community charts and black-boards placed in a prominent location showing proj-ect achievements, can generate interest and aware-ness.Suggestion B: Encourage involvement in the health programmefrom active organisations from as many differentsectors as possible, including non-health or-ganisations that contribute in some form to theadvancement of PHC. This approach could includeinvolvement of some less obvious groups, such asschool children, through school programmes.

Successful projects have been those in which the community had aparticular interest and a high perception of benefits. Community contri-butions to projects are most often in-kind services such as: provision ofIabour and materials for health centres, latrines, sanitation projects, con-structing wells, training visits; provision and selection of volunteers to serveas CHW's; compensation of some form for CHWs; organisation and supportof health committees.z

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ln general, projects successful in involving communities have been those:. in which the major capital-investment costs of health improvementwere carried by either the government or the ptoject, but not ihecommunitY;. which were small scale or locally implemented, and which tended toinvolve one-time efforts requiring little involvement once completed;. which emphasised the generation of community support and whichlinked the problem of sustained community participation to supervision;and. in which the community perceived the health benefits to be high.zExample In its seven years of operation, the Togo Rural water supply Projecti"riuif.?""urly 1,000 tube wells in745 villages and towns. A unique feature of this

managed community action plans themselves. In some district programmes con-traceptive prevalence rates have increased dramatically and community participa-

project was its socio-health component, which integrated community organisationand health education activities to involve villagers in installing, operating, andmaintaining their wells. The field workers initiating these activities were Togolesetr.i"i iffiit. agents. The final evaluation attributed a large part of the project'ssuccess to its community participation approach and to its careful training of thesocial affairs agents in heaittr education and commuttity organisation, of the villagedevelopment Committee (VDC) members in local management, and of villagers inh;gi""; education. In iis last three years, the project broadened communitypliii"iputio" to involve more women indecisions about the operation and mainte-.,un"n of the water system. It established the position of "pump minder," in which;;;-;n living nearihe well was made t"pot tibl" for oveseeing the proper use ofihe ,ystem ani monitoring the operation of the pump' T!" nurnp minders werenoi ontv appointed uy hJvoc's but also became full VDC members. During theii"ur v"ir,ln onr prolect was started in villages with compleEd well installations'irr" ipc selected iiu" *orn"n, who thereby-b"catne full VDC members, as oRTuoi,rnt""rr. These five women and one VDC member were then trained to givedemonstrations and provide individual counseling to mothers in therpreParation"nJ iJ-inittration oi sugar-salt solutions for children with diarrhoea.^"-xample, In Ivory Coait, a school health education prograrnme was initiated toimprove public participation in immunization activities. A simple lesson plan wasdistributed to primary school teachers Pupils were taught the need for their lDungersiblings and neighbourhood infants to be immunized against childhood diseases'After completing the lesson plan, the pupiis carried rit home together withappointment slips to have the target children immunized'^"Example In Bangladesh, district family planning management teams consistingof heaith and lamily planning officials, community leaderq and district heads visitedIndonesia's successful family planning board. These teams then designed and

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10tion and leadership have increased. 33Example: A research project in Bombay assessing how effective children could beas agents of change, found that children were quite successful in offering ORT indiarrhoea cases and in motivating families to accept immunization. The childrenorganised a procession in the streets and enacted a play about the consequences ofnot being vaccinated. A UNICEF sticker was put on the door of each house wherethere was a baby up to a year of age, and the mother was encouraged to take h91baby to the immunization centre. Coverage of 85o/o was achieved for tnird doses.22

Suggestion C: Reorganise the programme to intensify home visit-ing, making sure that support services are in placeto support the anticipated increase in utilisation.Example In the rural health zone of Katana in Zaire, a management teamaddressed the problem of under-utilisation, on the proviso that the solution requiredno new financial resources. After collaboration with local nurses, the team suggestedintensive home visiting by VHWs living in six villages. By asking the VHWs toidentify women who were not in the habit of using clinic services for curative care,and then confirming the selection by consulting clinic records, 25 mothers fromeach village were selected to participate, A one-week training reviewed the goalsand strategies, and offered a refresher course in health education techniques andmessages. The nurses were advised on techniques for supervising the VHWs andwere provided a newly formulated supervisory checklist to guide them in evaluatingperformance and offering feedback. Over the course of six months, the mothersreceived one home visit per month by a VHW. Each visit began with the completionof a brief questionnaire to survey the mother's current understanding of healthrelated topics and to assess her recent participation in child survival services. Then,the VHW counseled the mother on topics such as the completion of the vaccinationseries, management of diarrhoea, treatment oI tever,and prevention of malnutrition.Throughout the period, the local nurses conducted weekly supervisory visits to theVHW making home visit rounds. Over this six-month period, mothers'knowledgeof childhood illnesses and the utilisation of child survival services improveddramatically. Utilisation of preventive services rose from 33% in the first month ofthe study to 88%. similarly, utilisation of curative services rose from 26% to72%.9



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Suggestion D: Disperse service sites to increase outreach efforts.Example In the health zone ol Zongo (Zairel, an alternative strategy for increasingutilisation rates was tested. After consulting local officials, and health personnel,the zonemedical officer decided to test the impact of dispersing the sites of growthmonitoring and vaccination sessions. At least once a month, these services wereofferedby-local nurses at a distance of five km or more from the health centre andfrom all other outreach sites. A total of 202 mothers in the catchment area of twoseparate health centres were surveyed both before and after the 9-month interven-tion period. The intervention led to increased participation in the immunizationprogiu*-", from 3970 to610/o. Furthermore, the outreach effort was also associatedwitf, an increase lrom 44o/o to 610/o in the use of clinical services for curative carein the event of an episode of childhood illness. Finally, the dispersion of preventiveservices also provid-ed additionaloopportunity for the identification and referral olsick children requiring treatment''

Problem 4:

Suggestion A:

Family planning activities are hindered by a lack ofsupport from influential village members who holdnegative impressions of family,planning based onreports from dissatisfied clients.*Examine the quality of services and determine wherethey can be improved.

Quality oI care is increasingly being recognised as an important deter-minant of contraceptive acceptance and continuation. One framework forquality of family planning services emphasises six basic elements:o Choice of methods: number and variety of methods offeted. Information given: methods available, their use, potential side effects,service arrangements, etc.. Technical competencq providers' competence at performing clinicalfamily planning services. lnterpersonal relations: clients' perceptions of their interactions withservice providerso Mechanisms to encourage continuity: media campaigns, home visits,appointments, etc.o Appropriate constellation of services: convenience and acceptability of

services to clients



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Example A study was conducted on the impact of information given to clients onIUD continuation in Mysore, India. women who had accepted the IUD at theMysore branch of the Family Planning Association of India during the period from1983 to 1986were followed and interviewed in 1986 and 1987. coniinuers anddiscontinuers exhibited differences that have important implications for the qualityof care delivered by clinics: IUD continuers were more likeiy than discontinuers tohave received information on side effects prior to acceptance; continuers were morelikely than discontinuers to have received information on alternative methods. Thel2-month continuation rate was 63% among women with incomplete information.compared withTlo/o among those with more complete information.zgSuggestion B: Identify dissatisfied clients and visit with them todiscuss problems and provide advice or educationwhere needed.Example: In a district of the Indian state of Andhra Pradesh. dissatisfied clientswere identified and met with. Problems were discussed and resolved, when possible.Mllage leaders wereo"informed of the action taken. opposition to the programmedeclined over time. zo



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Management function: Information,education, and communicationGood communication and rapport with clients can stimulate use ofservices. People respond positively when they teceive privacy and respect,are treated with empathy, and have their questions answered. Communi-cation involves the sharing of ideas, knowledge, attitudes, and feelings. Ifefforts to communicate health messages do not achieve the results intendedit may be for one of the following rdsonS:The message may reach only some of the target audience because fewcommunication channels are used. For example, some health pro-grammes may rely heavily on printed materials such as posters andleaflets, or on radio and television to reach people who have no accessto these media.The message may be received but not understood. For example, themessage may be expressed in the wrong language or dialect, or useinappropriate or technical terminology.The message may be received but misinterpreted and applied incor-rectly. For example, mothers who are taught to use ORT may use too1nuci1 water, which makes the solution ineffective, or too little, makingthe solution potentially dangerous.The people may receive and understand the new information but beunabie to act upon it because of their poverty, or because basic servicesare not available. For example mass media campaigns can increasecommunity demand for packets of oRS, but if the packets are tooexpensive or unavailable from the health services or private pharmacies,the money spent on such campaigns is wasted'The people may receive and understand the information, and learn anew -hejlth aciion correctly, but the knowledge may conflict withexisting attitudes and beliefs. For example, mothers who are.taught tocontinJe feeding a child with diarrhoea may not act on this informationbecause it conflicts with traditional belief that the stomach needs to berested during diarrhoea.

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L4. The people may receive the information but change their behaviouronly temporarily because of disappointment with the results. Forexample, mothers may learn to prepare and administer ORT correctlybut lose faith in the therapy because what they want is a treatment tostop diarrhoea quickly rather than prevent dehydration.Communication breakdowns of this kind are not inevitable. They canusually be avoided if communicators first try to understand the atlitudes,beliefs and social factors that determine people's health behaviour.+r

Problem 5: Parents do not recognise the need for immunization.Suggestion A: Education campaigns can help raise awareness. Inagricultural societies, one could try to educate bycreating a parallel between the effort put into landor livestock and the health of their families.

Example In Yemen, there were difficulties in getting villagers to accept the needfor immunization of their children. However, villagers were concerned about asudden attack of Rinderpest disease in their cattle. Health workers recognised thisconcern and made arrangements for the cattle to be immunized. Once the villagersrecognised the value of immunization for their cattle, there was a much greaterinterest in immunization for children.Example A similar situation arose in Guatemala, where the community was moreconcerned about an illness among the chickens than about the need for medicalcare. Once the poultry problem was diagnosed as Newcastle disease and veterinarytreatment was made available, the community became interested in its own healthproblems and developed its own community health p.ogra-*e-l

Problem 6:

Suggestion A:

Despite high recognition of ORT among mothers,key messages about preparation and administrationare not being conveyed to mothers.Re-examine the quality and effectiveness of tech-niques being used to teach mothers about prepa-ration and administration of ORT. Encouragemothers to put into practice what they have learned.Go beyond evaluating only inputs and coverage, tomore thoroughly assessing and monitoring the pro-cess of service delivery.



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Extensive field experience with ORT has demonstrated that programmesuccess depends on effective communication between the mother andhealth *ork", to ensure that behaviour changes. systems analysis datarevealed that health workers, whether in the home or in the health centres,iiequently did not convey key messages, and that encounters were generallynot used to encourage motirers to put into practice those messages thatthey did understand. Operations research has shown in many countriesthai while mothers know of ORT, few can prepare and administer itcorrectly.Example: An ORf programme in The Gambia used mass media to promote theuse of a home-make ialtlsugar solution. A common container suitable for measur-i"g OnS ingredients was forind, and mothers_were told how to prepare the solution'Vt6tn"r, wJre also told how to administer ORS, how to determine if their child wasiiprt"i"g, "nd to seek help if the child did not get better..Experienced mothersruno nua -U""n trained in OIiT techniques flew "happy baby" flags over their homes'f"f"if,"rr were told thit they could go to the fiag holders for help with ORT'b;;;;;"tary (and pre+ested) radio, print, and face-to-face instructions rein-forced one another to have maximum impact. A contest was launched, in whichmothers could win small household items if tn"y mixed the solution correctly' The""-"r.f

*i"ning mothers were entered in a grand prize drawing for 15 radios' The;il6; i;t.i;s oit tn" -orl mothers for the contelt each week received a S0-kiloiuf;f *s"i"".a a 100-kilo bag of rice. Unlike other programmes in which theincentive was given to n"uttn w"orkers, in this one it was given to mothers' After"igni -r"tns Jf promotion and training, the number of mothers reporting usingOilf .fi-U"a from 3%o to 48o/o of all diairhoea episgles. The number of motherswho could recite the formula rose from Lo/o b 640/0'27

Problem 7:Suggestion A:

Family planning messages are not well receivedbecaule of strong religious influences'Combine family planning efforts with other helpfulinformation aUout healtlipromotion or other healthtopics, such as nutrition, which may be perceived asmore relevant. By demonstrating a practical linkbetween the two topics, family planning messagesmay be made more "palatable." Integration of ser-vices has been shown to be more cost effective thandelivery of separate services.



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Mothers are not alert to changes in their child'sweight that may signal the initihl stages of malnu-trition.Use cultural or traditional indicators to encourageawareness of growth. Emphasise size, using clothingas a useful indicator. Wth poor growth, clothesbecome loose around the body or are still a good fitmany month later. A survey in India found thatmothers used indicators for growth such as the childbeing heavier to lift or outgrowing her clothes.As malnutrition is not aways evident to mothers,give her a mental checklist of four or five key signs

and symptoms to look for that serve as a cue to bringthe child to the health centre such as: poor appetite,listlessness, not urinating enough, repeated colds orinfections, etc.Eximplet It is customary in central Ghana, as in many cultures, to make a stringof beads for a new-born and put it around the waist, wrist, or legs. It is intendedfor decoration but used by many parents to assess growth. One mother explainedthat by the time the child had reached the age of five months, the bead stringutouni the waist should have been changed or adjusted five tjmes. Other itemsmentioned included metal bracelets, necklaces, and finger rings.rProblem 1O: Mothers do not recognise the importance or utilityof growth monitoring.Suggestion A: Growth monitoring activities may be too focusedon weighing and plotting growth charts for data col-lection. There may not be enough feedback and edu-cation for the mother. Tell the mothers the results;whether their child has gained, remained the same, orlost weight. Discuss the reasons for the child's failureor success in growing. Give concrete and understand-able recommendations. Involve the mother interac-tively in the process by:

Encouraging the mother to weigh her baby herself,keep the growth monitoring card, interpret the child'sgrowth, and act on the results,Basing interpretation and action on weight change.



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. Weighing frequently, as often as every month or two,if feasible.. Feeding back monitoring results to the mother im-mediately, so she can take eflective action and seethe impact of her actions.5Example: Mothers often leave growth monitoring sessions without knowledge oftheir child's status or specific action to take. Focus on counseling skills that involvethe mother to the greatest extent possible. These skills can be taught intraining, or by supervisory example and guidance on the job. Supervisors them-selves often fail to discuss and explain issues and information with workers, settinga negative example for workers regarding communication and information sharing.Those responsible for growth monitoring can make it a point to provide each mother

with information about her child's growth and some concrete piece of advice tofollow until the next session. Several countries have successfully implemented schoolprogrammes to teach students about nutrition and growth monitoring. Studentsmonitor their siblings'growth and help mothers adopt good nutritional practices.Problem 1l: Health workers have difficulty convincing mothersof the importance of breast feeding. Efforts are oftenundermined by perceptions and media messages that

bottle feeding is "modern" and "better."Suggestion A: Communicate and reinforce health messages interms of traditional beliefs and value systems. Avoidpaternalistic or threatening messages; use a positivepsychology to educate.It pays to take the trouble to find areas ofagreement between the various knowledge systems.Adopting new ideas is easier and more dignified if theyrelate to existing knowledge systems.Example: A nurse in the maternity ward in a hospital in the yemen Arab Republicwas trying to convince a mother who had just given birth, of the benefits of breastfeeding. Breast milk, she explained, contained antibodies against diarrhoea, did not9os1 glv money, was cleaner and easier than bottle feeding, and was a gift fromGod. The mother was bottle feeding her child and believed snl aia not have enoughmilk to breast-feed her child. At this point, another nurse came over and said tothe mother, "You know, nowadays children are growing up without close bonds withtheir mothers because they were not breast-fed." The mother's attitude changedinstantly, and she began to take an interest in the benefits of breast-feedirrg herchild.



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Supplementary feeding programmes do not rein-force behaviour change or independence.Involve mothers by setting up a nutrition fund,training them as peer counsellors, etc. Remove ele-ments in your programme that encourage them to bepassive recipients.

E-.-pl", A" innovative activity in a programme in Thailand has been theestabliihment of a nutrition fund at the village level. Each project village is given astart-up fund of about US 5150.00 in materials and foodstuffs to start producingsupplementary food. Community members are given the opportunity to buy sharesto'add to the starting capital, *hi.h th"n entitles them to the profit generated,bythe sales of the suppLmentary food (about US 50.10 per 100-gram package)' In thisscheme, third degree mainourished children receive the package free.Exampie, A study in'Ibgo selected mothers from among the regular participantsat growth monitoiing s"sionr at a nutrition centre group to be trained as peercorinsellors. They conducted home visits to other mothers to reinforce healtheJucation *nrrui"r. Prior to beginning their home visiting activities the mothersparticipated in a*2-day training iession which covered procedures for conductingi,o*" uirits and basic iechniquls in health education. They also learned the use offictorial guides to help record information about messages communicated duringihe visit. I-t was concluded that mothers could help extend nutrition centre serviceseffectively. Futhermore, mothers reported that they were more comfortable beingvisited by other mothers tuth"ll!9tt-ly.jlinffil!Suggestion B: Recommend appropriate local foods which are al-ready in populai use for other nutritionally susceptiblegroups, such as the elderlY.

@amPithoWeaningFoodsProjectinNepalbeganasa*pple-entury feeding programme for mothers and pre-school children. Theprogramme *u, .or,l-y, exferienced several distribution problems, and createdlnd-esirable dependencies. A nutrition survey was conducted to identi{y appropriatelocal foods and current infant feeding practices. The survey of weaning age childrenshowed that all were breast feeding Uu1 tnut many were malnourished because theydid not receiveenough well-balanced supplemenial foods. The investigators noticedthat almost all mothLrs knew how to piepare a nutritious and popular traditionalsnack of beans and cereal grains, which were sometimes ground and mixed withmilk or water to prepare a gruel for elderly pople. Staff believed that a low-costweaning food couid be made in the same way A nutritious mixture was developed,and edulation on its preparation and use was included in an integrated campaignto reduce malnutrition via promotion of weaning foods, ORT, and growth monitor-



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Management function: Information systemsand record keepingManagement information systems provide workers, managers, donors,and community members with the information they need to plan,implement, and monitor service delivery and support activities. It is asystematic way of collecting, reporting, and using data at all programmelevels, and is organised around key indicators that measure a programme'sprogress toward its goals.Better record keeping promotes eflective supervision and monitoring,can aid in the evaluation of worker's performance, and can help monitor

progress and identify problem areas.Problem 13: Referring providers do not learn from their referrals.Suggestion A: Adapt referral forms contain a space for the hospitalphysician to write a brief note on the diagnosis andtreatment that the patient received at the hospital.Each month, when a staff member from each healthcentre visits the hospital, he/she collects the accu-mulated forms, which have been kept separately foreach clinic and distri-b.utes them to the provider whoinitiated the referral.34Problem 14: Semi-literate CHW's cannot easily record and reportinformation, identify needed information, or usehealth records to determine major health problemsand the families affected by each.

Preparc "rainbow" family cards with coloured tabsacross the top, each in a distinct colour.Suggestion A:Example Each coloured tab corresponds to a different condition, such as preg-nancy, need for vaccination, malnutrition, etc. If a given condition is present, thecorresponding tab is folded up. Otherwise, it is folded down. The cards are storedin a file box. Each month. the tabs are counted. The count indicates the relativemagnitude of the problem and trends from previous months. In addition, thefamilies with unfolded tabs can be identified for visitation by the health worker eachmonth. This system was developed by Fondacion CIMDER, Universidad del Valle,Cali, Colombia.

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Suggestion B: Make charts easier for CHW's and mothers to useand understand. Many forms are difficult to plot, read,or understand. In Mombasa, an AKF programmeintroduced an innovative "pictorial register" to dealwith this problem.Example: In Thailand, the PHC programme developed coloured stickers thatCHWs could stick onto family folders to identify a pregnant woman, an underweightchild, a child with diarrhoea, etc,Example: Kenyan students were assigned to help cHw's with their recording andreporting. They also helped in case-finding and follow-up. This study fbundcollaboration between schools and CHW's to be the most cost-effective teamarrangement for basic preventive services. School children, in addition to learningabout health, llglped monitor siblings and mothers needing growth monitoring anlimmunization.2S'Problem 15:Suggestion A:

Record-keeping and reporting requirements are time-consuming.CHW's should collect only data that will be useful tothem in performing their job. As a rule of thumb,CHW's should spend about t1o/o of their time onrecord keeping and reporting.

Example: An evaluation of a programme in Karachi, pakistan, found that healthworkers were spending up to 49o/o of their time on record keeping and reporting.The programme simplified the MIS by reducing the number of indicatois to bereported oq the frequency of data collection, and the frequency of tabulation andreporting' This made information collected more useful and has significantlyreduced th^e amount of time health staff spend on management iriformationactivities.28Example In India, a village record keeping and monitoring system is kept in aloose-leaf notebook. Included in the notebook are:. a map of the village,o individual family cards, listing family members by age, occupation, educationand immunization status,. pregnancy chart for each woman.recieving antenatal care,. weight charts for all children under five.



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Health workers have service delivery targets, and work with their supervisoreach month to prepare a report comparing actual service with targeted service.Managers are trained to look for unquantified events affecting health, such as:. local employment patterns,o local food prices and availability,. localised disease outbreaks,o changes in the physical and/or natural infrasturcture, oro the existence of other governmental of private programmes affectingnutrition.

They also use monthly and quarterly reports to identify villages that:. deviate from norms established by other villages,o deviate substantially from their own established trends, oro fail to exhibit positive improvements over a substantial period of time.Managers then visit exceptional villages to better understand successes andfailures. In addition, every village conducts an annual review to assess programmes,review progra-mme operations, and set goals and operating procedures for thecoming yeai.24

indicators.Example An analysis of Thailand's PHC management system revealed that mostof the PHC information from the provinces was sent to the Health Statistics Division(HSD) through a 10-page form consisting of over 200 service activities for eachprovince. ThIs cumbeisoine and expensive system of paperwork placed the greatestieporting burden on peripheral failities. More importantly, the information flowtended to go in one direction only, from the periphery to the central level. Finally,there was little analysis of the information and therefore limited use of the data forplanning or policy making and almost no feedback to the periphery. After severalworkshJps with division managers and provincial-level staff, a provincial-levelanalysis of project information flow and needs was completed and several changeswere madei l,) ihe use of coverage rates (versus counts) was endorsed as the mostapproproate PHC indicators,2l reporting frequency was reduced to no more than"u"ty iour months, 3)the list of essential coverage indicators for PHClchild survivalelements was reduced to seven, 4) a format for feedback reports was agreed upon,which would provide national, regional, and provincial coverage rates for all of theindicators in the system thus allowing for comparisons among provinces and withingeographic regions, a4{ allowing overall progress toward national service coveragegoals to be estimated.ru

23



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24Problem 16:Suggestion A:

Poor record keeping by field workers.Often data collection forms do not have enoughspace to write in. Some CHWs find them difficultand frustrating to use. Have forms with wider spacesto write in. Simplify record keeping to the minimuminformation necessary for day-to-day decision mak-ing.

Example In Honduras, it was found that not only illiterate but also literate motherscould not understand the vaccination card being used by the MoH. The script wastoo small, the graphics looked like a complex crossword puzzle, and some of thenurses had used roman numerals to write the dates. Even literate mothers couldnot tell the name or number of doses of each vaccine that had been given to herown child or that needed to be given to complete the series. when the MoHlaunched a new immunization campaign, it was decided that this old vaccinationcard should be replaced. Questions posed and answered in designing the new cardwere 1) how to represent the kind of immunization needed 2) how to represent thenumber of doses needed 3) how to indicate when a dose had been received 4) howto indicate the date to return 5) what size should the card be. Participant observationin rural clinics and in-depth interviews with mothers helped planners understandthat Honduran mothers identified the vaccine by the way it is given: if given orally,it is against polio; if a deep shot in the arm, it is against measles; if a superficial shotin the arm, it is against TB; if a shot in the hip, it is for tetanus. of the three diseasesDPT prevents, tetanus it the one most Honduran mothers remember.A new, easy-to-understand, 6-pagecard was designed with illustrations for eachimmunization, showing where the vaccination is given and the number of doses foreach. On the line provided next to the illustration, the nurse now fills in with inkthe date a dose is received and prints in with pencil the date the mother shouldreturn. To determine the optimal size, vaccination cards were collected from publicand private institutions. The vaccination cards used by private institutions werefour times larger than the card used by the MOH; about 5" x 5" versus 2" x 5." Thereason given was to avoid loss of the card. To decide what size was best, the projectplanners following social marketing principles, turned to the consumer, mothers.Three different models were prepared for pre-testing by rural women. Both illiterateand literate mothers understood the new design, whereas only a few of the literatemothers understood the old MoH card. The mothers overwhelmingly preferred thesmaller size, however, as it is easier to carry while also being easy to comprehend.Rural women in Honduras, as in many countries, carry money and valuables in aplastic bag in their brassiere where they feel it is safe. They also preferred thesmaller card because it presented only one, rather than two, vaccines on a singlepage. Coverage for children under five for DPT III and polio increased in two yearsfrom about 55Vo to an impressive 78o/o.The new graphics of 1!re vaccination cardare believed to have contributed significantly to this increase.zt



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EThis experience suggests the following guidelines for vaccination cardselsewhere:. The card must be able to stand on its own. Even if health staff havetime to do a good job of explaining it at the time of vaccination, themother must be able to comprehend it once she has returned home andtime has passed.. The card should show clearly four types of information: 1) whichvaccines are needed,2)the necessary number of doses for.each vaccine,3)how many of these doses have been received, and 4)when to returnfor the next immunization.. The card should be attractive. Illustrations make the card both moreattractive and help it communicate the information.

. The card should be culture-specific. It should be in the local languageand illustrations, if used, should look like local people and adhere tocultural standards.. The size should be neither too small nor too large, large enough tocomprehend easily but small enough to carry easily.Problem 17: Performance records show wide variations amongfield workers. For example, in the same period of time,

some recruit over 100 family planning adopters, whileothers recruit iewer than 20.suggestion A: Examine the factors that could account for thevariations in performance, and develop and imple-ment changes that would raise overall project effec-tiveness.E-"-pt"t F' f"-ily pl*t*ng project in rural Bangladesh, SOPIRET' conducted anOR propct which identified-some differences in practices between high-andlow-performing field workers: high performers tended to carry more supplies withthem, spent more time with non-ubrs, wre more likely to check client suppliesand visited clients more often; the low performers reported encountering consider-ably more religious opposition in their areas, did not cover their prescribedcatchment areai, only visited current users, did not contact younger womel -anddid not discuss side effects. In light of these findings, SOPIRET decided toimplement the foltowing changes: provide field workers with messages and materialsto respond to religious concerns, emphasise discussions of side effects, implementa uniform weekly work plan, and ask low performers to set targets for new adopters.Despite externai disruptions to the programme, modest results were obtained: theCPR rose, use continuition improved, reported pregnanicies dropped, and the low



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26performing field workers halved the-{ifference between themselves and the highperformerJ in the frequency of visits.37Problem 18: CHW'S involved in growth monitoring programmeslack interpretative skills and the supportive technicalstandards needed to properly respond to questions.They are not able to record weights correctly oncharts and have difficulty counseling mothers effec-tively.Conduct a skills assessment of CHWs. Develop alist of skills needed. Design training to emphasiseskill development (as opposed to teaching informa-tion). Provide training individually or in small groupsusing scenarios and role plays. Then conduct on-the-job training until skills are demonstrated properly.Have CHW's practice skills such as correct use andreading of scales, use and interpretation of growthcharts, maternal counseling with actual clients.

Suggestion A:

Example The National Family Nutrition Improvement Programme in Indonesiaused training techniques that involved repated practice of the actual skills needed.It was reported that after three or four weighing sessions, community health workerswith minimal education levels could accurately weigh a child in very little time. Theuse of the local market scale helped make this po-ssible, as it wai a familiar andappropriate technology for the workers concerned.oSuggestion B: Develop simple job aids that willpoints which must be discussedsessions.

help CHW's recallduring counsellingExample After research and testing, the Northwest Frontier Provincial HealthService in Pakistan developed two memory aids to guide service delivery in keyinterventions. These aids would.assist health workers to remember the relativelylarge number of procedures to be followed in delivering a given intervention. Oneof these aids consisted of a series oI relerence guides for each of the interventions,which were placed beneath the Plexiglas covers of examination tables. A modifiedoutpatient dispensary slip served as a second memory aid. On this slip, healthworkers were to fill in or check such key tasks as taking a history, conducting aphysical exam, providing treatment, and cotrnselling patients. A follow-up studyshowed that health workers carried out diagnostic procedures with greaterfrequency. Counselling also seemed to improve in both content and technique.Clearly, memory aids such as these should not be constructed as a panacea for



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28lllillliiliri$ilii;lri::IManagement function: Personnel andtraining

Personnel management ensures that the organisation attracts andretains competent people, that staff can be productive and efficient in theirjobs, and that they are recognised appropriately by the organisation fortheir service.Tiaining serves to continually improve upon the knowledge, skills, andcompetencies of health workers so that service delivery or managementactivities can be carried out correctlu.Problem 19: High attrition rates among CHW'S who suffer froma general lack of motivation and incentive to do theirwork, and often do not feel appreciated by thecommunity.suggestion A: Examine locally available alternatives to increaseCHW motivation and incentives. Upgrade otherbenefits such as opportunities for growth, increasedresponsibility, time off as a reward, travel to a con-

ference, public recognition for their accomplish-ments, etc.CHW attrition occurs for a variety of reasons. Among them are:. Low or irregular salaries. Studies of attrition rates from six USAID-supported projects suggest that attrition rates among CHW's whodepend on community financing are approximately twice the rates ofCHW'S who receive a fixed government salary.Displeasure with limited curative role,i.e., not allowed to give injections.Community acceptance of CHW's can be strained because, whilecommunities generally desire and expect curative care, CHW's aretrained for preventive care.Lack of community respect and support. Address how CHW's arechosen, and their roles defined. Too often a CHW is imposed on acommunity, or a community selects one for the wrong reasons. Involvethe community in choosing CHWs: make sure they understand whatthe CHW's role willbe, and the CHW understands what the communityexpects.



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Few opportunities for training, upgrading of skills.Lack of support from the project, i.e., travel, regular visits from centralstaff, regular feedback, etc.Inadequate frequency and/or effectiveness of supervisory visits.some countries have found that having the community discuss andimplement financing mechanisms before the CHW is selected helps addressthe problem of CHW sustainability and attrition. A project in Mauritania,for example, requires villages to work out a viable financial plan before aselected CHW can receive training''Non-material incentives are also effective:

. Create recognition for CHW's in their villages by having a health dayat the school or church and recognise them and their efforts publicly.o In some areas of Honduras, the Ministry of Health gives CHW's pictureI.D. cards. These help create a sense of belonging to the institution aswell as increasing their respect and position in the community'o Possession of charts, pictures, and simple equipment can help CHW'scommunicate better as well as enhance their status.o Another possibility is to routinely collect contributions to pay the CHWfrom the community. This can take the form of produce or in-kindservices. In Swaziland, for example, the community plowed the cHwsfield.At monthly meetings, teach cHW's a new concept or skill, conductrefresher courses to review knowledge and improve skills. In one case'interviewing of CHW'S, community members, and supervisors led toidentificatio-n of factors leading to attrition. Among them was a desireto learn more about curative services, which was incorporated intraining.

Career ladders are important for job satisfaction and retention. SomecHW's in Northern Pakistan have gone into training as Lady HealthVisitors, while in other countries, some have become "senior cHw's"and trainers after two or three years service. When they reach this level,communities may be more willing to pay them a stipend, since thisrequires more work, but also because it provides them with moreprestige.Provide free medical care to the CHW and his/her family'Exemption from military service' 28

aa

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Many countries also finance CHW's (partially) through:o Use of drug profits; this can be problematic - profits are too smalland irregular, and it encourages prescriptions. Fee for servicq in Bolivia and Kenya, some projects allow the CHWto charge a small fee fior curative care and MCH services.Social events can help develop a sense of camaraderie and show thatefforts are appreciated. Arrange to give out awards at a social event tofamily planning field workers with the longest continuous acceptors, or whohave the most new acceptors who have been educated appropriately, or forthe health worker whose clients can correctly describe how to mix ORT.Post the award in the health centre for all to see.

Example: Lack of funds is obviously problematic. Ideas from a project inNorth-western Somalia offer some low-cost alternatives:o Water tax on the village pump; a certain amount per household pays for a CHW,pump maintenance.o Shop and tea shop cash collection; travellers from outside the village indirectlysupport community health.r Insurance type collection; payment of a small fee. Payment-in.kind; once-a-year livestock or grain collection.r Waived village fees, e.g., for water.3Example: A Kenyan study provided different sets of incentives to three groups.One received token payments and a newsletter, the second received communityrecognition and lapel pins, and the third group received all of the above as well asdiplomas for "healthy households." A healthy household was defined as one in whichall children under five years were fully immunized, which had a clean water supply,which maintained adequate nutritional status for children under five, and whichpractised family planning. The study found no difference in the performance of thedifferent incentive groups, but all group areas showed improvement in healthstatus.zc

Suggestion B: Keep in touch with field workers not only at regularmeetings/visits but by commenting on their reports,offering praise where it is due. At monthly meetingsencourage a two-way flow of information. Givefeedback on the results of their work to encouragecommitment to the organisation and job. Discuss



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performance and problems and, where possible, de-velop new strategies together.Feedback to workers is critical, not only to improve their morale and

effectiveness, but also to give them an incentive for reporting correctly.Feedback can include:. suggestions for improving record-keeping. information that might be helpful in preventing or solving problems. results of home visits to patients (or referrals). congratulations on doing a good job in delivering a service36Feedback should be task-related, prompt, action-oriented, motivating,and constru ctive.42

Example Profamilia, a successful family planning project in Colombia, addressedtnir i.r'u" by rotating field workers into the health centre for a day so they couldexperience in" n"dtn project from the manager's perspective and gain an under-standing of the system and organisation.Problem 2O:Suggestion A:

Family planning workers are not accepted by thecommunity.Examine recruitment procedures. People hired asfield workers should be credible and acceptable tofamily planning acceptors. Known characteristicsof the community should be considered when re-cruiting family planning workers.

Recruitment should be done using a job description outlining what theresponsibilities willbe and the skills and qualifications necessary to accom-pliih them. Include attitudes and personal qualities you think the personshould have. This willensure tllqt you hire someone who can do the workand with whom you can work.*"A PHC project in two Bangladeshi upazilas found the following selectioncriteria of CHW's useful:. CHW'S should be permanent residents of the village. Avoid temporaryresidents and job seekers.. CHW'S should have good reputation in their area and be acceptable tothe people in their locality. Preterenceshould be given to traditionalbirthattendants, traditional healers, women, retired officers, and those who arealready doing social work.Problem-solving; Personnel


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32. Some basic education preferable. However, enthusiastic individuals activein community service can be selected even if they are illiterate.Preferenceis given to married women above 20 years oI ige.aoExample: In Bangladesh, field workers whose characteristics are closer to those ofthe eligible couples in their areawerefound to be more effective in promoting familyplanning. Important characteristics matched were language, socio-economic status,and residence in the local area. Credibility is extremely important. In general, femalefield workers were better able to motivate and serve female clients than male clients.Projects that follow formal procedures for recruitment, promotion, an{ terminationperform much better than those that do not follow such procedur"r.38Example: In Indonesia, it was found that at the provincelevel,midwives were moreaccepted as providers of family planning services, although they needed generalmanagerial and salesmanship training. o/

Suggestion B: Encourage satisfied users to advocate contraceptiveuse. They can be especially effective as family plan-ning promoters and contraceptive distributors.Project experience has shown that women counseled by satisfiedacceptors are less likely to discontinue use than those counseled by amidwife^.alone; satisfied users are better able to reduce the fears of sideeffects. tt Often, the adoption of a method by a charismatic and respectedlocal person can lead to rapid dissemination of the same method in a village.

Example: In Sri Lanka, satisfied acceptors with high community standing wereencouraged to motivate other mothers. This approach was found to be successfuland cost-effective. Satisfied acceptors were dffective in counseling womgn whobelieved temporary modern methods have too many negative side Jffects. 37Problem 21: There are not enough health workers to provide

Suggestion A:elfective coverage. The programme is not having astrong impact on family planning acceptance, or onreductions in fertility.Help CHW's take a selective approach to servingclients.

Example: Field workers should give maximum time to top priority couples, thosewith three or more children, the wife being under age 35. such couplel could bemarked in red on target couple registers for easy visual identification. This planwas implemented in aproject in India and made a considerable contribution to thesuccess of the project.z



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Suggestion B:33

Reduce client-worker ratios to increase frequency ofcontact. Field workers should spend more timewith new acceptors.

The use of paramedics to distribute contraceptives is beneficial forseveral reasons. In developing countries, they already offer fairly widecoverage of the population. Thus, once they are trained, they provide anextensive base for contraceptive service delivery. Physicians generally leavetheir villages to work in the cities, where the pay is usually higher, butparamedics tend to live and work in the vicinity in which they were raised.Also, because they work in the same area in which they live, paramedicsoften have long-standing relationships with their clients, which contributesto improved contraceptive use and longer continuation rates. Paramedicscan db much to extend contraceptive use and thereby reduce the incidenceof unwanted pregnancies. This, in turn, reduces medical complications,unsafe abortions,lnd maternaldeqihs. Such benefits greatly outweigh therisks attendant upon contraceptive use.

Example: In a project in rural Bangladesh, reducing the client-worker ratiosenabled field workers to complete their visits on time and allowed more time to bespent with each couple. Iqcreased home visits have been associated with increasedctntraceptive pr.u ui.n ".2lSuggestion C: One very eflective way to increase coverage is toauthorise paramedic personnel to distribute contra-ceptives.

Example A pilot study in Thailand demonstrated the safety and effectiveness ofallowing paramedics to dispense oral contraceptives, usin-g a simple checklist forcontraiidications. Following the success of this trial, the Ministry of Public Healthruled that all auxiliary nurse midwives who had received basic fhmily planningtraining were authorir"d to dirttibute the pill. This immediately increased the totalnumbei of providers offering the pill from approximatbly 350 to 3,500. The numberof acceptois rose from only 25,000 in the three months prior to,the ruling to over35,000 in the three montirs afterward. One and a half"years later, over 80,000women accepted the pill in a single three-month period. ""



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34tP;#$$i$$i:s$i;1\tE\\-a$,qsnr:i* $(.qi'Hrl[-!iFii;ii.il;lii.i.iiii:: ii;lllliflIl{llllll$til-q-\iiiij.{t#i"

Management function: LogisticsLogistic systems deal with the procurement, storage, and tracking of

supplies and equipment in order to ensure that drugs, materials, equipment,and transportation for service delivery and support services are available.Problem 22:Suggestion A:

Problem 23:

Refrigerator records show storage temperatures areabove those required for vaccines.Have only one person be in charge of monitoringthe temperature. Provide supervision to ensure thisis done every day. Make sure health centre staffunderstand the importance of the cold chain. Havea plan for each centre to follow for power outages.Have a kerosene supply for gas refrigerators. Makeone person directly responsible for cold chainmaintenance.Weighing data are often inaccurate because of suchfactors as using inappropriate scales, such as bath-room scales. Scales are not calibrated before eachweighing session, and are not set to zero before eachweighing; children are rarely fully undressed whenweighed. Age reporting as well as weight plottingare often inaccurate.Review equipment maintenance procedures andweighing protocols.Suggestion A:

Example: In the Philippines, modest improvements were observed after mainte-nance procedures were developed for scales and a manual prepared for staff athealth units. In-service training was conducted to improve workers' weighingtechnique as well as refresher training to improve weighing skills and ability tocalculate age correctly.

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Mangement function: SuPervisionThe supervision of personnel serves many critical purposes. It ensures

that staff perform thlir duties effectivelg through support, guidance,on-the-job iraining, and assistance in identifying and solving problems. Itis a means to motivate and boost the morale of staff; to provide continuingeducation and advice; to enhance field worker's credibility in the eyes ofcommunity members; to assess quality and quantity of staff efforts; and togather othier information which can be fed back to programme staff andcommunity members.Fieldworker performance has improved when supervisors make homevisits with workers and question clients about the worker's activities in thep."r".,." of the field worker, when supervisors discuss the client's Prgrblemwith the field worker, and when the supervisor visits clients'homes.'^

some general strategies to consider to improve supervision:. A regular village visitation programme where staff spend one full week"unry t*o months - nearly six weeks per year - in.each community canbe ai essential part of efforts to reinvigorate health workers and restarthealth-related ictivities in the villages, if they have slackened.. Regular meetings with CHW's ensure that potential problems can behandled early on'o Use two-way oradios, especially in isolated areas' to supervise, inform,and motivate.'Problem 24: Ineffective and infrequent supervision of CHW'S.

Suggestion A: Supervisors should use guidelines andchecklists foractual tasks performed by staff and field workers'Have supervisors emphasise feedback on technicalskills raiher than on administrative ones' Staffshould have a job description and performance ob-jectives to know what is expected of them and howiheir performance will be appraised' Cqnduct peri-odic performance appraisals to make sure objectivesare met and to discuss any problems CHW's arehaving.42"CHW'S have been found to benefit from high quality and frequentsupeivision and from unusually motivated community organisations; wherethese have been lacking, CAW'S have poor morale and high dropout

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Example: In Bangladesh, a community-based service project active in 24 urbanareas identified problems in client coverage, record keeping, planning and supervi-sion. Three -uttug"*"ttt interventions (work plans for field workers, a reducedclient-worker ratio, and a simplified record-keeping system) helped improve cover-age, supervision, and services, The most ellective of these interventions wasthought to be the work Plan.

Work plans expanded coverage- The new work plans set up aschedule for field workers to visit specific clients and ensured that allwould be visited during a 1-2 month cycle. Most project staff and fieldworkers understood the rational for the work plan and prepared themon a monthly basis. The main advantages were 1) they systematisedthe activities of the workers; 2'l they ensured regular visits to MWRA's;and 3) they facilitated supervision. The main disadvantage was "serialvisiting." All women had to be visited in turn, which precluded revisitsto those women who needed to be seen sooner.Better record keeping and improved monitoring. The newsystem was simpler and less time-consuming. The main advantages:1)ii systematised record keepin g; 2\ helped promote eflective supervisionand monitoring;and 3)helped in evaluating field worker performance.The main drawback, it didnt produce all the data needed for reports todonors. Thus, both the new and the new and the old system operatedside by side, which increased the workload.Reduced client-worker ratios improved coverage. Two of thethree projects that implemented this intervention hired additional fieldworkers and adjust"d some of the catchment areas to reduce theclient-worker ratios. The third project increased the number of assignedcouples per field worker, thus increasing the ratio. where the ratios*"te r"du."d, staff reported that the main advantages were that:1) fieldworkers completed their visit cycles on time; 2) more time could bespent with each couple; 3) more low-parity women coqld be recruited;and 4) new acceptor targets could be more easily met'"'Problem 26: lbo many tasks are assigned to cHws. Tasks do not

Suggestion A:have a clear priority.Institute work plans for field workers to help sys-tematise activities and establish priorities.

An effective work plan minimises travel time, maximises client con-tact, and systematicaliy covers all eligible clients in the assigned catch-ment area.

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Example: The village health centre personnel in some rural health centres inHonduras wilt not provide consultations unless the mother presents the child'svaccination card for verification. Children who are missing vaccinations are easilyidentified, and the importance of immunization is emphasised at each visit.Example At a health centre in Manila, a campaign was started that introducedchanges designed to reduce missed opportunities;l) measles vaccination was madeavailable for use at least once a week in every health facility, and the health facilityremained open until 8 p.m.to allow working mothers to bring their children, 2)there was a relaxation of wastage allowances so that the health workers could opena new vial for only one child, and 3) a communications programme was initiatedamong health centre staff about the importance of measles immunization. A surveyperformed after the introduction of these interventions showed that missed oppor-tunities for measles decreased by 20 prcentage points'lg

Problem 28: Lack of supervisory control in growth monitoringand counseling activities.Suggestion A: Consider using protocols that divide the growthmonitoring process into discrete tasks and specificactions to be performed. Once developed, they canbe extremely helpful throughout the training, irrl-plementation, and evaluation process. Supervision

iystems that use this system and provide direct andconcrete feedback to workers on how they canimprove have been found to be quite eflectlve.Many project reviewers have emphasised the importance of developingand using performance guidelines that divide the growth monitoringprocess into at least five discrete tasks (motivating, weighing, recording,interpreting, and taking action) and then clearly describe the specificbehaviours or actions that need to be completed at each step. They may

be developed initially for a variety of purposes, such as training, to serve aschecklists for supervisors or workers or to^serve as tools for systemsanalysis, project monitoring, and assessment27When developing a supervisionfollowing elements:. targeted supervision schedules. supervision forms

o task performance normso training of supervisors. improved supervision "style"Problem-solving; supervision

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40r time available calculations. number of supervisors available3SExample: A study in Togo had supervisors spend more time at health centres. Aday's activities were observed rather than just the growth moriitoring session.Feedback was provided to staff at the end of sessions. Supervisors focused on skillssuch as balancing the scale, reading and plotting weight, communicating results tothe mother. Findings were used to train personnel in calculating a child's age,interpreting the growth curve, tailoring individual recommendations.Supervisors also took note of counseling, observing whether mothers received.specific messages, whether the chart faced the mother when she was receivingfeedback, and whether mothers were able to interpret the chart.Supervisors identified and corrected mistakes and interacted directly with thestaff and mothers. Staff showed increased motivation and made fewer errors.Mothers became more active in interacting_wlth staff in identifying and resolvingproblems related to their children's growth.d

Problem 29: Lack of organisation in growth monitoring,/ supple-mental feeding projects.Suggestion A: Implement new selection criteria to focus the pro-gramme. Select those children who are most mal-nourished and those whose growth is faltering.Weigh these children each month and provide spe-cific steps and strategies for the mothers to under-stand and resolve the problem.

Organisational problems can be related to the size of the session andthe amount of time available for weighing and examining, interpretinggrowth charts, receiving information from the mother, and providing resultsand advice. Programmes in Togo and other countries have reorganisedclinics so that mothers distribute food, increasing counseling time andreducing overall session length.

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Example The Kasa Project in India makes sure that those children who arenutritionally at risk - those who have low nutritional status fail to gain weight e','crythree months, lose weight over two months, or are sick - are weighed every month.Other children are weighed every three months'Example In the Dominican Republic, participation criteria include both age andnutritional status. All children under five are weighed once ever six months in orderto compile a community profile; then high-risk children are selected and weighedmonthly. These children include all those under one and children three tg-five whoat"'cias'sifi"Jas -ufnourirnJ oi*no f'taue "ot gainea sufficient weigl'tt.$Suggestion B: Limit the number of children in one weighing group.Often weighing groups have"fifty or more childrenin them. Divide weighing groups so that each hasno more than 40 children. Have these groups comein for weighing on different dates.

bxampler A health centre in Honduras divides groups by degree of malnutrition,thus allowing specific and targeted communication with mothers.

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42'.s$iiigffiA-{. S$iiffi#+r$rl3}:jaEffii.ii:i,.r iiitiiiittet--$:;-*.ijjjjjjl,t--,1,iiii*iliai,tii.iir:.:$iil{,iiiProblem-solving process*

Frequently we talk about identifying, analysing, and solving problems.But there are also "opportunities for improvement," areas where there maynot be obvious problems but where a process or procedure could beimproved. Dont overlook them. Problems and opportunities can bethought of as the "gab" between what is happening and what is desired. Bycorrecting problems and making improvements you willclose that gap.Step t ldentify, select, and define the problemBegin seeking out potentialproblems or areas for improvement throughexisting information or data. Many teams have begun this process bybrainstorming to list khown areas of problems and frustrations. If the teammembers do not have ideas on potential problems, then you need to gathermore information from other staff.As you develop your list of problems, there are some dangers. You shouldbe aware of them so-you can avoid them or take corrective action whenthey are discovered:. You can become overburdened with problems; identifying more thanyou can handle.. You can raise y6ur people's expectations so that they believe that youor someone else will fix their problems immediately.. You can get side-tracked and identify others' problems but not yourown.

' Adapted frun; Peace Corps training, 'Continuous quality improvement and the problem-solvingprocess; continuous medical edrrcation.'Peace Crops Office of Medical Services; URC/CHS,1992.

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problem-solving processA gap between what is happening and what you want

Identify, select, and define the problem and clarify thedesired resultsSeek out potential problems or areas for improvement. Definecriteria for selecting the most important problems' Define theselected problem operationally: how do we know it is a problem?Determine how we know when the problem is solved by Bninrlsbcriteria for success. This is NOT the same thing as defrning thesolution. Choose a team to work on the problem.Learn everything about the existing processDetermine where and when the problem is occurring. Understandthe process in which the problem occurs.Determine the basic causes of the problem or where theprocess is flawedDetermine the factors that contribute to the problem. Use tools togenerate and test hypotheses about possible causes of the problem.bollect data to test hypotheses and determine which causes are the"critical few."Identify all possible solutions .Think creatively about how the critical causes might be addressed.Choose

Documents

Manager's Guide_Problem-Solving