THE PHC MAP SERIES OF MODULES.

GUIDES AND REFERENCE MATERIALS

o o

Each module includes: a User's guide a Facilitator's guide

.

Module Module Module Module Module Module Module Module Module

computer programs 1 Assessing information needs 2 Assessing community health needs and coverage 3 Planning and assessing health worker activities 4 Surveillance of morbidity and mortality 5 Monitoring and evaluating programmes 6 Assessing the quality of service 7 Assessing the quality of management 8 Cost.analysis 9 Sustainability analysis

Manager's guides and references o Better management: 100 tips

o

.

o

Problem-solving Computers The computerised PRICOR thesaurus

Production Managers: Ronald Wilson, Aga Khan Foundation, Geneva, and Thongchai Sapanuchart, Somboon Vacharotai Foundation, Bangkok Helene Sackstein, France Design & Layout: Marilyn J. Murphy, Suracha Suntarasut, Somboon VachaDesktop Publishing: rotai Foundation, Bangkok, Thailand and Atthapon Tanoi, Dept. of Medical Sciences, Thailand In 1993 by Thai Wattana Panich, Bangkok, Thailand First Printing: ln 7997 by Veteran Organization Printing Co.,Ltd, Thailand Printing: Second
Published by the Aga Khan Foundation USA, Suite 700,1901 L Street N.W., V\hshington DC, USA. Additional copies are available at the Somboon \lacharotai Foundation, 101

Boromratchonanee Road, Glingchan, Bangkok 10170, Thaland Fax. (662) 44'&.66f,2

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

Dedlcated to Dr. Duane L. Smlth (7939'1992), Dr. Willtam E. Steeler (7948-1992) and all other health leaders, managers and wotkers who follout thelr example tn the effott to btlng quallty health care to all In need.

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An overvi€w of PHC MAP
The maln purpose of the Prlmary Health Care Management Advancement 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 of the Aga Khan Health Network'and PRICOR'. An a<perienced design team and equally experienced PHC practitioner teams in saneral counhieg including Bangladesh Chile Colombi4 the Dominican Republig Guatemal4 Haiti, India Indonesi4 yq Pakistarq Senega[ Thailand arflTane"ha',e urcrked together to der.relop, test and refine the PHC MAP materials to make sure that they are understandable, easy to use and helpfirl" PHC MAP includes nine units called modules These modules focus on essential information that is needed in the traditional management cycle of planning{oing-anl-

k

uating. The relationship between the modules and this cycle is illustrated below

PHC MAP modules and the planning-evaluation cycle

PHC MAP MODULES

l.

Information needs 2. Community needs 3. Work planning

4. Surveillance
5. Monitoring indicators 6. Service quality
7. Management quality

8. Cost analysis 9. Sustainability

1. The Aga.Kha3. Health Network__ includes_ the Aga Khan Foundatiorl the Aga Khan Health Services, ' and the Aga Khan University, all of which are in',rolved in the strengthening of primary health care 2. Primary Health Care Operations Research is a uprldwide project of the Center for Human Services, funded by the United States Agency for International Development

u Managers can easily adapt these tools to fit local conditions. Both new and experienced programmers can use them. Govemment and NGO managers,

management teams, and communities can all use the modules to gather information that fits their rreeds. Each module explains how to collect, process and interpret PHC-specific information that managers can use to improve planning and monitoring. The modules include User's guides, sample data collecting and data processing instruments, optional computer programs, and Facilitator's guides, for those who want to hold training workshops. The health and management services included in PHC MAP are listed
below.

Health and management services
HEALTH SERVICES GENERAL
PHC household visits Health education

MANAGEMENT SERVICES
Planning Personnel management

OTHER HEAI.IH CARE
Water supply, hygiene and

sanitation
School health Childhood disabilities Accidents and injuries Sexually transmitted diseases

'Iiaining

MATERNAL CARE
Antenatal care Safe delivery Postnatal care Family planning

Supervision Financial management Logistics management Information management

HIV/AIDS
Malaria
Tuberculosis

Community organisation

CHILD CABE
Breast feeding

'Iieatment of minor ailments
Chronic, non-communicable
diseases

Growth monitoring

Nutrition education
lmmunization Acute respiratory infection Diarrhoeal disease control Oral rehydration therapy

Several Manager's guides supplement these modules. These are: Better management:7}}tips,a helpful hints book describing elfectlve ways to help managers improve what they do;Problem-soluing a guide to help managers deal with common problems; Computers, a guidebook providing useful hints on buying and operating computers, printers, other hardware and software; and The computerised PRICOR thesourus, a compendium of PHC indicators.

The Primary Health Care Management Advancement Programme has been funded by the Aga Khan Foundation Canada, the Commission of the European Communities, the Aga Khan Foundation U.S.A., the Aga Khan Foundation's
head office

in

Geneva, the Rockefeller Foundation, the

Canadian International Development Agency, Alberta Aid, and the United States Agency for International Development under two matching grants to AKF USA. The first of these grants was "Strengthening the Management, Monitoring and Evaluation of PHC Programs in Selected Countries of Asia and Africa" (cooperative agreement no. OTR-01584-00-8161-00, 1988-1991); and the second was "strengthening the Effectiveness, Management and Sustainability of PHC,zMother and Child Survival Programs in Asia and Africa" (cooperative agreement no. PCD-0158-A-00-II0200, 1991-1994). The development of Modules 6 and 7 was partially funded through in-kind contributions from the Primary Health Care Operations Research project (PRICOR) of the Center for Human Services under its cooperative agreement with USAID (DSPE-6920-A-00-1048-00). This support is gratefully acknowledged. The views and opinions expressed in the PHC MAP materials are those of the authors and do not necessarily reflect those of the
donors.

All PHC MAP material (written and computer files) is in the public domain and may be freely copied and distributed to others.

Problem-solving

Contents
INTRODUCTION Common problems in primary health care . Community organisation .. Information, education, and communication Information systems and record-keeping Personnel and training . . .. .. . Logistics Supervision MANAGEMENT FUNCTIONS: Community organisation Information,education and communication Information systems and record-keeping Personnel andtraining....
1

3 3

3 4 4 5 5

"""

Logistics ' "35 Supervision ....42 PROBLEM-SOLVINGPROCESS problem Sa"p It ldentify, select and define the Step 2: Learn lverything about the eiisting pronlem ' ' ' ' ' ' '45 " '45 Step 3: Determineihe blsic causes of the problem " "46 4t ldentify all possible solutions SaA " '47 Step 5: Choose and implement a solution ' ' improvement solutions ' ' " ' "47 Step 6: Implementing iuality ..... ".51 REFERENCES
ACRONYMS AND ABBREVIATIONS

" " "2L '"""28 ''""34

6 ' ' ' '13

Acknowledgements
The idea for this guide came from PHC managers, who requested a supplement to the PHC MAP modules that would provide practical suggestions for solving problems. Jack Reynolds developed the design for the guide, contributed the first examples, and oversaw the project throughout. Gael Murphy compiled the first draft from material prepared by a number of URC/CHS staff. Maria Francisco and Neeraj Kak prepared a revised draft, which was reviewed by participants at the International conference on the management and sustainability of PHC programmes, in May L992. They worked on revisions together with Martine Hilton to complete the final draft. special thanks are due to Pierre Claquin of the Aga Khan Foundation, Geneva, for his support and interest; several participants of the 1992PHC MAP conference including Peter Mabonga and Jeddah Katimo (Mombasa PHC Programme, Mombasa, Kenya), and Mjay Moses (Aga Khan Health services,lndia)for their suggestions on how to improve the guide; and Julia Friend for conducting the background
research.

we wish to thank all of the managers, consultants and others with first-hand PHC experience who generously contributed their experiences and guided us to other sources. The material for the problem-solving process is based on previous material developed by URC/GHS'S pRICoR and Quality Assurance projects.

Problem-solving

Introduction
"There are no problems, only opportunities." As a member of a primary health care (PHC) management team, you probably encounter a number of problems that demand innovative thinking and flexibility. Many of these managerial problems will be identified
through the tools and techniques in the PHC MAP modules. The modules will also help you identify most of the solutions, as well. Many will be obvious, but sometimes it may be a real challenge to identify an effective solution that will work in your situation. As the PHC MAP modules were being reviewed and tested, many PHC management teams asked for guidelines for problem-solving. This problem-solving guide is our response to those requests. The guide has two principal sections. The first is a compendium of common problems and solutions that come from PHC managers. These are ideas and strategies that they implemented and which worked. We have arranged them under six management headings:

. . . . o .

communityorganisation information, education and communication information systems and record-keeping
personnel logistics supervision

Each topic is first described briefly, together with some key lessons learned. Then a common problem is described, followed by one or more suggested solutions and some examples from field experience around the world. Several problems are presented for each topic, and as mentioned, several solutions are usually presented for each problem. Altogether, there are 29 problems discussed in this guide. The following table shows how they are distributed across management topics, and the specific services
Problem-solving; introduction

2

General Immunisatlon ORT

Famtly Growth Breast planning monitoring feeding

nutrition
Community organisation Information, education, communication Inlormation

L,2,3

4 5

6

7

8,9,10

II,L2

sptems and reord
keeping

13,14,15

16

L7

18

Personnel and
tralning Logistics Superuision

t9
22 24,25.26 27

20,2r
23 29,29

brainstorming, nominal group techniques, cause-effect analysis, flowcharts, and fishbone diagrams. .ln presenting these problems, suggestions and practical solutions, it is our.hope that programme managers, outreach, clinic and hospital-based health care providers and planners will be able to use the suggestions offered as a "springboard" for their own ideas, inspiring them to d-velop appropriate solutions to their own problems.

from which the examples were drawn. obviously, the problems and solutions described could apply to a number of services. Numbers in the chart correspond to the number assigned to each problem in this guide. A summary listing of these problems is at the beginning of the next section. The suggestions and solutions presented in this guide come from a number of sources, including operations research studiel, pHC consultants and teachers, case studies, articles, and trial-and-error experience of pHC managers. 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 can use to analyse problems, identify root causes, and develop appropriate solutions to address these causes. This section builds on'thl'probl.identification and analysis process embodied in the pHC MAp Modules. It also includes some simple tools that you and your team can use, such as

Problem-solvin g; introduction

3
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Common problems in primary health care
The following list summarises the problems discussed in this guide, arranged according to the six management functions described in the Introdluction. Thii list is followed by an in-depth discussion of each
problem, suggested solutions, and examples from PHC managers'

CommunitY organisation
Problem
1:

Even though project interventions are acceptable to individualcommunity members, they do not want to join in activities that would support those interven-

iions, since they perceive that they will enjoy the same benefits whether or not they themselves participate.

Problem 2: Problem 3: Problem 4:

Patients tend to bypass peripheral health units and seek care directly at the hospital outpatient department. Utilisation and support of health programmes are
low.

Family planning activities are hindered by a.lack of tuppotf from influential village members who hold negative impressions of family planning based on reports from dissatisfied clients.

Information, education and communication
Problem 5: Problem 6: Problem 7: Problem 8:
Parents do not recognise the need for immunization' Despite high recognition of ORT among mothers, key messages about preparation and administration are not being conveYed to mothers. Family planning messages are not wellreceived because of strong religious influences. Heavy case loads limit the opportunities for education in the health centre.

Problem-solving; common Problems

Problem 9: Problem Problem

Mothers are not alert to changes in their children's weights that may signal the initial stages of malnutrition. Mothers do not recognise the importance or utility of growth monitoring. Health workers have difficulty convincing mothers of the importance of breast feeding. Efforts are often undermined by perceptions and media messages that bottle feeding is "modern" and "better." Supplementary feeding programmes do not reinforce behaviour change or independence.

1O: 11:

Problem 12:

Information systems and record-keeping
Problem 13: Problem 14:
Referring providers do not learn from their referrals. Semi-literate CHW's cannot easily record and report information, identify needed information, or use health records to determine major health problems and the families allected by each. Record-keeping and reporting requirements are time-consuming. Poor record-keeping by field workers. Performance records show wide variations among field workers. For example, in the same period of time, some recruit over 100 family planning adopters, while others recruit fewer than 20. CHW's involved in growth monitoring programmes lack interpretative skills and the supportive technical standards needed to properly respond to questions. They are not able to record weights correctly on chart and have difficulty counseling mothers effectively.

Problem 15: Problem 16: Problem 17:

Problem 18:

Personnel and training
Problem 19:
High attrition rates among CHW'S who suffer from a general lack of motivation and lncentive to do their work, and often do not feel appreciated by the community.
Problem-solving; common problems

5

Problem 20: Problem 21:

Family planning workers are not accepted by the community. There are not enough health workers to provide elfective coverage. The programme is not having a strong impact on family planning acceptance, or on reductions in fertility.

Logistics
Problem22z Problem 23:
Refrigerator records show storage temperatures are above those required for vaccines. Weighing data are often inaccurate because of such factors as using inappropriate scales (such as bathroom scales). Scales are not calibrated before each weighing session, and are not set to 0 before each weighing; children are rarely fully undressed when weighed. Age reporting as well as growth plotting are often inaccurate.

Supervision
Problem 24: Problem 25: Problem 26: Problem
272

Problem 28: Problem 29:

Ineffective and infrequent supervision of CHW's. Staff have a limited amount of time to perform duties. Coverage, and hence prevalence of family planning use, for example, suffer as a result. 'lbo many tasks are assigned to CHWs. Tasks do not have a clear priority. Opportunities for immunization are often missed, even when a child does make contact with a health facility that is prepared to vaccinate. Lack of supervisory control in growth monitoring and counselling activities. Lack of organisation in growth monitoring/supplemental feeding projects.

Problem-solving; common Problems

organisation

Management function: Com-munity

community organisation addresses the processes and institutions through which community members organise for participation in health promotion, including involvement in the decisions related to the planning, financing, construction, operation, and maintenance of a projeci. It emi phasises the group process for learning and collective action, and is in contrast to the rapid installation approach in which groups outside the community make the majority of decisions related to the project. The benefits of this group process are not confined to improved pHc project performance or reduction in mortality and morbidity rates. The communities learn togrRlv lessons that they have learned to other development opportunities. ^" Programmes must involve the community in health activities to ensure that services reflect community needs and desires. In the process, it can also provide individuals with organisational and planning skills that they can apply to other development areas. As a management function, the process of community organising will vary quite extensively from one programme to another, and from one community to another. Participation in health activities is a natural outgrowth of efforts at community organisation. Throughout the modules, "community participation" has been defined as the involvement of the community inthe design, planning, promotion, or delivery of health enhancing activities (see Module 7, p-11). This definition can be expanded to include not only the contributions made to establish and sustain services, but also the acceptance and utilisation of services. Successful programmes have found that the first and most essential step in initiating health programmes is to establish a positive rapport with the intended beneficiaries, keeping in mind that prior negative experiences with the lpalth system may predispose individuals to reject new programmes."" Increasingly, programmeg are understanding the need for community participation at all levels of planning, implementation, and evaluation in order to have successful projects and outcomes. The more a community feels a sense of ownership of project activities, the more likely that project will be successful.

Problem-solving; community organisation

7

Problem

l:

Even

Suggestion A:

though project interventions are acceptable to individualcommunity members, they do not want to join in activities that would support those interventions, since they perceive that they will enjoy the same benefits whether or not they themselves participate. Don't expect people to join voluntarily in health activities that benefit the community as a whole. Develop or point out appropriate incentive(s) for either community leaders, residents, or organisation members. Incentives could include such things as monetary pay, prestige, power, extra privileges, better health, and increased economic productivity.

For example, a water sanitation project might expect that every family in a village would benefit if each built a latrine, ending pollution of the village water supply. But no family is likely to build a latrine by itself, and the effect on water quality would be too small. In fact, each family has an incentive not to build a latrine. An individual family is best off if everyone else builds one, while it retains old waste disposal practices. Such a family is a "free rider" -- it gets the benefits of cleaner water without having to bear the costs of providing it. If the latrine is seen as a source.of prestige for the household, more households may aspire to having one." Example: The Indonesia Rural tvVater Supply Project installed 100 gravity water
supply systems, and a few rainwater catchment systems. The implementing agency wasCARE-USA, whose development strategy stresses community involvement and fits well with Indonesia's national philosophy of selFhelp. CARE employed and trained Indonesian project workers who lived in the village during the construction phase, and participated in village life to draw political, religious, and other leaders

into the planning and implementing activities. In each village, the details of implementation were set by a subgroup of the village community endurance

institution (VCEI), a voluntary civic body found in most Indonesian communities. By tying water project responsibilities to the indigenous organisation, project workers encouraged the VCEI subgroup to organise neighborhoods and involve prestige and .villagers in the project. In addition, the VCEI subgroups enjoyed added power. The success of the CARE community participation approach is explained
largely by this strategy of using existing decision-making infrastructures, rather than creating a mechanism which would compete for human resources and power.'"

Problem-solving; community organisation

Problem 2: Suggestion A:

Patients tend to bypass peripheral health units and
seek care directly at the hospital outpatient depart-

ment.

Offer outpatient consultations only to patients who are referred by a health centre or CHW linked to that hospital.

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

their referrals.r

Problem 3: Suggestion

Utilisation and support of health programmes are
low.

A: B:

Public displays, such as community charts and blackboards placed in a prominent location showing project achievements, can generate interest and awareness.

Suggestion

Encourage involvement in the health programme from active organisations from as many different sectors as possible, including non-health organisations that contribute in some form to the advancement of PHC. This approach could include involvement of some less obvious groups, such as
school children, through school programmes.

Successful projects have been those in which the community had a particular interest and a high perception of benefits. Community contributions to projects are most often in-kind services such as: provision of Iabour and materials for health centres, latrines, sanitation projects, constructing wells, training visits; provision and selection of volunteers to serve as CHW's; compensation of some form for CHWs; organisation and support of health committees.z

Problem-solving; comrnunity organisation

9

ln general, projects successful in involving communities have been those: . in which the major capital-investment costs of health improvement were carried by either the government or the ptoject, but not ihe

. . .

communitY; which were small scale or locally implemented, and which tended to involve one-time efforts requiring little involvement once completed; which emphasised the generation of community support and which linked the problem of sustained community participation to supervision; and in which the community perceived the health benefits to be high.z

Example In its seven years of operation, the Togo Rural water supply Project i"riuif.?""urly 1,000 tube wells in745 villages and towns. A unique feature of this
project was its socio-health component, which integrated community organisation

and health education activities to involve villagers in installing, operating, and maintaining their wells. The field workers initiating these activities were Togolese tr.i"i iffiit. agents. The final evaluation attributed a large part of the project's training of the success to its community participation approach and to its careful organisation, of the village social affairs agents in heaittr education and commuttity in development Committee (VDC) members in local management, and of villagers three years, the project broadened community h;gi""; education. In iis last

pliii"iputio" to involve more women indecisions about the operation and mainte"pump minder," in which .,un"n of the water system. It established the position of for oveseeing the proper use of ;;;-;n living nearihe well was made t"pot tibl"pump' T!" nurnp minders were ihe ,ystem ani monitoring the operation of the

noi ontv appointed uy hJvoc's but also became full VDC members. During the ii"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 oRT give uoi,rnt""rr. These five women and one VDC member were then trained to counseling to mothers in therpreParation demonstrations and provide individual iJ-inittration oi sugar-salt solutions for children with diarrhoea.^" -xample, In Ivory Coait, a school health education prograrnme was initiated to "nJ plan was improve public participation in immunization activities. A simple lesson Pupils were taught the need for their lDunger distributed to primary school teachers siblings and neighbourhood infants to be immunized against childhood diseases' After completing the lesson plan, the pupiis carried rit home together with appointment slips to have the target children immunized'^" Example In Bangladesh, district family planning management teams consisting of heaith and lamily planning officials, community leaderq and district heads visited Indonesia's successful family planning board. These teams then designed and managed community action plans themselves. In some district programmes contraceptive prevalence rates have increased dramatically and community participa-

Problem-solving; community organisation

#

10

tion and leadership have increased. 33 Example: A research project in Bombay assessing how effective children could be as agents of change, found that children were quite successful in offering ORT in diarrhoea cases and in motivating families to accept immunization. The children organised a procession in the streets and enacted a play about the consequences of not being vaccinated. A UNICEF sticker was put on the door of each house where there was a baby up to a year of age, and the mother was encouraged to take h91 baby to the immunization centre. Coverage of 85o/o was achieved for tnird doses.22

Suggestion C:

Reorganise the programme to intensify home visiting, making sure that support services are in place to support the anticipated increase in utilisation.
team

Example In the rural health zone of Katana in Zaire, a management

addressed the problem of under-utilisation, on the proviso that the solution required no new financial resources. After collaboration with local nurses, the team suggested

intensive home visiting by VHWs living in six villages. By asking the VHWs to identify 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 from each village were selected to participate, A one-week training reviewed the goals and strategies, and offered a refresher course in health education techniques and messages. The nurses were advised on techniques for supervising the VHWs and were provided a newly formulated supervisory checklist to guide them in evaluating performance and offering feedback. Over the course of six months, the mothers received one home visit per month by a VHW. Each visit began with the completion of a brief questionnaire to survey the mother's current understanding of health related 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 vaccination series, management of diarrhoea, treatment oI tever,and prevention of malnutrition. Throughout the period, the local nurses conducted weekly supervisory visits to the VHW making home visit rounds. Over this six-month period, mothers'knowledge of childhood illnesses and the utilisation of child survival services improved dramatically. Utilisation of preventive services rose from 33% in the first month of the study to 88%. similarly, utilisation of curative services rose from 26% to72%.9

Problem-solving; community organisation

11

Suggestion

D:

Disperse service sites to increase outreach efforts.

Example In the health

zone ol Zongo (Zairel, an alternative strategy for increasing utilisation rates was tested. After consulting local officials, and health personnel,

the zonemedical officer decided to test the impact of dispersing the sites of growth monitoring and vaccination sessions. At least once a month, these services were offeredby-local nurses at a distance of five km or more from the health centre and from all other outreach sites. A total of 202 mothers in the catchment area of two separate health centres were surveyed both before and after the 9-month intervention period. The intervention led to increased participation in the immunization progiu*-", from 3970 to610/o. Furthermore, the outreach effort was also associated witf, an increase lrom 44o/o to 610/o in the use of clinical services for curative care in the event of an episode of childhood illness. Finally, the dispersion of preventive services also provid-ed additionaloopportunity for the identification and referral ol sick children requiring treatment''

Problem 4:

Suggestion A:

Family planning activities are hindered by a lack of support from influential village members who hold negative impressions of family,planning based on reports from dissatisfied clients.* Examine the quality of services and determine where they can be improved.

Quality oI care is increasingly being recognised as an important determinant of contraceptive acceptance and continuation. One framework for quality 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,

. . o o

service arrangements, etc.

Technical competencq providers' competence at performing clinical family planning services lnterpersonal relations: clients' perceptions of their interactions with service providers Mechanisms to encourage continuity: media campaigns, home visits, appointments, etc. Appropriate constellation of services: convenience and acceptability of services to clients

Problem-solving; community organisation

t2

Mysore branch of the Family Planning Association of India during the period from 1983 to 1986were followed and interviewed in 1986 and 1987. coniinuers and discontinuers exhibited differences that have important implications for the quality of care delivered by clinics: IUD continuers were more likeiy than discontinuers to have received information on side effects prior to acceptance; continuers were more likely than discontinuers to have received information on alternative methods. The l2-month continuation rate was 63% among women with incomplete information. compared withTlo/o among those with more complete information.zg

Example A study was conducted on the impact of information given to clients on IUD continuation in Mysore, India. women who had accepted the IUD at the

Suggestion B:

Identify dissatisfied clients and visit with them to or education where needed.
discuss problems and provide advice

declined over time. zo

Example: In a district of the Indian state of Andhra Pradesh. dissatisfied clients were identified and met with. Problems were discussed and resolved, when possible. Mllage leaders wereo"informed of the action taken. opposition to the programme

Problem-solving; community organisation

13

Management function: Information, education, and communication
Good communication and rapport with clients can stimulate use of services. People respond positively when they teceive privacy and respect, are treated with empathy, and have their questions answered. Communication involves the sharing of ideas, knowledge, attitudes, and feelings. If efforts to communicate health messages do not achieve the results intended it may be for one of the following r€dsonS: The message may reach only some of the target audience because few communication channels are used. For example, some health programmes may rely heavily on printed materials such as posters and leaflets, or on radio and television to reach people who have no access to these media. The message may be received but not understood. For example, the message may be expressed in the wrong language or dialect, or use inappropriate or technical terminology. The message may be received but misinterpreted and applied incorrectly. For example, mothers who are taught to use ORT may use too 1nuci1 water, which makes the solution ineffective, or too little, making the solution potentially dangerous. The people may receive and understand the new information but be unabie to act upon it because of their poverty, or because basic services are not available. For example mass media campaigns can increase community demand for packets of oRS, but if the packets are too expensive 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 a -hejlth aciion correctly, but the knowledge may conflict with new existing attitudes and beliefs. For example, mothers who are.taught to continJe feeding a child with diarrhoea may not act on this information because it conflicts with traditional belief that the stomach needs to be rested during diarrhoea.

Problem-solving; communication

L4

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

.

Problem 5: Suggestion

Parents do not recognise the need for immunization.

A:

Education campaigns can help raise awareness. In agricultural societies, one could try to educate by creating a parallel between the effort put into land or livestock and the health of their families.

Example In Yemen, there were difficulties in getting villagers to accept the need for immunization of their children. However, villagers were concerned about a
sudden attack of Rinderpest disease in their cattle. Health workers recognised this concern and made arrangements for the cattle to be immunized. Once the villagers recognised the value of immunization for their cattle, there was a much greater interest in immunization for children. Example A similar situation arose in Guatemala, where the community was more concerned about an illness among the chickens than about the need for medical care. Once the poultry problem was diagnosed as Newcastle disease and veterinary treatment was made available, the community became interested in its own health problems 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 administration are not being conveyed to mothers. Re-examine the quality and effectiveness of techniques being used to teach mothers about preparation and administration of ORT. Encourage mothers to put into practice what they have learned. Go beyond evaluating only inputs and coverage, to more thoroughly assessing and monitoring the process of service delivery.

Problem-solving; communication

.15

Extensive field experience with ORT has demonstrated that programme and success depends on effective communication between the mother health *ork", to ensure that behaviour changes. systems analysis data centres, revealed that health workers, whether in the home or in the health key messages, and that encounters were generally iiequently did not convey not used to encourage motirers to put into practice those messages that they did understand. Operations research has shown in many countries correctly.

thai while mothers know of ORT, few can prepare and administer it
promote the Example: An ORf programme in The Gambia used mass media to A common container suitable for measuruse of a home-make ialtlsugar solution. i"g OnS ingredients was forind, and mothers_were told how to prepare the solution' child was Vt6tn"r, wJre also told how to administer ORS, how to determine if their get better..Experienced mothers to seek help if the child did not iiprt"i"g, -U""n "nd trained in OIiT techniques flew "happy baby" flags over their homes' runo nua ORT' f"f"if,"rr were told thit they could go to the fiag holders for help with rein(and pre+ested) radio, print, and face-to-face instructions b;;;;;"tary in which forced one another to have maximum impact. A contest was launched, if tn"y mixed the solution correctly' The mothers could win small household items

a S0-kilo ""-"r.f ;il6; i;t.i;s oit tn" -orl mothers for the contelt each week receivedwhich the programmes in iuf;f *s"i"".a a 100-kilo bag of rice. Unlike other given to mothers' After one it was

*i"ning

mothers were entered in a grand prize drawing for 15 radios' The

incentive was given to n"uttn w"orkers, in this mothers reporting using -r"tns Jf promotion and training, the number of "igni .fi-U"a from 3%o to 48o/o of all diairhoea episgles. The number of mothers Oilf who could recite the formula rose from Lo/o b 640/0'27

Problem 7: Suggestion A:

Family planning messages are not well received becaule of strong religious influences' Combine family planning efforts with other helpful information aUout healtlipromotion or other health topics, such as nutrition, which may be perceived as more relevant. By demonstrating a practical link between the two topics, family planning messages may be made more "palatable." Integration of services has been shown to be more cost effective than delivery of separate services.

Problem-solving; communication

76

militant fundamentalists who might not otherwise Le viewed as relevant to reproductive decision-m.aking. overall, the problem of implementation was apwith their associated functional details, such as pertotttt"i] logistics, etc., and 2) the external environment, which conditions the kinds of programme implementation choices implied in ttre operational level of planning.23proached at two levels: 1) the operational level, considering tire determinants of use

Example The second Population Project, servicing zooto of theegyptian popr.rla-tion, integ-rated family planning and MCH service delivery in order to work lowards its goal of reduced fertility rates. It developed an implementation strategy rooted in the Qur'an, using a combination of birth spacing and breast feeding -i"rrug". with underJying health rationales. It relied upon eur'anic injunctions requiring a woman to breast feed two full years. The project presented modern contraception as a means to ensure the necessary spacing of births. A combination of *iitt"n and broadcast media as well as outreach aCtivities were used to communicate its message, many of which indirectly introduced the concept of family planning while addressing directly the issues of the Islamic family in maternal and child health. Using a non-confrontation manner, their -"suge *us not confined to the traditional target.population as defined in terms of fertility but was also directed to

Problem 8: suggestion

Heavy caseloads limit opportunities for education in the health centre.

A:

Institute a triage system to streamline the process and reduce "dead time."

Zaire, th modifications to the Pre-schoolClinic (PSC) System to illow tire nurse to increase the time allotted for the examination of malnourished children and the counselling of the mothers. Two changes were proposed: r) begin the weighings as soon as mothers arrive at the PSC session, to eiiminate'the-"dead time'ispent waiting for mothers to assemble and to ensure greater participation in the health education session, and2l institute a system of triage, whereby nurses examine only the children yh9l" weight had failed to.progress. A part of tlre solution, volunteer community health workers were trained to assist wiih the weighings, aliowing nurses to speni more time counseling the mothers of malnourished children.They flund that plicing the health education session in the middle of the PSC session decreased long waitini lines and imp-roved attendance at the health education lessons. The triate of ttrl malnourished children allowed nurses to triple the time they spent with malnourished children. Furthermore, there was a su'bstantial augme-ntation in the proportion of mothers who correctly understood whether their c-hild's weight had increased. ll,{^dlj"" jo improving the quality of services, the modifications frad the ;;pii.r-s effect of actually reducing the aveiage length of psc r"*io". bt t0

Example A national project in

;;t;11

Problem-solving; communication

17

Problem 9: Suggestion A:

Mothers are not alert to changes in their child's weight that may signal the initihl stages of malnutrition. Use cultural or traditional indicators to encourage awareness of growth. Emphasise size, using clothing as a useful indicator. Wth poor growth, clothes become loose around the body or are still a good fit many month later. A survey in India found that mothers used indicators for growth such as the child being 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 bring the child to the health centre such as: poor appetite, listlessness, not urinating enough, repeated colds or infections, etc.

is customary in central Ghana, as in many cultures, to make a string of beads for a new-born and put it around the waist, wrist, or legs. It is intended for decoration but used by many parents to assess growth. One mother explained that by the time the child had reached the age of five months, the bead string utouni the waist should have been changed or adjusted five tjmes. Other items

Eximplet It

mentioned included metal bracelets, necklaces, and finger rings.r

Problem

1O:

Suggestion

A:

Mothers do not recognise the importance or utility of growth monitoring. Growth monitoring activities may be too focused on weighing and plotting growth charts for data collection. There may not be enough feedback and education for the mother. Tell the mothers the results; whether their child has gained, remained the same, or lost weight. Discuss the reasons for the child's failure or success in growing. Give concrete and understandable recommendations. Involve the mother interactively in the process by: Encouraging the mother to weigh her baby herself, keep the growth monitoring card, interpret the child's growth, and act on the results, Basing interpretation and action on weight change.

Problem-solving; communication

1R

. .

Weighing frequently, as often as every month or two,

if feasible. Feeding back monitoring results to the mother immediately, so she can take eflective action and see the impact of her actions.5

their child's status or specific action to take. Focus on counseling skills that involve the mother to the greatest extent possible. These skills can be taught in training, or by supervisory example and guidance on the job. Supervisors themselves often fail to discuss and explain issues and information with workers, setting a 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 to follow until the next session. Several countries have successfully implemented school programmes to teach students about nutrition and growth monitoring. Students monitor their siblings'growth and help mothers adopt good nutritional practices.

Example: Mothers often leave growth monitoring sessions without knowledge of

Problem 1l:

Suggestion

A:

Health workers have difficulty convincing mothers of the importance of breast feeding. Efforts are often undermined by perceptions and media messages that bottle feeding is "modern" and "better." Communicate and reinforce health messages in terms of traditional beliefs and value systems. Avoid paternalistic or threatening messages; use a positive psychology to educate. It pays to take the trouble to find areas of agreement between the various knowledge systems. Adopting new ideas is easier and more dignified if they relate to existing knowledge systems.

Example: A nurse in the maternity ward in a hospital in the yemen Arab Republic was trying to convince a mother who had just given birth, of the benefits of breast feeding. Breast milk, she explained, contained antibodies against diarrhoea, did not 9os1 glv money, was cleaner and easier than bottle feeding, and was a gift from God. The mother was bottle feeding her child and believed snl aia not have enough milk to breast-feed her child. At this point, another nurse came over and said to the mother, "You know, nowadays children are growing up without close bonds with their mothers because they were not breast-fed." The mother's attitude changed instantly, and she began to take an interest in the benefits of breast-feedirrg her
child.

Problem-solving; communication

1,9

Problem

12:

Suggestion A:

Supplementary feeding programmes do not reinforce behaviour change or independence. Involve mothers by setting up a nutrition fund, training them as peer counsellors, etc. Remove elements in your programme that encourage them to be
passive recipients.

innovative activity in a programme in Thailand has been the establiihment of a nutrition fund at the village level. Each project village is given a start-up fund of about US 5150.00 in materials and foodstuffs to start producing supplementary food. Community members are given the opportunity to buy shares to'add to the starting capital, *hi.h th"n entitles them to the profit generated,by the sales of the suppLmentary food (about US 50.10 per 100-gram package)' In this

E-.-pl", A"

scheme, third degree mainourished children receive the package free. Exampie, A study in'Ibgo selected mothers from among the regular participants at growth monitoiing s"sionr at a nutrition centre group to be trained as peer corinsellors. They conducted home visits to other mothers to reinforce health eJucation *nrrui"r. Prior to beginning their home visiting activities the mothers participated in a*2-day training iession which covered procedures for conducting i,o*" uirits and basic iechniquls in health education. They also learned the use of during fictorial guides to help record information about messages communicatedservices nutrition centre ihe visit. I-t was concluded that mothers could help extend effectively. Futhermore, mothers reported that they were more comfortable being visited by other mothers tuth"ll!9tt-ly.jlinffil!

Suggestion B:

Recommend appropriate local foods which are already in populai use for other nutritionally susceptible groups, such as the elderlY.

@amPithoWeaningFoodsProjectinNepalbeganasa *pple-entury feeding programme for mothers and pre-school children. The programme *u, .or,l-y, exferienced several distribution problems, and created

lnd-esirable dependencies. A nutrition survey was conducted to identi{y appropriate local foods and current infant feeding practices. The survey of weaning age children they showed that all were breast feeding Uu1 tnut many were malnourished because investigators noticed did not receiveenough well-balanced supplemenial foods. The

that almost all mothLrs knew how to piepare a nutritious and popular traditional snack of beans and cereal grains, which were sometimes ground and mixed with milk or water to prepare a gruel for elderly pople. Staff believed that a low-cost weaning 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 campaign to reduce malnutrition via promotion of weaning foods, ORT, and growth monitor-

Problem-solving; communication

20

in9. Evaluations suggest there have been positive changes associated with this intervention.c suggestion

c:

separate food distribution activities from growth monitoring

Experience has shown that if food distribution is combined with monitoring, it will tend to take "centre stage," diverting attention from preventive/promotive aspects of the intervention. Example The Tamil Nadu project (TNINP) in India experi-lntegrated Nutrition mented with innovative methodsJor providing food supplements, when but with a preventive emphasis. It focused on early detlction of'growth""""r!iry, falterini. Monitoring was followed by various promotive activities, as well as fJod supplemenis when appropriate. Rather than focusing on older children *no ur" easier to find but among whom malnutrition is often far advanced, TNINP concentrated on children from birth to 36 months in order to prevent poor growth. Feeding was
Iimited to-90 days for each lfre. "admission." The food s6rved ur'i ,uppt"-ent tJhelp young chlldren with faltering growth, and also provided an educa'tilnal experienc'e parents. The project was able to economise significanilv o. roJ l;il 4; f.or.!fe limiting the-frequency of participation and by more seleftive t"rdti";. A mid -term impact ernluation showed that during the first 3.5 years of oieraiion, third and
considered^lo be primarily parent's,.rerpor,ribitity. particifiation in feedini wis

fourth degree malnutrition in the project block_frai control block the percentage had increasedLgVo.n

decliii-Aoi, *i,it"

i.

th"

Problem-solving; communication

21,

Management function: Information systems and record keeping
and community members with the information they need to plan, implement, and monitor service delivery and support activities. It is a systematic way of collecting, reporting, and using data at all programme
levels, and is organised around key indicators that measure a programme's progress toward its goals.

Management information systems provide workers, managers, donors,

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: Suggestion A:

Problem 14:

Suggestion A:

Referring providers do not learn from their referrals. Adapt referral forms contain a space for the hospital physician to write a brief note on the diagnosis and treatment that the patient received at the hospital. Each month, when a staff member from each health centre visits the hospital, he/she collects the accumulated forms, which have been kept separately for each clinic and distri-b.utes them to the provider who initiated the referral.34 Semi-literate CHW's cannot easily record and report information, identify needed information, or use health records to determine major health problems and the families affected by each. Preparc "rainbow" family cards with coloured tabs across the top, each in a distinct colour.

Example Each coloured tab corresponds to a different condition, such as pregnancy, need for vaccination, malnutrition, etc. If a given condition is present, the corresponding tab is folded up. Otherwise, it is folded down. The cards are stored in a file box. Each month. the tabs are counted. The count indicates the relative magnitude of the problem and trends from previous months. In addition, the
families with unfolded tabs can be identified for visitation by the health worker each month. This system was developed by Fondacion CIMDER, Universidad del Valle, Cali, Colombia.

Problem-solving; information

22

Suggestion B:

Make charts easier for CHW's and mothers to

use

or

understand. In Mombasa, an AKF programme introduced an innovative "pictorial register" to deal with this problem. Example: In Thailand, the PHC programme developed coloured stickers that CHWs could stick onto family folders to identify a pregnant woman, an underweight child, a child with diarrhoea, etc, Example: Kenyan students were assigned to help cHw's with their recording and reporting. They also helped in case-finding and follow-up. This study fbund collaboration between schools and CHW's to be the most cost-effective team arrangement for basic preventive services. School children, in addition to learning about health, llglped monitor siblings and mothers needing growth monitoring anl immunization.2S'

and understand. Many forms are difficult to plot, read,

Problem

15:

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

Suggestion A:

activities.28

Example: An evaluation of a programme in Karachi, pakistan, found that health workers 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 be reported oq the frequency of data collection, and the frequency of tabulation and reporting' This made information collected more useful and has significantly reduced th^e amount of time health staff spend on management iriformation

Example In India, a village record keeping and monitoring system is kept in a

. o . .

loose-leaf notebook. Included in the notebook are: a map of the village,

individual family cards, listing family members by age, occupation, education and immunization status, pregnancy chart for each woman.recieving antenatal care, weight charts for all children under five.

Problem-solving; information

23

Health workers have service delivery targets, and work with their supervisor each 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,

. o o

localised disease outbreaks, changes in the physical and/or natural infrasturcture, or

the existence of other governmental of private programmes affecting
nutrition.

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, or o fail to exhibit positive improvements over a substantial period of time. Managers then visit exceptional villages to better understand successes and failures. In addition, every village conducts an annual review to assess programmes, review progra-mme operations, and set goals and operating procedures for the coming yeai.24

indicators.
analysis of Thailand's PHC management system revealed that most the PHC information from the provinces was sent to the Health Statistics Division of (HSD) through a 10-page form consisting of over 200 service activities for each province. ThIs cumbeisoine and expensive system of paperwork placed the greatest

Example An

ieporting burden on peripheral failities. More importantly, the information flow tended 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 for planning or policy making and almost no feedback to the periphery. After several workshJps with division managers and provincial-level staff, a provincial-level analysis of project information flow and needs was completed and several changes were madei l,) ihe use of coverage rates (versus counts) was endorsed as the most approproate PHC indicators,2l reporting frequency was reduced to no more than iour months, 3)the list of essential coverage indicators for PHClchild survival "u"ty elements 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 the indicators in the system thus allowing for comparisons among provinces and within geographic regions, a4{ allowing overall progress toward national service coverage goals to be estimated.ru

Problem-solving; information

24

Problem 16: Suggestion A:

Poor record keeping by field workers.

Often data collection forms do not have enough in. Some CHWs find them difficult and frustrating to use. Have forms with wider spaces to write in. Simplify record keeping to the minimum information necessary for day-to-day decision makspace to write
ing.

Example In Honduras, it was found that not only illiterate but also literate mothers could not understand the vaccination card being used by the MoH. The script was too small, the graphics looked like a complex crossword puzzle, and some of the nurses had used roman numerals to write the dates. Even literate mothers could not tell the name or number of doses of each vaccine that had been given to her own child or that needed to be given to complete the series. when the MoH launched a new immunization campaign, it was decided that this old vaccination
card should be replaced. Questions posed and answered in designing the new card were 1) how to represent the kind of immunization needed 2) how to represent the number of doses needed 3) how to indicate when a dose had been received 4) how to indicate the date to return 5) what size should the card be. Participant observation in rural clinics and in-depth interviews with mothers helped planners understand that 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 shot in the arm, it is against TB; if a shot in the hip, it is for tetanus. of the three diseases DPT prevents, tetanus it the one most Honduran mothers remember. A new, easy-to-understand, 6-pagecard was designed with illustrations for each immunization, showing where the vaccination is given and the number of doses for each. On the line provided next to the illustration, the nurse now fills in with ink the date a dose is received and prints in with pencil the date the mother should return. To determine the optimal size, vaccination cards were collected from public and private institutions. The vaccination cards used by private institutions were four times larger than the card used by the MOH; about 5" x 5" versus 2" x 5." The reason given was to avoid loss of the card. To decide what size was best, the project planners following social marketing principles, turned to the consumer, mothers. Three different models were prepared for pre-testing by rural women. Both illiterate and literate mothers understood the new design, whereas only a few of the literate mothers understood the old MoH card. The mothers overwhelmingly preferred the smaller 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 a plastic bag in their brassiere where they feel it is safe. They also preferred the smaller card because it presented only one, rather than two, vaccines on a single page. Coverage for children under five for DPT III and polio increased in two years from about 55Vo to an impressive 78o/o.The new graphics of 1!re vaccination card are believed to have contributed significantly to this increase.zt

Problem-solving; information

E
This experience suggests the following guidelines for vaccination cards elsewhere: . The card must be able to stand on its own. Even if health staff have time to do a good job of explaining it at the time of vaccination, the mother must be able to comprehend it once she has returned home and time has passed. . The card should show clearly four types of information: 1) which vaccines are needed,2)the necessary number of doses for.each vaccine, 3)how many of these doses have been received, and 4)when to return for the next immunization. . The card should be attractive. Illustrations make the card both more attractive and help it communicate the information. . The card should be culture-specific. It should be in the local language and illustrations, if used, should look like local people and adhere to cultural standards. . The size should be neither too small nor too large, large enough to comprehend easily but small enough to carry easily.

Problem

17:

Performance records show wide variations among field workers. For example, in the same period of time, some recruit over 100 family planning adopters, while others recruit iewer than 20.

suggestion

A:

Examine the factors that could account for the variations in performance, and develop and implement changes that would raise overall project effectiveness.

E-"-pt"t

project in rural Bangladesh, SOPIRET' conducted an OR propct which identified-some differences in practices between high-and low-performing field workers: high performers tended to carry more supplies with them, spent more time with non-ubrs, w€re more likely to check client supplies and visited clients more often; the low performers reported encountering considerably more religious opposition in their areas, did not cover their prescribed catchment areai, only visited current users, did not contact younger womel -and did not discuss side effects. In light of these findings, SOPIRET decided to implement the foltowing changes: provide field workers with messages and materials to respond to religious concerns, emphasise discussions of side effects, implement a uniform weekly work plan, and ask low performers to set targets for new adopters. Despite externai disruptions to the programme, modest results were obtained: the CPR rose, use continuition improved, reported pregnanicies dropped, and the low
F'

f"-ily pl*t*ng

Problem-solving; information

26

performing field workers halved the-{ifference between themselves and the high performerJ in the frequency of visits.37

Problem 18:

Suggestion A:

CHW'S involved in growth monitoring programmes lack interpretative skills and the supportive technical standards needed to properly respond to questions. They are not able to record weights correctly on charts and have difficulty counseling mothers effectively. Conduct a skills assessment of CHWs. Develop a list of skills needed. Design training to emphasise skill development (as opposed to teaching information). Provide training individually or in small groups using scenarios and role plays. Then conduct on-thejob training until skills are demonstrated properly. Have CHW's practice skills such as correct use and reading of scales, use and interpretation of growth charts, maternal counseling with actual clients.

Example

The National Family Nutrition Improvement Programme in Indonesia

used training techniques that involved repated practice of the actual skills needed. It was reported that after three or four weighing sessions, community health workers

with minimal education levels could accurately weigh a child in very little time. The use of the local market scale helped make this po-ssible, as it wai a familiar and appropriate technology for the workers concerned.o

Suggestion B:

Develop simple job aids that will help CHW's recall points which must be discussed during counselling
sessions.

Example After research and testing, the Northwest Frontier Provincial Health Service in Pakistan developed two memory aids to guide service delivery in key interventions. These aids would.assist health workers to remember the relatively large number of procedures to be followed in delivering a given intervention. One of 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 modified outpatient dispensary slip served as a second memory aid. On this slip, health workers were to fill in or check such key tasks as taking a history, conducting a physical exam, providing treatment, and cotrnselling patients. A follow-up study showed that health workers carried out diagnostic procedures with greater frequency. Counselling also seemed to improve in both content and technique. Clearly, memory aids such as these should not be constructed as a panacea for
Problem-solving; information

27

resolving service delivery problems. While improvements can be made, other problems willremain. Detailed information about the types of problems that impede elfeclive service delivery enables,decision makers to implement simple corrective measures that make a difference.'"

Problem-solving; information

28
lllillliiliri$ilii;lri::I

Management function: Personnel and

training

Personnel management ensures that the organisation attracts and retains competent people, that staff can be productive and efficient in their jobs, and that they are recognised appropriately by the organisation for their service. Tiaining serves to continually improve upon the knowledge, skills, and competencies of health workers so that service delivery or management activities can be carried out correctlu.

Problem 19:

suggestion

A:

High attrition rates among CHW'S who suffer from their work, and often do not feel appreciated by the community. Examine locally available alternatives to increase CHW motivation and incentives. Upgrade other benefits such as opportunities for growth, increased responsibility, time off as a reward, travel to a conference, public recognition for their accomplisha general lack of motivation and incentive to do

ments, etc.

CHW attrition occurs for a variety of reasons. Among them are: . Low or irregular salaries. Studies of attrition rates from six USAIDsupported projects suggest that attrition rates among CHW's who depend on community financing are approximately twice the rates of CHW'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, while communities generally desire and expect curative care, CHW's are trained for preventive care. Lack of community respect and support. Address how CHW's are chosen, and their roles defined. Too often a CHW is imposed on a community, or a community selects one for the wrong reasons. Involve the community in choosing CHWs: make sure they understand what the CHW's role willbe, and the CHW understands what the community
expects.

Problem-solving; information

29

a

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

. o o o

a a

Create recognition for CHW's in their villages by having a health day at the school or church and recognise them and their efforts publicly. In some areas of Honduras, the Ministry of Health gives CHW's picture I.D. cards. These help create a sense of belonging to the institution as well as increasing their respect and position in the community' Possession of charts, pictures, and simple equipment can help CHW's communicate better as well as enhance their status. Another possibility is to routinely collect contributions to pay the CHW from the community. This can take the form of produce or in-kind services. In Swaziland, for example, the community plowed the cHws field. At monthly meetings, teach cHW's a new concept or skill, conduct refresher courses to review knowledge and improve skills. In one case' interviewing of CHW'S, community members, and supervisors led to identificatio-n of factors leading to attrition. Among them was a desire to learn more about curative services, which was incorporated in training. Career ladders are important for job satisfaction and retention. Some cHW's in Northern Pakistan have gone into training as Lady Health Visitors, 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 this requires more work, but also because it provides them with more prestige. Provide free medical care to the CHW and his/her family' Exemption from military service'
28

Problem-solving; personnel

30

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

o

Example: Lack of funds is obviously problematic.
North-western Somalia offer some low-cost alternatives:

Ideas from

a project in

o o

Water tax on the village pump; a certain amount per household pays for a CHW, pump maintenance.

Shop and tea shop cash collection; travellers from outside the village indirectly support community health.
Insurance type collection; payment of a small fee

r . r

Payment-in.kind; once-a-year livestock or grain collection.
Waived village fees, e.g., for water.3

Example: A Kenyan study provided different sets of incentives to three groups. One received token payments and a newsletter, the second received community recognition and lapel pins, and the third group received all of the above as well as diplomas for "healthy households." A healthy household was defined as one in which all children under five years were fully immunized, which had a clean water supply, which maintained adequate nutritional status for children under five, and which practised family planning. The study found no difference in the performance of the different incentive groups, but all group areas showed improvement in health
status.zc

Suggestion

B:

Keep in touch with field workers not only at regular meetings/visits but by commenting on their reports, offering praise where it is due. At monthly meetings encourage a two-way flow of information. Give feedback on the results of their work to encourage

commitment to the organisation and job. Discuss

Problem-solving; personnel

31

performance and problems and, where possible, develop 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 service36

Feedback should be task-related, prompt, action-oriented, motivating, and constru ctive.42

Example Profamilia, a successful family planning project in Colombia, addressed tnir i.r'u" by rotating field workers into the health centre for a day so they could experience in" n"dtn project from the manager's perspective and gain an understanding of the system and organisation.

Problem

2O:

Suggestion A:

Family planning workers are not accepted by the community. Examine recruitment procedures. People hired as field workers should be credible and acceptable to family planning acceptors. Known characteristics of the community should be considered when recruiting family planning workers.

Recruitment should be done using a job description outlining what the responsibilities willbe and the skills and qualifications necessary to accompliih them. Include attitudes and personal qualities you think the person should have. This willensure tllqt you hire someone who can do the work and with whom you can work.*" A PHC project in two Bangladeshi upazilas found the following selection criteria of CHW's useful:

. .

CHW'S should be permanent residents of the village. Avoid temporary residents and job seekers. CHW'S should have good reputation in their area and be acceptable to the people in their locality. Preterenceshould be given to traditionalbirth attendants, traditional healers, women, retired officers, and those who are already doing social work.

Problem-solving; Personnel

32

.

Some basic education preferable. However, enthusiastic individuals active in community service can be selected even if they are illiterate.Preference is given to married women above 20 years oI ige.ao

Example: In Bangladesh, field workers whose characteristics are closer to those of the eligible couples in their areawerefound to be more effective in promoting family
planning. Important characteristics matched were language, socio-economic status, and residence in the local area. Credibility is extremely important. In general, female field workers were better able to motivate and serve female clients than male clients. Projects that follow formal procedures for recruitment, promotion, an{ termination perform much better than those that do not follow such procedur"r.38 Example: In Indonesia, it was found that at the provincelevel,midwives were more accepted as providers of family planning services, although they needed general managerial and salesmanship training. o/

Suggestion B:

Encourage satisfied users to advocate contraceptive
use. They can be especially effective as

family planning promoters and contraceptive distributors. Project experience has shown that women counseled by satisfied acceptors are less likely to discontinue use than those counseled by a midwife^.alone; satisfied users are better able to reduce the fears of side effects. tt Often, the adoption of a method by a charismatic and respected local person can lead to rapid dissemination of the same method in a village.
Example: In Sri Lanka, satisfied acceptors with high community standing were encouraged to motivate other mothers. This approach was found to be successful and cost-effective. Satisfied acceptors were dffective in counseling womgn who believed temporary modern methods have too many negative side Jffects. 37

Problem 21:

Suggestion A:

There are not enough health workers to provide elfective coverage. The programme is not having a strong impact on family planning acceptance, or on reductions in fertility. Help CHW's take a selective approach to serving
clients.

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

Problem-solving; personnel

33

Suggestion B:

Reduce client-worker ratios to increase frequency of

contact. Field workers should spend more time with new acceptors.

Example: In a project in rural Bangladesh, reducing the client-worker ratios
enabled field workers to complete their visits on time and allowed more time to be spent with each couple. Iqcreased home visits have been associated with increased ctntraceptive pr.u ui.n

".2l

Suggestion C:

One very eflective way to increase coverage is to authorise paramedic personnel to distribute contraceptives.

The use of paramedics to distribute contraceptives is beneficial for several reasons. In developing countries, they already offer fairly wide coverage of the population. Thus, once they are trained, they provide an
extensive base for contraceptive service delivery. Physicians generally leave

their villages to work in the cities, where the pay is usually higher, but paramedics 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, paramedics often have long-standing relationships with their clients, which contributes to improved contraceptive use and longer continuation rates. Paramedics

can db much to extend contraceptive use and thereby reduce the incidence of unwanted pregnancies. This, in turn, reduces medical complications, unsafe abortions,lnd maternaldeqihs. Such benefits greatly outweigh the risks attendant upon contraceptive use.

Example A pilot study in Thailand demonstrated the safety and effectiveness of allowing paramedics to dispense oral contraceptives, usin-g a simple checklist for
contraiidications. Following the success of this trial, the Ministry of Public Health ruled that all auxiliary nurse midwives who had received basic fhmily planning training were authorir"d to dirttibute the pill. This immediately increased the total

numbei of providers offering the pill from approximatbly 350 to 3,500. The number of acceptois rose from only 25,000 in the three months prior to,the ruling to over 35,000 in the three montirs afterward. One and a half"years later, over 80,000 women accepted the pill in a single three-month period. ""

Problem-solving; personnel

34

tP;#$$i$$i:s$i;1\tE\\-a$,qsnr:i*

$(.qi'Hrl[-!iFii;ii.il;lii.i.iiii::

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Management function: Logistics
Logistic 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:

Suggestion A:

Refrigerator records show storage temperatures are above those required for vaccines. Have only one person be in charge of monitoring the temperature. Provide supervision to ensure this is done every day. Make sure health centre staff understand the importance of the cold chain. Have a plan for each centre to follow for power outages. Have a kerosene supply for gas refrigerators. Make one person directly responsible for cold chain maintenance. Weighing data are often inaccurate because of such factors as using inappropriate scales, such as bathroom scales. Scales are not calibrated before each weighing session, and are not set to zero before each weighing; children are rarely fully undressed when weighed. Age reporting as well as weight plotting are often inaccurate. Review equipment maintenance procedures and weighing protocols.

Example: In the Philippines, modest improvements were observed after maintenance procedures were developed for scales and a manual prepared for staff at health units. In-service training was conducted to improve workers' weighing technique as well as refresher training to improve weighing skills and ability to
calculate age correctly.

Problem-solving; logistics

35

Mangement function: SuPervision
The 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. It is a means to motivate and boost the morale of staff; to provide continuing education and advice; to enhance field worker's credibility in the eyes of community members; to assess quality and quantity of staff efforts; and to gather othier information which can be fed back to programme staff and community members. Fieldworker performance has improved when supervisors make home visits with workers and question clients about the worker's activities in the p."r".,." of the field worker, when supervisors discuss the client's Prgrblem with 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 t*o months - nearly six weeks per year - in.each community can "unry essential part of efforts to reinvigorate health workers and restart be ai health-related ictivities in the villages, if they have slackened. . Regular meetings with CHW's ensure that potential problems can be handled early on' o Use two-way oradios, especially in isolated areas' to supervise, inform, and motivate.' Ineffective and infrequent supervision of CHW'S. Problem 24:

Suggestion A:

Supervisors should use guidelines andchecklists for

actual tasks performed by staff and field workers' Have supervisors emphasise feedback on technical skills raiher than on administrative ones' Staff should have a job description and performance objectives to know what is expected of them and how iheir performance will be appraised' Cqnduct periodic performance appraisals to make sure objectives are met and to discuss any problems CHW's are
having.42

"CHW'S have been found to benefit from high quality and frequent supeivision and from unusually motivated community organisations; where these have been lacking, CAW'S have poor morale and high dropout

Problem-solving; suPervision

36

"when supervision is ineffectual or focused o11 clerical matters, an increase in frequency had no effect on performance."3l
rates."28

99-" simple tasks that -can improve supervision include revising guidelines for content and frequency of supervisory visits; identifyini appropriate personnel for supervision; using standardized checktists foi monitoring and forms for inventory control.
Example: An operations research project in Bangladesh found that high performing supervisors: visited more homes with the field workers; asked clieits whether they were screened for contraindications and had side effects explained to them; had more extensive and frequent contact with field workers; and ch?cked on client's contraceptive supplies. Field workers in high performing programmes followed a regular visting plan, visited homes more oftJn, visited non-u."r-r more often, varied messages to suit the listener, promoted the advantages of contraception more forcefuLly, an"d provided more thorough information on method use and on possible
side effects.r/

Example: In Guatemala, the major factors for high turnover rate among cHw's and- ensuing loss of community confidence were irrlgular and insufficient irovision of drugs and lack of supe_rv-ision. The dropout rate was two to three timls higher among- unsupervised cHW's than among those with regular supervision. In the eyes of the community, the supervised -cHw seemed io e"py i"creased status because of the evident-link to_outside projects in Mali and Niger have also noted that for illiterate cHw's, "*[rtir". -orl p"rronal contact is indicated and that literate CHW's can be effectively supervised with a mixture p"ironut contact and correspondence."t

Problem 25:
Suggestion A:

Staff have

a

limited amount

duties. Coverage and hence prevalence of family planning practice, for example, suffer as a result.

of

time

to

perform

Work with the staff to help them allocate their time better. Help them organise their time and maximise their efforts, including targeting of high-risk groups. Suggest that for certain activitiel, the CHW -"Lt *ith specific groups of mothers to provide education on a common problem to save time. This willalso provide an opportunity to learn different teaching skills.

Problem-solving supervision

37

Example: In Bangladesh, a community-based service project active in 24 urban areas identified problems in client coverage, record keeping, planning and supervision. Three -uttug"*"ttt interventions (work plans for field workers, a reduced

client-worker ratio, and a simplified record-keeping system) helped improve coverage, supervision, and services, The most ellective of these interventions was thought to be the work Plan.

workers and adjust"d some of the catchment areas to reduce the client-worker ratios. The third project increased the number of assigned couples per field worker, thus increasing the ratio. where the ratios *"te r"du."d, staff reported that the main advantages were that:1) field workers completed their visit cycles on time; 2) more time could be spent with each couple; 3) more low-parity women coqld be recruited; and 4) new acceptor targets could be more easily met'"' lbo many tasks are assigned to cHws. Tasks do not Problem 26: have a clear priority. Institute work plans for field workers to help sysSuggestion A: tematise activities and establish priorities. An effective work plan minimises travel time, maximises client contact, and systematicaliy covers all eligible clients in the assigned catchment area.

schedule for field workers to visit specific clients and ensured that all would be visited during a 1-2 month cycle. Most project staff and field workers understood the rational for the work plan and prepared them on a monthly basis. The main advantages were 1) they systematised the activities of the workers; 2'l they ensured regular visits to MWRA's; and 3) they facilitated supervision. The main disadvantage was "serial visiting." All women had to be visited in turn, which precluded revisits to those women who needed to be seen sooner. Better record keeping and improved monitoring. The new system was simpler and less time-consuming. The main advantages:1) ii systematised record keepin g; 2\ helped promote eflectiv e supervision and monitoring;and 3)helped in evaluating field worker performance. The main drawback, it didnt produce all the data needed for reports to donors. Thus, both the new and the new and the old system operated side by side, which increased the workload. Reduced client-worker ratios improved coverage. Two of the three projects that implemented this intervention hired additional field

Work plans expanded coverage- The new work plans set up a

Problem-solving; supervision

38

Bangladesh found that the work plans allowed for better supervision and organisation. A schedule was set for field workers to visit specific clients on the same day of the week at the same time. The clients can be expected to be there and they, in turn, will know when their field worker should be with them. Regular visits to clients are ensured, and supervisors know where their subordinates will be on _any day of the year, providing a strong incentive for workers to make their rounds. Supervisors should occasionally accompany field workers on visits to verify that work plans are being followed and to provide guidance and on-the-job training.39

Example A project in

Ptoblem2T:
Suggestion A:

Opportunities for immunization are often missed,
even when a child does make contact with a health facility that is prepared to vaccinate.

liy to identify reasons for missed opportunities. Ask yourself some questions: Is the health centre too busy? Do health personnel have to review each patient file to examine the immunization record? Do waiting times and case loads preclude attention to immunization? Can patient intake procedures be better structured to help minimise the chances of a missed opportunity? What is the best time in the visit for a child to receive immunization? Use answers to these kinds of questions to reorganise your clinic's system for immunization and patient attention. More sophisticated studies might include indepth interviews at a clinic, health workers'interpretations of national EPI policies, observations about how health workers calculated ages and dose schedules, and observations of clinic organisation and supply systems.

separately.

Example: In Lagos, Nigeria a paediatric clinic reorganised itself to reduce waiting by setting up a separate vaccination station and then vaccinating all sicl children after they had received treatment for illness. Coverage rates acielerated with no increase in cost, and staff work load decreased because staff no longer had to do a full medical history and examination to prepare for vaccinations. Waiting time for siqh patients fell as the ones coming for vaccinations only *"r" seru"d 19
ti.me_s
no'.r,r

Example: The EPI in Mozambique
its clinics sothat yaccinations are

are',raccinated before leaving the clinic or soon after a required hospitalisation. 19

reclassified its immunization schedules and reorganised given at the time a child registerq seriouly sic[ Ehildren

Problem-solvin g; supervision

39

Example: The village health centre personnel in some rural health centres in Honduras wilt not provide consultations unless the mother presents the child's vaccination card for verification. Children who are missing vaccinations are easily

identified, and the importance of immunization is emphasised at each visit. Example At a health centre in Manila, a campaign was started that introduced changes designed to reduce missed opportunities;l) measles vaccination was made available for use at least once a week in every health facility, and the health facility remained 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 open a new vial for only one child, and 3) a communications programme was initiated among health centre staff about the importance of measles immunization. A survey performed after the introduction of these interventions showed that missed opportunities for measles decreased by 20 prcentage points'lg

Problem 28: Suggestion

Lack of supervisory control in growth monitoring
and counseling activities.

A:

Consider

using protocols that divide the growth

monitoring process into discrete tasks and specific actions to be performed. Once developed, they can be extremely helpful throughout the training, irrlplementation, and evaluation process. Supervision iystems that use this system and provide direct and concrete feedback to workers on how they can improve have been found to be quite eflectlve.

Many project reviewers have emphasised the importance of developing and using performance guidelines that divide the growth monitoring process into at least five discrete tasks (motivating, weighing, recording, interpreting, and taking action) and then clearly describe the specific behaviours 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 as checklists for supervisors or workers or to^serve as tools for systems analysis, project monitoring, and assessment27 When developing a supervision strategy also consider including the following elements:

. . o o .

targeted supervision schedules supervision forms task performance norms training of supervisors improved supervision "style"

Problem-solving; supervision

40

r .

time available calculations number of supervisors available3S

Example: A study in Togo had supervisors spend more time at health centres. A day's activities were observed rather than just the growth moriitoring session.
Feedback was provided to staff at the end of sessions. Supervisors focused on skills such as balancing the scale, reading and plotting weight, communicating results to the 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 receiving feedback, and whether mothers were able to interpret the chart. Supervisors identified and corrected mistakes and interacted directly with the staff and mothers. Staff showed increased motivation and made fewer errors. Mothers became more active in interacting_wlth staff in identifying and resolving problems related to their children's growth.d

Lack of organisation in growth monitoring,/ supplemental feeding projects. Suggestion A: Implement new selection criteria to focus the programme. Select those children who are most malnourished and those whose growth is faltering. Weigh these children each month and provide specific steps and strategies for the mothers to understand and resolve the problem. Organisational problems can be related to the size of the session and the amount of time available for weighing and examining, interpreting growth charts, receiving information from the mother, and providing results and advice. Programmes in Togo and other countries have reorganised clinics so that mothers distribute food, increasing counseling time and reducing overall session length.

Problem 29:

Problem-solvin g; supervision

4L

Example The Kasa Project in India makes

sure that those children who are nutritionally at risk - those who have low nutritional status fail to gain weight e','cry three 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 and nutritional status. All children under five are weighed once ever six months in order to compile a community profile; then high-risk children are selected and weighed monthly. These children include all those under one and children three tg-five who gainea sufficient weigl'tt.$ at"'cias'sifi"Jas -ufnourirnJ oi*no f'taue

Suggestion

B:

"ot Limit the number of children in one weighing group. Often weighing groups have"fifty or more children in them. Divide weighing groups so that each has no more than 40 children. Have these groups come in 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.

Problem-solving; supervision

l
42

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Problem-solving process*

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Frequently we talk about identifying, analysing, and solving problems. But there are also "opportunities for improvement," areas where there may not be obvious problems but where a process or procedure could be improved. Dont overlook them. Problems and opportunities can be thought of as the "gab" between what is happening and what is desired. By correcting problems and making improvements you willclose that gap.

Step

t

ldentify, select, and define the problem

Begin seeking out potentialproblems or areas for improvement through

existing information or data. Many teams have begun this process by brainstorming to list khown areas of problems and frustrations. If the team members do not have ideas on potential problems, then you need to gather more information from other staff.
As you develop your list of problems, there are some dangers. You should be aware of them so-you can avoid them or take corrective action when they are discovered: . You can become overburdened with problems; identifying more than you can handle. . You can raise y6ur people's expectations so that they believe that you or someone else will fix their problems immediately. . You can get side-tracked and identify others' problems but not your own.

'

Adapted frun; Peace Corps training, 'Continuous quality improvement and the problem-solving

process; continuous medical edrrcation.'Peace Crops Office of Medical Services; URC/CHS,1992.

Problem-solving; process

43

problem-solving process
A gap between what is happening and what you want Identify, select, and define the problem and clarify the desired results Seek out potential problems or areas for improvement. Define criteria for selecting the most important problems' Define the selected problem operationally: how do we know it is a problem? Determine how we know when the problem is solved by Bninrlsb criteria for success. This is NOT the same thing as defrning the solution. Choose a team to work on the problem. Learn everything about the existing process Determine where and when the problem is occurring. Understand the process in which the problem occurs. Determine the basic causes of the problem or where the process is flawed Determine the factors that contribute to the problem. Use tools to generate 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 a solution to imPlement Analyse the possible solutions against their ability to meet your criteria for success, the costs involved, the feasibility of implementation, or other criteria.

Pilot test the solution and evaluate its effectiveness This is the Plan-Do-Check-Act cycle. It involves planning out the

steps of implementation (including addressing resisfon ce to changeJ, doing it (implementing the solution), checking out whether it had the desirld effect (monitoring the results), and acting on what you found

(modifying the solution, changing to another solution, extending implementation).

Problem-solving; process

44

Selecting a problem
You cannot work on all problems at the same time. The list is usually long and needs to be narrowed to the most important areas. For initial problem-solving activities, it is best that the problem is a small or a well-focused issue, emotionally appealing, one that others can readily see the value of solving, and one where data are relatively easy to obtain. Other criteria are needed to narrow down the list. The problem should be considered to be important to the people working on it. It should be feasible (size and complexity are manageable), the benefit of solving the problem should be worth the cost and effort required, and there should be support for changes and improvements in the current process.

Define the problem operationally
Many problem-solving efforts go astray because the group does not have a clear and common understanding of what it is supposed to solve. It is best to develop a statement of the problem in specific and observable terms. The answers to the following questions willassist in defining the problem: o What do you think is the problem? o How do you know it is a problem? o What are the effects of this problem? . How long has this been a.problem? How frequently does it occur? o How will you know the problem is solved? o Where do you want to begin looking at the problem? And where do you want to end looking (boundaries of the problem)?

The problem statement should answer these questions, be measurable, and be process-oriented. It should never give or imply any preconceived indication of what the cause might be, state or imply a particular solution, or affix or imply blame for the problem.

Choosing a team
Problem solving is most eflective when those involved in the problem participate in analysing it and developing solutions. Once the problem statement is written, the next step is to answer the question, "Who knows about the process where this problem is found?"'lb answer this question you may need to do a flow chart that identifies the major steps in the process and helps you to focus on the key problem area. Once you know the key problem area(s), ask yourself the following questions:

Problem-solving; process

45

who is experiencing difficulty

because of this problem? These are the

a a

people who are experiencing the problem's symptoms. Who do you think may contribute to the problem? It is important not to blame these individuals. Who might help solve this problem? Who can help you understand this problem?

These people will provide special knowledge, insights, and services during your problem-solving journey. some you will work with closely, otheri you may just call on when you have a specific need.

Step 2z Learn everything about the existing problem
start with what you know about the problem: clarify your understanding of what is presently happening. Analyse the data that you already have to-see if you.in uttr*"t the "who, what, when and where" of the problem. Very often people do not have a clear picture of the process, especially the links between what they do as individuals and the work of others in the process. A flow chart is a useful tool to help you understand how the proi"tt operates. If you use a flow chart, be sure that it reflects the process is it actually functions so that everyone is working within the same context.

Step 3: Determine the basic causes of the problem
Effective problem-solving involves identifying and understanding the root causes oi th" problem so that an appropriate solution can be chosen. There are three steps to identifying root causes; 1) identify all potential causes, 2l develop t6eories of cause, and 3) collect data to test theories of
cause.

Identify possible causes

In order to identify the root cause, you should generate a list of as many potential causes of the problem as possible. An excellent tool for helping io organise and sort your ideas and to begin creating theories is the causeland-effect analysis. A cause-and-effect analysis helps you to look beyond the symptoms of the problem, which reflect the manifestation of the cause buf do not necessarily indicate the specific cause. A cause-andeffect analysis pushes you to ask, "What causes that and what is behind it?" It is also designed to bioaden your thinking about causes and explore other areas that might be contributing to the problem.

Problem-solving; process

46

Develop hypotheses of cause When you have finished identifying all possible causes and displayed them, you may find that you have more causes than you could possibly investigate. You now need to narrow down and develop some hypotheses about what might be the root cause. This can be done by various decision making methods: expert opinion, voting, etc. The point here is to produce
a limited number of options from the vast array of possible causes you have identified. The narrowing process willproduce your group's hypotheses of
causes.

Collect data to test hypotheses of cause
It is important to remember that all the causes you have generated are only theories. Now it is time to collect data to prove or disprove these theories: specifically, the goal of data collection is to test theories of cause. Data collection is the key component to making improvements. Your picture of what is going on must be based on facts, not opinions or assumptions. Data collection can also be used to reveal areas for process improvement, verify the existence of a problem, assess the effectiveness of
a solution, and prevent problems.

Step 4: Identify all possible solutions
Once the root causes of the problem have been identified, it is time for the group to think creatively about how they can be addressed. Selecting a good solution involves having a range of good options from which to choose. The following are suggestions concerning how to ensure that as many solutions as possible are considered:

Review steps 1-3 (defining the problem, learning about the existing process, determining the basic causes). Once again look at the precise problem, the unfulfilled need, and the people involved. o Brainstorm to get ideas. Be sure to consider conventional, minor, and unconventional solutions. Don't forget your past experiences! . Clarify each suggested solution. . Involve people outside the group. Look for those who may be doing similar tasks, even if they are not in the same business. This is referred to as bench marking. You can find out what others are doing through interviews or surveys. The irnportant thing to remember when you are developing solutions is "to think outside the box," to get ideas from other rour.es, io Jvoid evaluation, and to ensure that everyone has a common understanding of the suggested
solutions. Problem-solving; process

o

47

Step 5: Choose and implement a solution

Once you have identified as many solutions as possible, it is time to ut utyr" thLm to determine which is the best one to implement. As in Step 1 (siecting the problem), you must determine the choice by examining criteria and constraints'

Criteria
Typical criteria for solutions include:

. . e . .

Costs of the solution Technical difficulties of implementation Potential side effects

Resistance to change Time required to implement the solution It is also important to distinguish between which criteria are a "must" in order to be cbnsidered and which are only "wants"'

Constraints

you constraints are unchangeable factors that will limit the options these constraints can realistically consider. 11 is important to note that many times should be chailenged and tested prior to acceptance, for things that are considered "unchingeable" are, in fact, flexible'

Decision maklng

each poOnce you haveldentified the criteria and constraints, discuss phase, identify teniial soiution in lighi of them . During this discussion atternatives. Essential to efpositive and negati,ie .ont"qu"nces of the id;; d;;;ioninaking is th'e amount of time spent in active discussion view' ;;;;il;;; must feet ireetopresent his or her individual point ofhave feel that they once the team reaches a point where the members various tools for sufficient information to make a decision, it can-employ a".irio"-.aking. These decisions can be made by an expert or by using rank ordering, multivoting , and/or matrices'

Step 6: Implementing quality improvement solu-

tions

. . .

There are four steps to effective implementation of solutions: plan the imPlementation do the implementation check the results of implementation

Problem-solving; Process

48

act on what you find, by either continuing implementation, modifying the solution, or returning to look for a better solution Plan: Before you start implementing the solution, you need to determine the objectives and criteria for success. You must also decide who, what, where, when, and how the solution willbe implemented. It is important to clarify your assumptions at this stage and to think about possible resistance you might encounter. Finally, you need to decide whit data to collect to monitor implementation. Do: Implementing the solution often involves providing training and always involves collecting information to monitorongoing changei and ease of implementation. observe how implementation isleing iarried out. Document anything that goes wrong: Every problem or error is an opportunity for improvement. check: observe the effects of implementation and draw conclusions about "lessons learned." Act: Thke action on what was learned: Adopt the solution, abandon it, or go through the cycle again to test modifications.

.

Problem-solving; process

I

51

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References
1.
Aqa Khan Health Services. Planning and managingPHC programmes, riport of a workshoP. KenYa, 1984. American Public 2. 'iro1i-io"J Health Association . Primary health caret Progress and onolysis t'or 52 A.LD.-ossisted piograms. Washington, DC, August,1982. 3. Bentley, C. "Primary health.care in north-western Somalia: A case study.;' Social science and medicine, Vol. 28, No.10, l'989' 4. Blumenfeld, s.N. operotions ResearchMethods: AGeneral Approach in P;;;;iHr;"ttncaie. PRIC9R Monograph Series: Methods Paper L' 5. Brown lee, A. Breastfeedi ng, un aning and nutr it ion: The behaaoro I iss ues' Monoqruph No. 4, internitional Health and Development Associates, Washiigton, D.C., July, 1990. Brownlee, A. Growth monitoring and Promotion: The behavioral issues. tuto"oorjin No. 6, International Health and Development Associates, Washiigtbn, D.C., July, 1990. Center for Human Services."The challenge for ORT programs: Increase

;ff";ti;; il; filconChild
1988.

Suruiuo I Report, Bethesda, Marvland, May,

center for Human services. "child survival reporL supervisorslqPlo]/g orowth monitorinq sessions through operations research"' PRICOR bhild Suruiual Rep,-ort. Bethesda, Maryland, May, 1991' 9. Center for Human Services. "lmproving utilisation rates of child survival r"*i""r1ni.ugh operations reiearch.o PnrcOR Child Suruiual Report, Bethesda, Maryland, November, 1990. 10. Center for Human Services. "Revising national reporting systems to -- inar." pup.r*oiii-""d ir** impact.'TPRICOR Child Suiuiual Report. Bethesd-a, Maryland, MaY, 1989. 11. Center for Human Services. "Using operations research tq -.!g-uqlgp --' ;;;i;"i solutionr ior improving heJlth worker performance." PRICOR
L2. Center for Human Services. "Using operations research to increase the - ;f f";li;;"lir .t growth monitorin!' a[ preschggljlinics." PRICOR Child -Bethesda, Maryland, June, 1990. Suruiual Report 13. Chowdhurv, M. "Evaluating community oRT programmes: Indicators -- t* ur"- an6' safetV." Healt{ policy and planninE A journal on health in detselopment, Vol. L, No.3, September,1986.

b;ids;'il;lR;;;;i.s"[n"'aalMarvland,June,lee0'

Problem-solving; references

52

May,1.984. 17. Goldsmith, A. B. Pillsbury and D. Nicholas. operations research issues: Community organisation. PRICOR, May, 1985. 18.9ltll1t!.-, M. Informatigy_for action issue paper: Growth monitoring.

A. Thesen, J. Motiwala and N. Seshadri. Sysfems tools oJ project Olqq2ing. International Development Institute, BloomingtOn, Indiana.1977. 15. Eng. E. "Community participation in water supply project and ORT activities in^I^oSo and Indonesia." WASH F ield Report N o.26Q Rosslyn, Mrginia, 1989. 16. Favin, M.-Information for action issue paper:Immunizations. UNICEE
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UNICtr, Septembea7985.

19. Grabows_k_y, 20. Hendratta,

M.

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Problem-solving; references

54

Acronyms and abbreviations
A.I.D.

AKF
CHS

CHW
CPR

DPT
EPI

HSD
I.D.

IEC

IUD MCH
MIS

MOH MWRA
OR

ORS
ORT PHC

PHC MAP
PSC

TB

TB,{
TT
URC VCEI VDC

VHW WHO

(United States) Agency for International Development Aga Khan Foundation Center for Human Services Community health worker Contraceptive prevalence rate Diptheria, pertussisand tetanus vaccines Expanded Programme on Immunization Health statistics division Identification Information, education, communication Intra-uterine device Maternal and child health Management information system Ministry of health Married women of reproductive age Operations research Oral rehydration salts Oral rehydration therapy Primary health care Primary Health Care Management Advancement Programme Pre-school clinic Tuberculosis Traditional birth attendant Tetanus toxoid University Research Corporation Village community endurance institution Village development committee Village health worker World Health Organization

Problem-solving; acronymr

PHC MAP MANAGEMENT COMMITTEE
'.

i!$'\

1 i',

i

rI;ii

Dr. Ronald Wilson o Aga Khan Foundation, Switzerland (Co-Chair) Dr. Jack Bryant . Aga Khan University, Pakistan (Co-Chair) Dr. William Steeler . Secretariat of His Highness the Aga Khan, France (Co-Chair) Dr. Jack Reynolds . Center for Human Services, USA (PHC MAP Director) Dr. David Nicholas . Center for Human Services, USA Dr. Duane Smith . Aga Khan Foundation, Switzerland Dr. Pierre Claquin . Aga Khan Foundation, Switzerland Mr. Aziz Currimbhoy ' Aga Khan Health Service, Pakistan Mr. Kabir Mitha . Aga Khan Health Service, lndia Dr. Nizar Veriee . Aga Khan Health Service, Kenya Ms. Khatidja Husein . Aga Khan University, Pakistan Dr. Sadia Chowdhury ' Aga Khan Community Health Programme, Bangladesh Dr. Mizan Siddiqi . Aga Khan Community Health Programme, Bangladesh Dr. Krasae Chanawongse . ASEAN Institute for Health Development, Thailand Dr. Yawarat Porapakkham . ASEAN Institute for Health Development, Thailand Dr. Jumroon Mikhanorn ' Somboon Vacharotai Foundation, Thailand Dr. Nirmala Murthv . Foundation for Research in Health Systems, India

PHC MAP TECHNICAL ADVISORY COMMITTEE
Dr. Nirmala Murthy . Foundation for Research in Health Systems, India (Chair) Dr. Krasae Chanawongse . ASEAN Institute for Health Development, Thailand Dr. AlHenn . African Medicaland P^esearch Foundation (AMREF), formerly of the Harvard Institute for International Development Dr. Siraj-ul Haque Mahmud ' Ministry of Planning, Pakistan Dr. Peter Tugwell . Faculty of Medicine, University of Ottawa, Canada Dr. Dan Kaseje . Christian Medical Commission, Switzerland, formerly of the University of Nairobi, Kenya

KEY PHC MAP STAFF AT THE CENTER FOR HUMAN SERVICES
Dr. Jack Reynolds (PHC MAP Dr. Paul Richardson Dr. David Nicholas Dr. Wayne Stinson Ms. Maria Francisco

Director)

Dr. Neeraj Kak
Ms. Lori DiPrete Brown Ms. Pam Homan

Dr. Lynne Miller-Franco
Ms. Mary Millar

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