THE PHC MAP SERIES OF MODULES, GUIDES AND REFERENCE MATERIALS Each module includes: a User's guide a Facilitator's guide computer programs Module 1 Assessing information needs Module 2 Assessing community health needs and coverage Module 3 Planning and assessing health worker activities Module 4 Surveillance of morbidity and mortality Module 5 Monitoring and evaluating programmes Module 6 Assessing the quality of service Module 7 Assessing the quality of management Module 8 Cost analysis Module 9 Sustainability analysis Manager's guides and references Better management: 100 tips Problem-solving Computers The computerised PRICOR thesaurus Production Managers: Ronald Wilson, Aga Khan Foundation, Geneva and Thongchai Sapanuchart, Somboon Vacharotai Foundation, Bangkok, Thailand Co-Editors: Jennifer Sharples, Colin De'Ath, Bangkok, Thailand Design & Layout: Helene Sackstein, France Desktop Publishing: Marilyn J. Murphy, Suracha Suntarasut, Somboon Vacharotai Foundation, Bangkok, Thailand Printing: Thai Wattana Panich, Bangkok, Thailand Published in 1993 by the Aga Khan Foundation USA, Suite 700, 1901 L Street N.W., Washington DC and the Aga Khan Foundation, P.O. Box 6179, 1211 Geneva 6, Switzerland. Additional copies are available at the Aga Khan Foundation Canada in Toronto; Aga Khan Foundation (United Kingdom) in London; and AKF offices in Dhaka, Bangladesh; Delhi, India; Nairobi, Kenya; Karachi, Pakistan; Lisbon, Portugal; and Dar-es-Salaam, Tanzania; the Aga Khan University Faculty of Health Science in Karachi, Pakistan; the Somboon Vacharotai Foundation and the ASEAN Institute for Health Development in Thailand PLANNING AND ASSESSING HEALTH WORKER ACTIVITIES MODULE 3 FACILITATOR'S GUIDE Dedicated to Dr. Duane L. Smith (1939-1992), Dr. William B. Steeler (1948-1992) and all other health leaders, managers and workers who follow their example in the effort to bring quality health care to all in need. 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-0158-A-00-8161-00, 1988-1991); and the second was "Strengthening the Effectiveness, Management and Sustainability of PHC/Mother and Child Survival Programs in Asia and Africa" (cooperative agreement no. PCD-0158-A-00-1102-00, 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. Contents FOREWORD 1 SESSION 1: INTRODUCTION AND OVERVIEW 7 Transparencies 3-1: Workshop objective 12 3-2: Steps in PHC work planning 13 SESSION 2: CATCHMENT AREA AND PRIORITY NEEDS (STEPS 1 AND 2) 15 Transparencies 3-3: Session 2: Objectives 21 3-4: Work planning steps 22 3-5: A catchment area 23 3-6: Village/community level information 24 3-7: Larger catchment area information 25 3-8: Information sources 26 3-9: Purpose of mapping 27 3-10: Purpose of a community/village register 28 3-11: Data sources 29 3-12: Indicator categories 30 3-13: Sources of indicator information 31 SESSION 3: SET PRIORITIES AMONG HEALTH PROBLEMS AND IDENTIFY HIGH-RISK GROUPS (STEP 3) 37 Transparencies 3-14: Session 3: Objectives 42 3-15: Examples of ranking criteria 43 3-16: Relative and attributable risks 44 3-17: Sources of demographic information 45 SESSION 4: PLAN PHC ACTIVITIES (STEP 4) 49 Transparencies 3-18: Session 4: Objectives 55 3-19: Deciding activities and strategies 56 3-20: Types of activities 57 3-21: Formulae to determine staff requirements 59 3-22: Tools for planning community-based and outreach activities 62 SESSION 5: DEVELOP JOB DESCRIPTIONS AND RECRUIT STAFF (STEP 5) 65 Transparencies 3-23: Session 5: Objectives 68 3-24: Purposes of a job description 70 3-25: Test questions 72 SESSION 6: DEVELOP WORK PLANS AND ASSESS PERFORMANCE (STEPS 6 AND 7) 73 Transparencies 3-26: Session 6: Objectives 79 3-27: Advantages of work plans 80 3-28: Principles of work planning 81 3-29: Purposes of performance assessments 82 3-30: Performance assessment principles 83 3-31: Suggested performance assessment process 84 Foreword What is the purpose of the Facilitator's guide? The Facilitator's guide contains a suggested workshop design for use by individuals who will help PHC managers and staff learn how to use the Primary Health Care Management Advancement Programme (PHC MAP) series. There is a Facilitator's guide for each module in the PHC MAP series. What information does it contain? Each Facilitator's guide contains instructions for conducting a workshop on one of the modules in the PHC MAP series using the information contained in the User's guide. The instructions are arranged in one to two hour sessions. The number of sessions depends on the amount of information and/or the number of steps contained in the User's guide. The first page of each session lists session objectives, major topic headings, time required, and materials and equipment. The following pages describe the instructional activities in outline form. The outline is divided into two columns. The right-hand column indicates what the facilitator says or does to conduct the session. The left-hand column lists the handouts, overhead transparencies, or other materials needed to support the activity. Copies of these materials, suitable for duplication, appear at the end of the session in which they are first used. Some transparencies are used in more than one session. How are the workshops organised? The first session of each workshop contains activities designed to introduce the PHC MAP series and explain its importance to PHC programmes, present an overview of the workshop, explain the purpose of the module, review specific terms or concepts used in the module, and acquaint the participants with the organisation and content of the User's guide. The final session of each workshop contains activities designed to review key points of the User's guide, if appropriate, help participants prepare an action plan, and brings the workshop to a formal conclusion. The sessions in between present the steps required to accomplish the purpose of the module and provide an opportunity for participants to apply those steps to their own programmes. Each workshop is designed to be given on consecutive days, uninterrupted except for breaks, meals, and rest, if the workshop is longer than one day. It is recognised, however, that situations vary and the PHC MAP modules will be used singly or in combination by individuals and organisations in the field and on university campuses. Therefore, it is expected that the workshops described in the Facilitator's guides will be adapted to fit a range of circumstances. Indeed, those who facilitate PHC MAP workshops are encouraged to make adaptations to meet the needs of participants and/or specific PHC programmes. Who can be a facilitator? Ideally, the person who serves as facilitator has training and experience in the fields of public health, management, planning, and evaluation, as well as sampling and survey design. It is recommended that this person also be skilful in working with small groups. The facilitator should be someone from outside the PHC programme, perhaps from another agency or a university. As a person with no direct interest in the programme, the facilitator can be neutral in disagreements that may arise and help the group members resolve an issue objectively. Having an outside person as facilitator also allows the programme director, who usually has a leadership role, to contribute his or her knowledge and experience as a full participant in the work of the group. It is also recommended that a facilitator have a full set of PHC MAP User's guides and Facilitator's guides. It is sometimes necessary, in the course of completing one module, to refer to information in another module. Who should participate in the workshop? The primary audience for the PHC MAP series is the team that manages PHC programmes or other population-based health programmes in either the public or private sector. An example of a PHC management team in the public sector is the core staff of a district ranging from 100,000 to 300,000 in size of population served. An example of a PHC management team in the private sector is the core staff of an NGO that provides PHC services to a specific population in a given geographic area. The average size of the service population may range from 40,000 to 60,000, but may be as small as 10,000 or more than 100,000. In either case, the management team should have: the knowledge and skills needed to complete the steps in the module the time and resources required to collect and analyse the required data the authority to plan and implement improvements in management systems and procedures based on this analysis. If feasible, teams from several districts or from several PHC programmes within a given NGO, may work simultaneously with one facilitator to complete a module. It is recommended that one facilitator work with no more than four teams or 20 people at one time. What does the facilitator do? Understands the needs of participants. If the facilitator is working with one PHC programme, the most efficient way to gather information about participants and the programme in which they work is to meet with the PHC director to determine: the nature of the PHC programme (services provided, size and description of area served, number and type of facilities, number and qualifications of staff, community involvement, computer capability, strengths, major problems, etc.) if information needs have been clearly identified previous staff training in management information systems or related topics resources available for training (time, space, equipment) possibility for subsequent technical assistance to workshop participants. Understands the content of Module 1. Read the User's guide and Facilitator's guide for Module 1 and consider options for workshop delivery. The purpose of Module 1 is to help participants select priority information needs and to review some basic concepts underlying management information systems. Depending on participant background, the amount of time available, and the need to establish priorities among management information needs, Module 1 can be presented in its entirety, limited to Level 1: Quick start, limited to the PHC MAP systems framework, or in summary form as contained in the first session of the Facilitator's guides for Modules 2 through 9. If information needs have not been clearly identified and participants have no background in systems, then Module 1 should be presented in full. The selection of the next module will depend upon priorities set by the participants as they complete the steps in Module 1. If information needs have been clearly identified and participants have no background in systems, then that portion of Module 1 can be added to the first session of the selected module. If information needs have been clearly identified and participants have a background in systems, then the overview of PHC MAP in the selected module will be sufficient. Understands the content of the selected module. Read the User's guide and Facilitator's guide for the selected module and consider options for workshop delivery. Depending upon the length of the module and the availability of staff for training, the workshop sessions may be presented as described in the Facilitator's guide, or workshop sessions may be delivered at intervals (for example, every morning for a certain number of days, one session per week, or one day per week for three or four weeks). If follow-on technical assistance is available, the content of the module could be presented in the workshop and the application of the procedure to the PHC programme could be conducted on the job. Participants could plan steps in the workshop, complete them on the job, and bring the results to the next workshop session. This approach is particularly applicable to Module 2 which requires development of a questionnaire, selection of a survey sample, training of data collectors, and data collection. These steps cannot actually be carried out within the time limits of the workshop as contained in the Module 2 Facilitator's guide. Other options are possible depending upon the circumstances of each situation. Determines what programme information, if any, is needed for completion of the module. For example, census data and lists of households are required to complete some of the steps in Module 3. Determines the most appropriate people to attend the workshop. For example, Module 7 is best completed by those responsible for planning, training, supervision, logistics, and other management services. Discusses the delivery options and participants with the PHC manager and make decisions regarding the most appropriate option and participant selection. Also determines if the needed information is available and if it is not, the alternatives for obtaining the information. Notifies participants of the date, time, and purpose of the workshop and confirms attendance. Initial notice of the meeting may come from the PHC manager, with follow-up by the facilitator. Prepares the agenda, using as a model the sample in Session 1 of the Facilitator's guide for the selected module. Inspects the room where the workshop will be held and answers these questions: Is the room large enough to seat all the participants? Can chairs and tables be arranged in a variety of ways; all participants around one table; participants in groups of three or four at smaller tables? Is the lighting adequate? Can temperature and humidity be controlled? Is there an electrical outlet for an overhead projector? Is a microphone necessary for everyone to hear and to be heard? Are toilets conveniently located? Is the site convenient to parking, restaurants and public transportation? Are supporting facilities available and convenient: duplication, word processing, computers? Prepares notes to conduct the workshop using the session outlines in the Facilitator's guide for the selected module, and makes the necessary adaptations. Refer to the appropriate User's guide for content. Duplicates the worksheets and other handouts as indicated in the Facilitator's guide and obtains the necessary equipment. Conducts the workshop as planned. Provides follow-on assistance, if appropriate.Session 1:Introduction and overview Objectives: Participants will be able to: Explain the purpose of Module 3. Describe at least two limitations of Module 3. Explain the steps involved in planning and assessing health worker activities. Session outline: I. Introduction (30 minutes) II. Overview of workshop (10 minutes) III. Purpose of Module 3 (20 minutes) IV. Module 3 User's guide (5 minutes) Materials: Module 3 User's guide Handout 3-1: Agenda Transparency 3-1: Workshop objectives Transparency 3-2: Steps in PHC work planning Equipment: Flip chart, stand, markers, masking tape, overhead projector and screen I. Introduction (30 minutes) Note: Omit Section I if you have presented Module 1, or some other module, immediately prior to the presentation of Module 3. A. OPENING REMARKS Introduce self and other staff, as necessary. Explain your role in the workshop. If you do not know the participants, ask each one to state his or her name, position title, and job location. Note: If the group is larger than 6 or 8, you may wish to have them wear name tags or place cards with their names at places where they are sitting. Ask each participant to complete this sentence: "As a result of attending this workshop, I expect . . ." and write their responses on the flip chart. When all responses have been recorded, say that you will return to this list after giving an overview of the workshop. B. OVERVIEW OF PHC MAP Explain why information is important for PHC programmes. Summarise PHC MAP programme, including: Purpose of PHC MAP Title and purpose of each module and other materials. Make the following points about PHC MAP: Has been field tested and revised to ensure usefulness to PHC programme staff. Modules can be used in any sequence. Checklists and other materials can, and should, be adapted to fit a particular situation. The procedures outlined in the modules can be adopted as routine monitoring activities in a PHC programme. Explain why MAP is being introduced in this PHC programme. Note: The remarks here should be tailored to the specific programme and should provide the answers to these questions: Why are we doing this workshop? What do we expect to achieve? It may be appropriate for the PHC manager to make these remarks. II. Overview of workshop (10 minutes) Review the workshop objectives. Distribute and review the workshop agenda, describing the activities that will take place to accomplish the workshop objectives. Review the expectations contributed by participants at the beginning of the session. Indicate which ones will be met and which ones will not and why. Suggest, if possible, alternatives for meeting the expectations that will not be met in this workshop. Ask for questions or comments. III. Purpose of Module 3 (20 minutes) Explain that the purpose of Module 3 is to help PHC programme staff to: Set priorities for meeting community health needs. Develop realistic workplans to ensure that health workers spend their time most effectively to meet those needs. Improve assessment of health worker performance. Explain that Module 3 does not: Deal with overall PHC programme planning. Discuss ways to involve communities, although community members should be involved in setting priorities and evaluating progress. Provide a comprehensive approach to personnel management. IV. Module 3 User's guide (5 minutes) Distribute a User's guide to each participant. Highlight key sections of the User's guide: The overview of PHC MAP with the description of modules and other materials, which they may wish to refer to for review of information needs met by other modules. Step-by-step directions for developing workplans individual assignments, and performance assessment procedures. Appendices containing blank worksheets and other reference material. Review briefly the steps in Module 3, including substeps and expected outcomes. Ask for questions or comments. SAMPLE AGENDA MODULE 3* Session 1(1 hr,, 5 mins), Introduction and overview Session 2(1 hr,, 30 mins), Map catchment area and identify priority needs (Steps 1 & 2) Session 3(1 hr,, 30 mins), Set priority among health problems and identify high-risk groups (Step 3) Session 4(1 hr,, 40 mins), Plan PHC activities (Step 4) Session 5(1 hr,, 20 mins), Develop job descriptions and recruit staff (Steps 5) Session 6:(1 hr,, 25 mins), Develop work plans and assess performance(Step 6 & 7) *For an actual presentation, substitute the appropriate clock hours in the first column. WORKSHOP OBJECTIVES 1. Set up a system that identifies the PHC programme's various target populations, determines their health needs and sets priorities among those needs 2. Design simple and effective procedures to increase health services coverage of high-risk groups through planning and assessing of health worker activities STEPS IN PHC WORK PLANNING Step 1: Describe and map catchment area Step 2: Identify community needs and available resources Step 3: Set priorities among health problems and identify high-risk groups Step 4: Plan PHC activities Step 5: Develop job descriptions and recruit staff Step 6: Develop individual work plans and schedules Step 7: Assess job performance Session 2:Catchment area and priority needs (Steps 1 and 2) Objectives: Participants will be able to follow the directions in the Module 3 User's guide to: Define and describe the catchment area and the target population that the PHC programme serves. Identify community needs and available resources. Set priorities among health care needs and identify groups at highest risk. Session outline: I. Introduction (5 minutes) II. Describe and map catchment area (40 minutes) III. Identify community needs and available resources (45 minutes) Materials: Module 3 User's guide Transparency 3-3: Session 2: Objectives Transparency 3-4: Work planning steps Transparency 3-5: Definition of catchment area Transparency 3-6: Village/community level information Transparency 3-7: Larger catchment area information Transparency 3-8: Information sources Transparency 3-9: Purpose of mapping Transparency 3-10: Purpose of a community/ village register Transparency 3-11: Data sources Transparency 3-12: Indicator categories Transparency 3-13: Sources of indicator information Handout 3-2: Worksheet for defining catchment area Handout 3-3: Worksheet for describing catchment area Handout 3-4: Village register Handout 3-5: Worksheet to make a house hold register Handout 3-6: Worksheet for determining indicators and their source Equipment: Flip chart, stand, markers, masking tape, overhead projector and screen I. Introduction (5 minutes) Review the session objectives. Review the steps to be completed in this session. II. Describe and map catchment area (40 minutes) Explain that the purpose of this step is to: Define and describe the catchment area and target population. Develop a register of households and/or individuals in the catchment area. Define catchment area. Distribute the worksheet and direct participants to complete the worksheet for their catchment area. (Exhibit 1, User's guide, appendix E) Explain the types of information needed to describe a village or community level catchment area and larger catchment areas. Review some possible sources of this information. Distribute worksheet and direct participants to fill in the information they have for their PHC catchment area. (Exhibit 2, User's guide, appendix E) Review the purpose of mapping catchment areas. Explain that more than one map may be required depending on the level of service delivery and review the information that should be depicted on each. District level Health facility level Community/village level Say that it may be useful to show target populations for different PHC services. Direct participants to make at least one type of map of their catchment area, referring to Exhibits 1 and 2 and Appendix A as necessary. Explain the purpose of making a community/village register. Refer participants to Exhibit 6, and review the information it contains. Distribute handout and review the information that may be included. (Exhibit 6, User's guide, appendix E) Direct participants to compare the handout to their own village register (if available) and discuss differences, if any, or begin to prepare a village register based on the information they have. Explain that someone should be assigned to maintain the register so that information is always current. Explain that a household register can help identify individuals or underserved groups in need of a specific type of PHC service. Refer participants to Exhibit 7, and review the information required for household registers. Explain how household registers are used to determine the size of the target population for a specific PHC service. Explain that if a household register cannot be made the target population can be estimated using demographic or census data. Note: Be prepared to demonstrate how this is done if the participants cannot describe the process to you. Distribute the handout and direct participants to complete it. (Exhibit 7, User's guide, appendix E and page 35 of this FG.) If participants do not have the information to complete a register for one household, lead them in a discussion of the relevance of the information and how they would modify it to fit their situation, if at all. Ask for questions and comments. III. Identify community needs and available resources (45 minutes) Explain that this step is important because it enables a PHC programme to: Identify community needs based on various data sources. Identify resources that will help in providing better service. Review some possible sources of information about community needs and available resources. Assist participants in selecting indicators necessary to assess the health status in their community. Explain that this information will help in setting priorities and determining strategies. Discuss the four types of information that these indicators will measure. Distribute worksheet and direct participants to fill in the first column. (Exhibit 8, User's guide, appendix E) Facilitate a discussion of what indicators were chosen and why. Review possible sources of information for the indicators selected. State that similar sources were used to obtain information about needs and resources.Direct participants to complete Handout 3-6. Based on the indicators selected, assist participants in developing a survey instrument about the community and the health facilities. Refer participants to Appendix C and Module 2 for examples of questionnaires that can be modified to fit their needs. Ask for questions and comments. SESSION 2: OBJECTIVES 1. Define and describe catchment area and target population 2. Identify community needs and available resources 3. Set priorities among health care needs and identify groups at highest risk WORK PLANNING STEPS 1. Describe and map catchment area 1.1 Define catchment area 1.2 Describe catchment area 1.3 Map catchment area 1.4 Make a village register 1.5 Make a household register 2. Identify community needs and available resources 2.1 Select indicators 2.2 Identify sources of information 2.3 Develop a survey instrument A CATCHMENT AREA . . . is the geographical area surrounding a single health facility or group of health facilities includes the target population is determined by the type of PHC service or by geographical or administrative boundaries VILLAGE/COMMUNITY LEVEL INFORMATION Number of individuals/households in the area Age, gender, ethnic group, health status of household members Socio-economic status Social activities Size and terrain; roads LARGER CATCHMENT AREA INFORMATION Roads, transport, cost Social differences Industry Listing of communities INFORMATION SOURCES Government offices Village registers Household registers Community surveys Interviews and observations PURPOSE OF MAPPING Plan work assignments Conduct surveys Monitor services Determine physical parameters of service coverage PURPOSE OF A COMMUNITY/VILLAGE REGISTER Helps identify ethnic, religious, or social groups; and health facilities which serve the communities/villages DATA SOURCES Existing records Surveys Interviews with community members INDICATOR CATEGORIES Health problem indicators simple frequencies community perceptions of priorities prevalence rates mortality rates Demographic indicators population composition age-sex distribution sex ratio number of births and deaths Risk factor indicators environmental biological socio-economic behavioural health care related Indicators of existing health services and available resources type and quality of health services number of health providers access to health services and supplies community perceptions other resources, such as transportation and human resources SOURCES OF INDICATOR INFORMATION Existing data sources Interviews Observations a)Select criteria to define the boundaries of your catchment area. ___Fixed distance of___kms around health facility ___Administrative unit (specify level and name) ___Panggang (sub district)___in Gunung Kidul (district) ___PHC service target group, socio-economic or geographically defined population ___A practically defined population (please specify) b)Define sub-catchment areas for different services: ___Curative care ___MCH ___Family planning ___TB ___Other Exhibit 1: Worksheet for defining catchment area Information Number of facilities Name of facilities Name of villages Number of villages Location of facility(s) Size & terrain of area Number of households position of HHs Sources of income Education levels Religion/ethnicity Status of houses/roads Distance to health facility Level District level Facility level Village level Data sources Government offices Government offices Village registers Village registers Village registers Observation Household register Household register Community surveys Community surveys Community surveys Interviews and observations Interviews and observations Exhibit 2: Worksheet for describing catchment area Others remarks No. of house- holds Being addressed Public transport available Distance to health facility (Km.) Health problems Health volunteers Population Local leaders S. No District: ________________ Sub-district:________________ Village Priority Exhibit 6: Village register, , , +, , , , , , , , , , , , , 1 1 1 1 1 2 2 1 Remarks Migration out Date of :Death Chronic health problem SexM/F Date of birth/age* Father's/husband's name Name ID No SECTOR #/HOUSE #/ HOUSEHOLD #:________NAME OF HEAD OF HOUSEHOLD:___________HH. INCOME:________ REGISTRATION DATE:________OCCUPATION:_______________CENTRE NAME:______________ At least 1 child << 1 yr>>2 Infant deaths in past 5 yrs>>2 children << 5 yrsIlliterate womenRestriction on mobility of womenPresence of TB caseLow family incomeImproper/no use of toilet facilities Risk profile of Household Score if present Score Total * List oldest member first and youngest last Exhibit 7: HOUSEHOLD REGISTER, , , +, , , , , INDICATORS I. Health status indicators Clinical Prevalence rates Age-specific morbidity rates Frequency of cause of deaths Cause-specific mortality rate Community survey II. Demographic indicators Age distribution Sex ratio CBR CDR III. Risk factors Biological - malnutrition - immunization status Environmental - water - sanitation Socio-economic - literacy - behavioural IV. Health service related Quantity Quality Accessibility - distance - cost Clinic/hospital records Community survey Community survey Community survey Verbal autospy Verbal autospy Community survey Village household registers Community survey Village household registers Community survey Village household registers Community survey Village household registers MCH card MCH card Observation Observation Community survey Community survey Facility survey Facility survey Community survey Community survey Exhibit 8: Worksheet for determining indicators and source of indicators Session 3:Set priorities among health problems and identify high-risk groups (Step 3) Objectives: Participants will be able to follow the directions in the Module 3 User's guide to set priorities to enable their programme to: Provide equitable health care; Increase the frequency of services for those in greater need. Session outline: I. Introduction (5 minutes) II. Set priorities among health problems (20 minutes) III. Determine the risk factors (20 minutes) IV. Set priorities for the risk factors (20 minutes) V. Identify target groups and high-risk groups (10 minutes) VI. Use risk factors to monitor high-risk groups (15 minutes) Materials: Module 3 User's guide Transparency 3-14: Session 3: Objectives Transparency 3-15: Examples of ranking criteria Transparency 3-16: Relative and attributable risks Transparency 3-17: Sources of demographic information Handout 3-7: Worksheet for setting priorities among health problems Handout 3-8: Worksheet for setting priorities among risk factors Handout 3-9: Worksheet for developing risk profiles of households Equipment: Flip chart, stand, markers, masking tape, overhead projector and screen I. Introduction (5 minutes) Review session objectives. State that this step should be conducted by the PHC team and the community, but for the purposes of this training, it will be done by the participants. II. Set priorities among health problems (20 minutes) Explain that one method of setting priorities among health problems is by ranking specified criteria, and explain the purpose of each criterion. Review the information in Exhibit 9, and explain the difference between multiplicative and additive scores. Distribute Handout 3-7, and assist participants in completing it for their programme. (Exhibit 9, User's guide, appendix E) III. Determine the risk factors (20 minutes) Explain that identifying risk factors will help in developing appropriate strategies for health promotion, disease prevention, and the reduction of morbidity, disability and mortality. Explain that determination of priority risk factors should be based on research and data from the programme site. Review broad classifications of risk factors: -Biological -Environmental -Socio-economic -Behavioural -Health-care related Assist participants in determining the priority risk factors for their programme. Define relative risk and attributable risk, and explain that these will help determine the magnitude of risk associated with each factor identified. (Refer to Appendix B.) Assist participants in calculating the relative and attributable risks for at least one of the factors they have identified. Note:If incidence data is not available for individual programmes, the Facilitator should provide an example for participants to work from. Ask for questions and comments. IV. Set priorities for the risk factors (20 minutes) Explain that a process similar to the one just used to set priorities among health problems can also be used to set priorities among the risk factors identified. Review modifications to be made for this process. Distribute Handout 3-8 and instruct participants to complete it for at least one of the risk factors they have identified. Facilitate a discussion about which risk factors were prioritised and why. V. Identify target groups and high-risk groups (10 minutes) Explain how the identification of priority target groups and high-risk groups are related. Review sources of demographic information to be used in the identification of individuals or households in the target groups. Review the example of the maternal health record card, as an example of a mechanism for identifying individuals or households. Assist participants in identifying individuals or households that will be the target of their PHC services, as well as those who are at higher risk. Discuss why this selection was made. This selection should be consistent with the priorities identified by the participants. Use risk factors to monitor high-risk groups (15 minutes) Explain the purpose of a risk profile and how to create one. Explain that groups with high risk scores (based on the risk profile) are at high risk of morbidity and mortality. Review binomial scoring (0 or 1) and weighting. Review and explain the information contained in Exhibit 11. Distribute Handout 3-9, and direct participants to develop a list of risk conditions and then complete the worksheet. (Exhibit 11, User's guide, appendix E) Explain that based on these scores, PHC services should be organised according to the special needs of the high-risk groups. Ask for questions or comments. SESSION 3: OBJECTIVES Participants will be able to follow the directions in the Module 3 User's guide to set priorities to enable their programme to: 1. provide more equitable health care 2. increase the frequency of services for those in greater need EXAMPLES OF RANKING CRITERIA seriousness of the disease prevalence of the disease feasibility of control community acceptance Relative risk:measures association between a characteristic and the disease. It is calculated as follows: Relative risk = Incidence in an exposed group Incidence in an unexposed group Attributable risk: measures the additional incidence of disease following exposure over and above that experienced in an unexposed group. It is calculated as follows: Attributable risk = Incidence of disease in an unexposed group Incidence of disease in an exposed group RELATIVE AND ATTRIBUTABLE RISKS, , , , , , SOURCES OF DEMOGRAPHIC INFORMATION Household registers Surveys Administrative records Interviews of key persons Health Problems Prevalence Seriousness Feasibility of control Multiplicative scores (X) Additive sources Community acceptance Malnutrition Diarrhoea/dehydration Cancer AIDS 3312 11131010 3211 2443 54961624 3444 Exhibit 9: Worksheet for setting priorities among health problems, , , , , Multiplicative score (x) Additive scores (+) Community acceptance Feasibility of control Seriousness Prevalence Health problems HOUSEHOLD No SCORE IF PRESENT CONDITIONS * Weight determined by number of children Rating scale: 0-3 4-6 High risk Low risk Moderate risk >>7 Number of infant deaths in past 5 years Number of children under the age of 5 Illiterate mother Culture/religious restriction on mobility of women Presence of infectious diseases (e.g., TB) Low family income (below locally accepted level) Improper/no use of toilet facilities* Total risk score **11111 13110118 11111106 11010115 01100103 Exhibit 11: Worksheet to develop risk profiles of households, , , Session 4:Plan PHC activities (Step 4) Objectives: Participants will be able to follow the directions in the Module 3 User's guide to: Plan outreach activities for groups at risk for a priority health problem in their PHC programme. Plan clinic-based services for the same target group. Session outline: I. Introduction (10 minutes) II. Identify strategies and activities (20 minutes) III. Plan outreach and community-based activities (35 minutes) IV. Plan clinic-based activities (35 minutes) Materials: Module 3 User's guide Transparency 3-18: Session 4: Objectives Transparency 3-19: Deciding activities and strategies Transparency 3-20: Types of activities Transparency 3-21: Formulae to determine staff requirements Transparency 3-22: Tools for planning clinic-based activities Handout 3-10: Worksheet for identifying services, strategies and activities Handout 3-11: Worksheet for planning PHC activities<+> Handout 3-12: Worksheet to determine staff requirements Equipment: Flip chart, stand, markers, masking tape, overhead projector and screen I. Introduction (10 minutes) Review session objectives. Review the information needed to complete Step 4. Programme goals, objectives, and strategies from Module 1. Assessment of community needs from Module 2 (for PHCs with large catchment areas). Selected PHC components from Module 1. High risk group(s) from Module 3, Step 2. II. Identify strategies and activities (20 minutes) Remind participants about the group nature of this activity. Review decisions that will need to be made in deciding on how to provide services. Define community-based, outreach, and centre-based activities, and provide examples of each. Refer participants to Exhibit 12 and explain the information it contains. Review basic questions that will help in deciding how to provide the services selected earlier. What overall strategy will be used to provide each service? Which activities are needed to provide the service? Who will perform the activities, how, and at what service delivery level? Distribute the worksheet and assist participants in completing it and identifying each service or component as community-based, centre-based, or outreach. (Exhibit 12, User's guide, appendix E) Ask for questions and comments. III. Plan outreach and community-based activities (35 minutes) Describe the relationship between community-based, clinic-based, and outreach activities. Refer participants to Exhibit 13 for a chart showing the information that will be developed in this session and explain the information it contains. State that the same chart for clinic-based services appears on the following page in the User's guide Explain the substeps involved in this step and state that although each activity is examined separately, activities should be viewed as a whole. Determine number of units to be covered. Determine optimal time interval for each activity. Determine resource requirements, using the formulas provided. Identify an optimal number of visits. Review guidelines for frequency. Develop tools to plan and monitor activities. Refer participants to models 1-5 presented in the User's guide, and assist them to adapt one to fit their own PHC programme needs. Distribute worksheet and direct participants to list the community-based outreach services for a health problem of their choice in the first column. (Exhibit 13, User's guide, appendix E) Assist participants in completing sections A and B of the worksheet, following the substeps outlined in the User's guide. IV. Plan clinic-based activities (35 minutes) Explain the purpose of planning clinic-based activities: Supplement field-based preventive services by providing back-up referral and centralised preventive services. Determine the types of services which are or will be in demand. Explain that section C of the worksheet will be used for recording the outcomes of the substeps to planning clinic-based services. Assist participants to complete the handout, referring to each substep used to complete it. Determine client load. Distribute handout and explain the two methods that can be used to calculate demand for services or project client load. Determine staff requirements and resource requirements. Determine availability of resources. Compare availability with need and identify an optimal solution. Develop tools to plan clinic-based activities. Refer participants to examples in the User's guide and direct them to develop one for the services they have planned by: developing a new form; modifying a sample form contained in the User's guide; or modifying a form they are currently using. Ask for questions or comments. SESSION 4: OBJECTIVES 1. Plan outreach activities for households at risk for a priority health problem in the PHC programme 2. Plan clinic-based services for the same target group DECIDING ACTIVITIES AND STRATEGIES What overall strategy will be used to provide each service? What activities are needed to provide the service? Who will perform the activities? How? At what level? TYPES OF ACTIVITIES , , Performed at:, Performed by: 1., Community-based, Community level, Community members 2., Outreach, Community level, Health centre staff 3., Centre-based, Centre, Health centre staff Service/component List Strategy Who will do it How and when Activities Exhibit 12: Worksheet for identifying services,, strategies and activities, , , , , , , , , , , , , , , , , Staff capacity/month = [days/month] x number of units that can be covered per day per worker Staff requirement = units to be covered staff capacity FORMULAE TO DETERMINE STAFF REQUIREMENTS, , , , OPTIMAL LEVEL OF SERVICES GIVEN RESOURCE CONSTRAINTS AVAILABLE AVAILABLE FREQUENCY SERVICE/ACTIVITIES NEEDED TARGET GROUP A. COMMUNITY-BASED REQUIRED TYPE AMOUNT REQUIRED TYPE NUMBER(FTEs) MANPOWER LOGISTICS/SUPPLIES B.OUTREACH Exhibit 13: Planning PHC Activities, , +, +, , , , , , , OPTIMAL LEVEL OF SERVICES GIVEN RESOURCE CONSTRAINTS AVAILABLE AVAILABLE FREQUENCY SERVICE/ACTIVITIES NEEDED TARGET GROUP A. COMMUNITY-BASED REQUIRED TYPE AMOUNT REQUIRED TYPE NUMBER(FTEs) MANPOWER LOGISTICS/SUPPLIES Exhibit 13: Planning PHC Activities, , +, +, , , , , , , TOOLS FOR PLANNING COMMUNITY-BASED AND OUTREACH ACTIVITIES CHW activity register Pictorial CHW activity record Pictorial TBA activity record LHV activity register Computer lists of individuals who need a service Staff capacity per month = days/month x number of units that can be covered/day per worker Staff requirement = units to be covered staff capacity Note: When determining the number of units that can be covered for one type of activity in a day, take into account the time it takes to effectively cover the units for that activity and travel time if needed. For example, if you were planning LHV's outreach support visits: Number of villages in catchment area: 50 Frequency for visiting each village: once a month Number of working days per month: 25 Number villages that can be visited per day per LHV: 1 Staff capacity per month = 25 x 1 = 25 per LHVs Staff requirement = 50/25 = 2 full time (FTE) LHVs Exhibit 14: Worksheet to determine staff requirements Session 5:Develop job descriptions and recruit staff (Step 5) Objectives: Participants will be able to follow the directions in the Module 3 User's guide to: Develop job descriptions for the positions needed to provide planned PHC services. Plan to recruit and hire individuals to fill those positions. Session outline: I. Introduction (5 minutes) II. Develop role and task list (15 minutes) III. Prepare job descriptions (25 minutes) IV. Plan staff recruitment (20 minutes) V. Agree on expectations (15 minutes) Materials: Module 3 User's guide Transparency 3-23: Session 5: Objectives Transparency 3-24: Purposes of a job description Transparency 3-25: Test questions Handout 3-13: Worksheet for roles and tasks Handout 3-14: Job description worksheet Equipment: Flip chart, stand, markers, masking tape, overhead projector and screen I. Introduction (5 minutes) Review session objectives. II. Develop role and task list (15 minutes) Explain that the tasks included in programme plans are the basis for developing job descriptions Refer participants to Exhibit 24 and explain each section of the role and tasks list. Distribute worksheet and direct participants to complete it for at least one staff position identified in Step 3. (Exhibit 24, User's guide, appendix E) III. Prepare job descriptions (25 minutes) Explain the purposes of a job description. Refer participants to Exhibit 25 and describe he information contained in each section. Distribute Handout 3-13 and assist participants to complete it based on the role and task list just completed. (Exhibit 25, User's guide, appendix E) Recommend that participants check that the job description is realistic and feasible, using test questions. IV. Plan staff recruitment (20 minutes) Ask participants to list the steps usually followed by their agency when filling a staff position and record their responses on the flip chart (be sure they include necessary approvals). Ask participants to speculate on the outcome of this process given the way the position description was developed (better, worse, the same). Facilitate a discussion on this point, depending on the time available. V. Agree on expectations (15 minutes) Describe the intent and purpose of this substep. Explain that this activity will lead to the successful development of individual work plans (Step 6). Ask participants to comment on the extent to which this process has been done in the past with new staff and the extent to which it is done with current staff. Ask for questions and comments. SESSION 5: OBJECTIVES 1. Develop job descriptions for the positions needed to provide planned PHC services 2. Plan to recruit and hire individuals to fill those positions Exhibit 24: Role and tasks list worksheet PHC programme goals: Service objectives: Strategies:, +, +, +, + Position title, Role, Tasks list, Experience, Ability/skills PURPOSES OF A JOB DESCRIPTION Describe staff roles and tasks needed to help achieve programme objectives Identify skills and experience required to carry out role and tasks Ensure a mutual understanding of expectations for job performance Exhibit 25: Job description and announcement 1.POSITION TITLE:, 2.POSITION STATUS: 2.1 Full-time a.Permanent 2.2 Part-time b.Temporary, 3. DATE OF PREPARATION: 4.POSITION SUMMARY:, +, + 5.REPORT TO:, 6.POSITION DIRECTLY SUPERVISED BY INCUMBENT:, + 7.SPECIFY REQUIREMENTS: 7.1 Education/professional qualifications 7.2 Experience and training 7.3 Knowledge,, skills,, ability, +, + 8.DESCRIPTION OF DUTIES/RESPONSIBILITIES: List duties under two separate headings: REGULAR DUTIES and PERIODIC DUTIES, +, + , +, % TIME SPENT: A.REGULAR DUTIES/RESPONSIBILITIES: B.PERIODIC DUTIES/RESPONSIBILITIES:, +, PREPARED BY:, 10.REVIEWED BY:, TEST QUESTIONS Does the job description adequately reflect programme needs? Does the job description include all necessary activities? Is the projected workload reasonable? Are suitable candidates available? Are they likely to apply, given the terms and conditions of the job? Is the job secure; will there be adequate funding to continue it? Are there any other factors that could positively or negatively affect recruitment of suitable candidates? Session 6:Develop work plans and assess performance (Steps 6 and 7) Objectives: Participants will be able to follow the directions in the Module 3 User's guide to: Develop individual work plans based on planned PHC activities. Plan for performance assessment based on individual work plans. Plan next steps in implementing work planning and performance assessment. Session outline: I. Introduction (10 minutes) II. Develop work plans (20 minutes) III. Assess job performance (30 minutes) IV. Next steps (15 minutes) V. Conclusion (10 minutes) Materials: Module 3 User's guide Transparency 3-26: Session 6: Objectives Transparency 3-27: Advantages of work plans Transparency 3-28: Principles of work planning Transparency 3-29: Purposes of performance assessments Transparency 3-30: Performance assessment principles Transparency 3-31: Performance assessment process Equipment: Flip chart, stand, markers, masking tape, overhead projector and screen I. Introduction (10 minutes) Review session objectives. List the information needed from prior steps. Outreach and clinic-based plans for PHC services from Step 4 which contain programme objectives and priorities and provide basis for determining how much time each worker will spend: - on each task - at each site - with each individual Individual job descriptions from Step 5, which define the role and tasks each worker is responsible for. II. Develop work plans (20 minutes) Review benefits to programme of developing and using work plans. Explain the principles of work planning. Underscore the importance of a team approach to work planning to ensure common understanding of who is doing what and coordination among staff when indicated. Explain that work plans link programme/ activity planning to what each worker will do. Refer participants to work plan examples in Exhibits 28 and 29 of the User's guide and explain each section, emphasising the focus on job-related performance. Distribute blank work plan and instruct participants to develop a work plan for at least one job description. Develop an annual work plan based on PHC activity plans from Step 3 and the job description developed in Step 4. Select one of the types of plans just discussed and develop a one month work plan based on the annual plan. Participants will then explain their monthly plan and the rationale for their choice of work plan. Note: The number of participants who do this will depend on time available. Refer participants to examples of work plan scheduling forms and explain each type. - Gantt charts - Time and task charts - "To do" lists - Duty rosters Ask for questions and comments. III. Assess job performance (30 minutes) Review the purposes of performance assessments. Explain that individual work plans provide the basis for assessing health worker performance. Explain the principles of performance assessment, and that this tool links programme goals to health worker activities. Stress the importance of continuous and formal performance assessments. Refer participants to the sample performance review form and explain the purpose and origin of each section. (Exhibit 34, User's guide). Suggest a process for carrying out the performance assessment. Lead participants in a discussion of the performance review system they have in place, with these questions: What procedures are now in place for assessing worker performance? How are they working? Are they being followed? What are the strengths and weaknesses of the present system? What changes, if any, would you like to implement? Ask for questions or comments. IV. Next steps (15 minutes) Briefly summarise the steps in this module and the outcomes of each step. Direct participants to review their completed worksheets and write down the actions that they need to take when they return to the job to: -Complete tasks begun in the workshop. - Collect more information. - Implement or improve work planning and performance assessment in their PHC programmes. Ask each participant (or participant team) to briefly describe the actions they will take when they return to their jobs. V. Conclusion (10 minutes) Review the expectations participants expressed at the beginning of the workshop and ask them to assess informally how well they think those expectations have been achieved. If any were not achieved, ask how the workshop could be improved to make that happen. Thank participants for their time and attention, congratulate them on the effort they put into the workshop, and wish them good luck in implementing their plans. Note: Indicate what follow-on assistance will be available, if appropriate. SESSION 6: OBJECTIVES Develop individual work plans for planned PHC programme activities Plan for performance assessment based on individual work plans Plan steps to implement work planning and assessment ADVANTAGES OF WORK PLANS Monitor activities to ensure that: planned activities are carried out they are carried out in the correct sequence priority tasks are carried out first Help the staff manage its time efficiently Maximise programme impact Improve coordination among staff Facilitate assessment of worker performance PRINCIPLES OF WORK PLANNING Clearly stated objective List of all tasks necessary to achieve the objective Specification of the priority tasks and activities A specific time frame Clear indicators Specification of resources PURPOSES OF PERFORMANCE ASSESSMENTS Helps staff improve their effectiveness in reaching objectives Increases efficiency in carrying out work Allows mutual effort at improving job performance PERFORMANCE ASSESSMENT PRINCIPLES Focus on improving worker performance Supportive rather than critical Praises accomplishments as well as identifies weaknesses Educational rather than judgmental Regularly and frequently conducted A collaboration between the supervisor and subordinate, not a top-down, parent-child relationship Based on open, frequent communication, and mutual trust Designed to find solutions to problems, not to fix blame for them SUGGESTED PERFORMANCE ASSESSMENT PROCESS 1. Worker completes work plan and then consults with supervisor for final agreement 2. Worker does self-assessment 3. Supervisor does supervisory-assessment 4. Worker and supervisor meet to discuss performance, identify strengths and weaknesses, and make adjustments and set goals for the next period 5. Frequency of reviews depends on agency policy and worker performance