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 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. 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 PHC MAP. Explain the connection between management information and improvement of primary health care service, quality, coverage, effectiveness and efficiency. Give PHC examples of these terms in the systems framework: inputs, processes, outputs, effects, and impacts. Explain the purpose of Module 1. Session Outline: I. Introduction (15 minutes) II. Overview of workshop (10 minutes) III. The systems framework (25 minutes) IV. Module 1 User's guide (10 minutes) Materials: Module 1 User's guide Handout 1-1: PHC MAP modules Handout 1-2: Agenda Handout 1-3: A systems diagram of management and health services relationships Transparency 1-1: PHC MAP purpose Transparency 1-2: PHC MAP modules and the management cycle Transparency 1-3: Workshop objectives Transparency 1-4: The PHC MAP systems framework Transparency 1-5: The expanded PHC MAP systems framework Transparency 1-6: A systems diagram of family planning Transparency 1-7: The systems framework and the planning-evaluation cycle. Transparency 1-8: PHC MAP modules related to system elements Transparency 1-9: PHC MAP modules and PHC programme components Equipment: Flip chart, stand, markers, masking tape, overhead projector and screen I. Introduction (15 Minutes) 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 to 8, you may wish to have them wear name tags or put cards with their names at the places where they are sitting. Ask each participant to complete this sentence: "As a result of attending this workshop, I expect." 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 Summarise PHC MAP programme, including: Purpose of PHC MAP. Title and purpose of each module Make the following points about PHC MAP: Has been field-tested and revised to ensure usefulness to PHC programme staff. The entire series of modules may be used to strengthen a PHC programme, or each module may be used independently to fill information gaps. Modules can be used in any sequence, although some provide input to others. For example, the cost analysis data from Module 8 provide a basis for doing a sustainability analysis (Module 9). Checklists and other materials can be adapted to fit a particular situation. Explain why information is important to a PHC programme. Information is required to plan, operate, monitor, and evaluate a PHC programme. Each PHC MAP module helps gather information useful to one or more of these phases in the management cycle. C. EXPLAIN WHY THE PHC MAP SERIES IS BEING INTRODUCED IN THIS PHC PROGRAMME. Note: The remarks here should be tailored to the specific programme and should provide 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. The systems framework (25 Minutes) Note: Omit this section if participants are familiar with systems concepts and terminology. Show the simplified systems framework and define the terms. Show the expanded framework and explain the different kinds of outcomes. Show the family planning example for the expanded framework. Leave Transparency 1-6 on the projector and ask participants to substitute ORT examples for the family planning example in the expanded diagram. Explain the relationship between PHC management and PHC services. Management services (for example, planning, training, supervision, logistics management) support the PHC services (for example, antenatal care, immunization, treatment of malaria). Both management services and PHC services are systems. The outcome of the management system, in this case CHWs with demonstrated competence in family planning, become inputs to the family planning system. The goal (impact on health status) of the family planning system is increased birth interval. The management system contributes indirectly to the goals (improved health status) through support of the health service delivery system. Ask for questions and comments. Explain the link between what goes in at the beginning of a system and what comes out at the end of the system. Explain how the systems framework can help PHC programmes plan services geared to needs of their population. Note: Start at the far right of the transparency with "needs" work to the left across the top and then across the bottom to the right, using the information on pages 6 to 9 in the User's guide Explain that the MAP modules help PHC staff to collect and analyse information about each of the elements in the system and identify the modules that provide the most complete data for each element. Explain that MAP modules can also be organised according to whether they help collect information primarily for health or management services. Ask for questions and comments. IV. Module 1 User's guide (10 Minutes) Distribute a User's guide to each participant. Highlight key sections of the User's guide, referring participants to appropriate pages in the guide: OVERVIEW The overview of the Primary Health Care Management Advancement Programme has details on the purpose of PHC MAP and the materials included; information that has already been presented in summary form. Point out that the diagram on page iv of the overview is another way to illustrate the relationship between the modules and the management cycle (show Transparency 1-2). Draw attention to the specific health and mangement services addressed in the PHC MAP modules. Describe the PHC MAP Manager's guides that supplement the modules. INTRODUCTION TO MODULE 1 Paraphrase the purpose of the module, as stated on page i. Review the programme information that is helpful to have for this module and provide it, as appropriate. Note: This information should be obtained from the PHC programme manager prior to the workshop. If it is not available, the need for Module 2 will become quickly apparent in the workshop. Distinguish between level 1 and level 2 and explain that the level 2 PHC MAP information audit will be the focus of the workshop. Level 3 will be used as necessary to consider information needs in detail. LEVEL 2: THE PHC MAP INFORMATION AUDIT Remind participants that the matrix showing modules and the management cycle was discussed earlier. Point out that the systems framework has already been discussed and can be reviewed by reading this section after the workshop. Point out key terms on page 5 and the glossary at the end of the Guide for future reference. Explain the diagram illustrating the PHC boundaries on page 11 and ask participants to identify what information, if any, they need from other agencies. Record this list on a flip chart for future reference. Say that the remainder of the module contains a series of questions and worksheets to help participants identify their information needs and select the MAP modules they will use to help them collect and analyse that information. Ask for questions and comments. PRIMARY HEALTH CARE MANAGEMENT ADVANCEMENT PROGRAMME (PHC MAP) PURPOSE: to help PHC management teams: collect process and, interpret information necessary to improve programme planning and monitoring PHC MAP Modules 1. Assessing information needs. This module helps managers to identify information needs, set priorities, and determine which PHC MAP modules are likely to be of most use to them. 2. Assessing community health needs and coverage. This module provides PHC managers with simple tools to gather required data on community health needs for planning programme strategies and resource use. The managers can use the same instruments later to assess programme effects on health knowledge, behaviour, and coverage, as well as programme impact on morbidity and mortality. 3. Planning and assessing health worker activities. A module that supervisors and other managers can use to help field workers and clinic staff plan their work better. It shows how to identify individuals in need of services, set realistic targets, assess individual performance, and take corrective action, if warranted. 4. Surveillance of morbidity and mortality. The module describes the basic indicators of morbidity and mortality to be included in a PHC surveillance system. It discusses how to set up a surveillance system, how to monitor the incidence and other rates of diseases, how to identify causes of mortality and morbidity, and how to use that information to improve programme planning and implementation. 5. Monitoring and evaluating progammes. Lists of indicators and guidelines that managers can use to monitor PHC and management activities for short periods. Managers can also use them to construct a project-specific "mini-MIS." 6. Assessing the quality of service. Simple, but comprehensive, discussion guides and checklists of essential service resources and processes. Supervisors can use these to assess the quality of care provided and to set priorities for improving service delivery. 7. Assessing the quality of management. Discussion guides and checklists for assessing PHC management services (planning, training, supervision, etc.). 8. Cost analysis. This module can help PHC managers to set up simple systems to monitor costs themselves. They can also make projections about future revenues and expenses. 9. Sustainability analysis. Guidelines and tools that managers can use to develop and analyse alternative strategies for sustaining health improvement, service coverage, and the PHC services and resources needed to do so. PHC MAP MODULES AND THE MANAGEMENT CYCLE , Needs assessment, Planning, Monitoring, Evaluation Module 1: Information needs Module 2: Community needs Module 3: Work planning Module 4: Surveillance Module 5: Monitoring indicators Module 6: Service quality Module 7: Management quality Module 8: Cost analysis Module 9: Sustainability WORKSHOP OBJECTIVES: 1. Identify priority information needs in your PHC programme using the steps and worksheets contained in Module 1 2. Identify one or more of the PHC MAP Modules 2 through 9 which will be most helpful in collecting and analysing that information SAMPLE AGENDA MODULE 1* , Session 1(1 hr 40 min), , Introduction and overview, , Session 2(2 hrs 40 min), , Determining information needs, , Session 3(1 hr), , Setting priorities, *For an actual presentation, substitute the appropriate times in the first column. THE PHC MAP SYSTEMS FRAMEWORK INPUTS PROCESSES OUTCOMES THE EXPANDED PHC MAP SYSTEMS FRAMEWORK INPUTS PROCESSES OUTPUTS EFFECTS IMPACTS A SYSTEMS DIAGRAM OF FAMILY PLANNING INPUTS PROCESSES OUTPUTS EFFECTS IMPACTS A SYSTEMS DIAGRAM OF MANGEMENT AND HEALTH SERVICES RELATIONSHIPS THE SYSTEMS FRAMEWORK AND THE PLANNING-EVALUATION CYCLE PHC MAP MODULES RELATED TO SYSTEMS ELEMENTS INPUTS PROCESSES OUTPUTS EFFECTS IMPACTS PHC MAP modules and programme components, +, + Health services , , Management services 1. Information needs, , 1. Information needs 2. Community needs, , 3. Work planning, , 3. Work planning 4. Surveillance, , 5. Monitoring, , 5. Monitoring indicators (Part 1), , indicators (Part 2) 6. Service quality, , 7. Management quality 8. Cost analysis, , 8. Cost analysis 9. Sustainability, , 9. Sustainability Session 2: Determining information needs Objectives: Participants will be able to follow the directions in the Module 1 User's guide to: Determine if they are collecting adequate information about PHC health services. Determine if they are collecting adequate information about PHC management services. Session outline: I. Introduction (10 minutes) II. Step 1: List PHC health and mangement services (20 minutes) III. Step 2: Define inputs, processes, outputs and outcomes (40 minutes) IV. Step 3: Identify information needs for health services (60 minutes) V. Step 4: Identify information needs for health services (30 minutes) Materials: Module 1 User's guide Transparency 1-10: Session 2 objectives Transparency1-11: Indicators for breast feeding, growth monitoring, and nutrition education Transparency 1-12: Rationale for knowing health status of targets Transparency 1-13: A and B: Sample health goals Transparency 1-14: Methods for collecting morbidity/mortality data Transparency 1-15: Types of cost analysis Handout 1-4: Worksheet A, defining service indicators Handout 1-5: Worksheet B, summarising information needs Trainer Reference 1-1: Sample priority matrix Equipment: Flip chart, stand, markers, masking tape, overhead projector and screen I. Introduction (10 Minutes) Review the session objectives. Explain the steps in the information audit. Step 1 is to list the health and management services in order of importance. Step 2 is to identify indicators for inputs, processes, and outcomes of each type of service. Step 3 has two parts: The first involves asking a series of questions to determine whether your information system correctly gives you the data you need for each indicator. The second involves setting priorities for the information you need to obtain as high, medium, or low. Step 4 uses a priority-setting technique to help you determine which information will be collected first, if all needs cannot be addressed at once. Explain that steps 1-3 will be completed in this session. II. Step 1: list PHC health and management services(20 Minutes) 12Refer participants to the list of PHC services. Ask them to name the health services in their project while you list them on the left side of a flip chart as they are named. Note: Use the participants' terminology for health services. For example, vitamin A distribution may be designated as a service or breast feeding, growth monitoring, and nutrition education may be combined. Direct each participant to list the health services in order of importance, using 1 to indicate least important, 2 the next least important, and so on. If the project offers 7 health services, the highest ranking service would be numbered 7. While participants are ranking the services, prepare a matrix on the flip chart. The services are the rows, and initials of each participant are the columns. Next, ask participants, in turn, to call out the numbers they assigned to each service. For example, one participant may assign a 2 to maternal care, a 5 to family planning, a 1 to BF/GM/NE, and so on. When all participants' rankings have been recorded, total the numbers for each service. The service receiving the highest score is top priority, and so on. Repeat these steps for management services. Direct participants to review the ranking of health and management services and indicate their satisfaction with the rankings in each category. The ranking process is arbitrary and may not take all factors into account. If there is a good rationale for changing the order and all participants concur, make the indicated changes. III. Step 2: Define inputs, processes, outputs, and outcomes(40 Minutes) Assign each health service to a small group of 2 or 3 participants. If the group is large all health services can be addressed. If the group is small and the list of services is long, select only 3 or 4 high scoring (top priority) health services for the remainder of the information needs assessment process. Note: Participants can complete the information process for the other health services and the management services after the workshop. Distribute Worksheet A to each participant. Direct participants to write in column 2, Inputs, the name of the health service they have been assigned, e.g., immunization, family planning. Next, direct participants to describe the target group of that particular health service, e.g., children, women 15-49 and enter that information in the first column. Direct participants, working on their assigned health service in small groups, to identify the key inputs, processes, outputs, effects, and impacts for that service. They may start with inputs in column 2 or impacts in the last column. These inputs, processes, outputs, and outcomes will be the indicators for monitoring and evaluation. The example in Figure 7 of the User's guide shows two indicators for each category. More can be listed. The important thing is to list the most significant indicators and be sure they are logically linked across the rows Participants may wish to refer to the example on page 20 as they select indicators for their assigned health service. If BF, GM, and NE or family planning are among the health services assigned to small groups, participants should think about what is important to their PHC programme and not be bound by the sample indicators on page 20. Note: You may wish to provide copies of Module 5, Indicators for Monitoring and Evaluating PHC programmes, to each group to assist them in identifying indicators. Small groups work on selecting indicators and writing them in the appropriate columns on Worksheet A and putting a check next to those indicators for which information is already available. Reconvene the entire group to review the selected indicators. Ask a member of the first small group to read the indicators they have chosen for the health service they were assigned. Invite members of the other small groups to comment or raise questions considering two major criteria: Significance of planning and monitoring the service being provided. Linkage of indicators from one category to the next. Facilitate discussion until the group reaches consensus on the indicators for that service. Ask the entire group to review the final list of indicators and identify those for which they clearly have information. Direct small group members to circle those indicators. Repeat steps 1-4 until all health services have been discussed. Say that the next step in the information audit involves asking a series of questions to help you confirm that you are collecting adequate information for the indicators and to help define more precisely additional information needs. IV. Step 3: Identify information needs for health services(60 Minutes) Refer participants to page 21 and suggest that they follow along as you explain the three sets of questions and relate them to the modules that will help them get the information they do not have. Distribute Worksheet B to each participant. Explain to participants that they will record their answers to each of the 10 questions on this form. The information needed is recorded in the same row as the related module. Small groups will record the information for their assigned service. Question 1. Do you have enough information about the health status of your target groups? Explain why health status information is important. Review the sample health goals pointing out the four elements of a good statement in the first two sample goals. Ask participants to identify the elements in the next two. Direct each small group to write a goal statement containing the four elements for their assigned health service. Ask each small group to read their goal statement aloud and make revisions as needed, based on comments from other participants. Ask each small group to list the indicators needed to measure the goal statement and determine whether that information is already available. Direct participants to revise Worksheet A to be consistent with that determination and to enter needed information about health status in columns 2 and 3 on Worksheet B. Question 2. Do you have enough information about the coverage of each PHC service? Explain why coverage information is important. Ask participants to name the target groups they have listed on Worksheet A, recording them on the left side of the flip chart as they do. Ask for the health services pertaining to each target group, recording them in the middle of the flip chart. Ask participants to suggest any services they wish to add to their programme for any of the target groups. Ask participants for the indicators of the effects of these services on the target group. For newly added services, refer participants to the examples of indicators on page 28 in Module 1. Direct participants to compare the information on the flip chart to the information they have on Worksheet A and to make any changes in the services they have already listed. Note: If new services have been added, assign them to the small group that has the services for the same target group. Direct participants to enter, on Worksheet B, general information needs and specific indicators for coverage. Direct participants to the excerpt from a Module 2 questionnaire on page 30 of the User's guide as an example of one of the tools for collecting information on health status (impacts) and coverage (effects) provided in Module 2. Question 3: Do you have enough information about your target groups needs to plan PHC activities? 19Explain why target group information is important. Refer participants to the summary of Module 3 contents on page 29 of the Module 1 User's guide and summarise the major steps. Direct participants to enter in column 2 of Worksheet B any information they do not have for work planning, such as: location of people who need service job descriptions work plans and schedules performance and assessment tools Question 4: Is there adequate information about changes in morbidity and mortality? <$&s208>Explain why information about changes in morbidity and mortality is important. 20Describe methods that can be used to collect this information. Direct participants to enter into column 2 of Worksheet B any needed surveillance data that they are not already collecting. Question 5: Do you have adequate indicators to monitor your PHC services? 21Explain why monitoring is important. Refer participants to the excerpt from Module 5 on page 35 of the Module 1 User's guide. Explain how the indicators are organised and what the various categories of indicators tell you. Direct participants to review Worksheet A and see if they have at least one indicator in each system category to help them monitor services.<%0> Direct each small group to add appropriate indicators to Worksheet A, place a checkmark next to those they already have information on, and transfer information that needs to be collected to Worksheet B. Question 6: Do you know enough about the quality of your health services? Explain that Module 6 focuses on information about processes and how it can be used in a PHC programme. Refer participants to the excerpt from Module 6 on page 37 of the Module 1 User's guide to see a sample checklist. Direct participants to review their entries on Worksheet A under processes, make necessary additions and list needed information that's not now available on Worksheet B in column 2. Summarise health service information needs. Remind participants that they are in the process of identifying information needs to improve planning and monitoring of their PHC programmes, the main purpose of Module 1. Explain that so far they have examined information needs for health services by answering questions 1-6. Information needs for health services may be addressed by using PHC MAP Modules 2-6. Ask for comments or questions about the process so far. Indicate that the next activity will be to repeat the same process for management services by considering questions 7-10. V. Step 4: Define information needs for management services (30 Minutes) Question 7: Do you have adequate indicatorsto monitor your management services? Question 8: Do you know enough about thequality of your management services? Give directions for considering question 7. See Exhibit 6 (p. 40) of the User's guide. For question 8 see Exhibit 7 (p. 42). Assign a management service to each small group. If the group is small, assign only priority services. If the group is large, you may assign all services. Direct each small group to read the information beginning at the bottom of p. 39 and ending with question 8 on p. 41 and enter information needs on Worksheet B for Module 5 (Management) and Module 7. Remind participants to refer to Worksheet B on page 21 if they need assistance and to Module 5 for monitoring indicators, if necessary. Participants work on questions 7 and 8. Reconvene the large group. Ask each group in turn to report the results of their consideration of these two questions for their assigned management service. Ask for comments and suggestions from the other small groups and direct the first small group to make revisions, if necessary. Ask for questions and comments on questions 7 and 8. Question 9: Do you have enough information about the cost of your programme and its services? Explain that Module 8 covers information needed to analyse costs and can help analyse costs in nine different ways. Explain the value of having cost information. Refer participants to the description of Module 8 on p. 41 of the User's guide to see what types of information are required for cost analysis. Direct participants to enter, on Worksheet B, the cost information they want for the programme overall or for any health service or management service. Question 10: Do you have adequate information to determine how to sustain the PHC programme in the future? Explain how Module 9 is organised and the process it contains to help a management team assess programme sustainability. Explain that they can use the module to develop strategies to sustain the health status of the target populations and the PHC services and resources needed to do so. Refer participants to the sustainability factors that can be assessed using Module 9 and explain the "What-If" analysis it enables managers to do. Direct participants to determine if they need sustainability information and to enter that in column 2 of Worksheet B if they do. Ask for questions and comments about Modules 8 and 9 and the related information needs. SESSION 2: OBJECTIVES Determine if you need more information about: PHC health services PHC management services INDICATORS FOR BREAST FEEDING, GROWTH MONITORING AND NUTRITION EDUCATION Inputs Processes Outputs Effects Impacts SAMPLE PRIORITY MATRIX PARTICIPANTS HEALTH SERVICES, AA, BB, CC, DD, EE, FF, GG, HH, TOTAL maternal care Family planning BF, GM, NE Child immunization DDC/ORT WORKSHEET A: DEFINING SERVICE INDICATORS Instructions: 1) List each priority PHC or management service; 2) Identify key indicators you need for planning and/or monitoring; 3) Identify those that are already available (mark with an x); 4) Identify the low, medium and high priority items, e.g., with *,**, and ***; 5) Revise and update this list as you proceed through Module 1 and other modules. TARGET GROUP, INPUTS, PROCESSES,OUTPUTS,EFFECTS, IMPACTS (resources), (activities), (products and services), (knowledge, attitudes, behaviour/practice), (morbidity, mortality, fertility) WORKSHEET B: SUMMARISING INFORMATION NEEDS Instructions: 1) After you list each question, summarise your general information needs for each type of information under the appropriate model; 2) Identify the specific typr of indictors needed if known; 3) Set priorities for each need,e.g., * for low, ** for medium, and *** for high. MODULE, GENERAL INFORMATION NEEDS, SPECIFIC INDICATORS, PRIORITIES RATIONALE FOR KNOWING HEALTH STATUS OF TARGET GROUPS To set programme goals If you don't know where you are going, any road will get you there. To determine programme impact If you don't know where you are, you may already be there, or you may not be. SAMPLE HEALTH GOALS MORTALITY Reduce neonatal deaths among urban slum dwellers to a rate of 65/1,000 live births by the end of 1994 Indicator: number of deaths of children under 1 month of age/1,000 live births MORBIDITY Decrease the prevalence of third degree malnutrition among children under age 3 by 30% by September 1995 Indicator: number of cases of third degree malnutrition among children <<3 years of age total number of children <<3 years of age SAMPLE HEALTH GOALS (continued) DISABILITY Decrease the incidence of polio among children under age 5 to 0 (zero) by the year 2000 Indicator: number of new polio cases among children <<5 years old Total number of children << 5 years of age FERTILITY Reduce the total fertility rate of women in the programme area to 4.5 by the end of 1996 Indicator: total number of births to women 15-45 years old total number of women 15-45 years old METHODS FOR COLLECTING MORBIDITY/MORTALITY DATA Vital event registration systems "Sentinel" systems Special surveys Case/outbreak investigations TYPES OF COST ANALYSIS Total costs Expenditures compared to budget Costs by line item Costs by site, facility, location Trends in cost over time Projection of future costs Average costs Revenues Break-even analysis Session 3: Setting priorities Objectives: Participants will be able to: Set priorities among information needs using the directions in the Module 1 User's guide. Prepare an action plan for using the MAP modules selected to help them address priority information needs. Session outline: I. Introduction (5 minutes) II. Step 4: Summarize information priorities (25 minutes) III. Next steps (20 minutes) IV. Closure (10 minutes) Materials: Module 1 User's guide Transparency 1-16: Session 3 objectives Equipment: Flip chart, stand, markers, masking tape, overhead projector and screen I. Introduction (5 Minutes) Review session objectives. Explain the session activities briefly. II. Step 5: Summarise information priorities (25 Minutes) Summarise the steps that have been accomplished so far: Listing the PHC health and management services that comprise the programme and selecting priority services in each category. Defining the principal inputs, processes, and outputs for the priority services and recording these on Worksheet A along with the target group for each health service. Identifying needed information for planning and monitoring those services by answering 10 questions and recording the needed information on Worksheet B. Explain that the next step is to set priorities for needed information as all needs cannot be addressed at once. Outline the steps in priority setting. Each small group will list the information needs for the priority service they were assigned on a flip chart. All flip charts will be assembled so they are visible to all participants. Next the large group will establish criteria for selecting priorities and discuss the criteria so that all participants understand what they mean. Individual participants then rate each information need according to the criteria. Note: See the scoring procedures in Appendix A, Item 2. Ask for questions or comments about the procedure. Direct participants to carry out the priority setting procedure. Note: While individual participants are scoring the items, prepare a matrix similar to the one shown in Appendix A using the criteria selected by participants. Record the scores of each participant. Total the scores. Put the number of the module that will help participants collect the needed information next to that item on the flip chart. These are the modules that participants will work on next. Ask for final questions or comments about Module 1 and the process of identifying information needs. III. Next steps (20 Minutes) Ask participants to list the steps necessary to begin work on the next module, recording each step on a flip chart as it is named. When all steps are listed, ask participants to arrange them in sequence. Next, have participants assign a tentative completion date to each step and indicate the name of the responsible person. IV. Closure (10 Minutes) Review the workshop objectives Review the list of participant expectations you recorded on a flip chart in Session 1 and ask participants to indicate the extent to which they were met Thank participants for their attention and hard work. SESSION3:OBJECTIVES Set priorities forinformation needs Prepare an action plan