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 Murphy, Somboon Vacharotai Foundation, Bangkok 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 1679, 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 Cover photo: Health workers of the Northern Pakistan PHC Project provide maternal and child health services at an outdoor "clinic" in a high mountain valley in Chitral PHC MANAGEMENT ADVANCEMENT PROGRAMME PLANNING AND ASSESSING HEALTH WORKER ACTIVITIES MODULE 3 USER'S GUIDE ISBN: 1-882839-02-1 Library of Congress Catalog Number: 92-75463 In Bangladesh, health workers use a major share of their time to train other women about measures they can take to promote health and prevent disease Photo by Jean-Luc Ray for AKF 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. In Kenya, a community health nurse trains and helps plan the work of the community health volunteers Photo by Jean-Luc Ray for AKF An overview of PHC MAP The main purpose of the Primary Health Care Management Advancement Programme (PHC MAP) is to help PHC management teams collect, process and analyse useful management information. Initiated by the Aga Khan Foundation, PHC MAP is a collaborative programme of the Aga Khan Health Network1 The Aga Khan Health Network includes the Aga Khan Foundation, the Aga Khan Health Services, and the Aga Khan University, all of which are involved in the strengthening of primary health care.> and PRICOR.2 Primary Health Care Operations Research is a worldwide project of the Center for Human Services, funded by the United States Agency for International Development.> An experienced design team and equally experienced PHC practitioner teams in several countries, including Bangladesh, Chile, Colombia, the Dominican Republic, Guatemala, Haiti, India, Indonesia, Kenya, Pakistan, Senegal, Thailand and Zaire, have worked together to develop, test and refine the PHC MAP materials to make sure that they are understandable, easy to use and helpful. PHC MAP includes nine units called modules. These modules focus on essential information that is needed in the traditional management cycle of planning-doing-evaluating. The relationship between the modules and this cycle is illustrated below. PHC MAP modules and the planning-evaluation cycle PHC MAP MODULES 1. Information needs 2. Community needs 3. Work planning 4. Surveillance 5. Monitoring indicators 6. Service quality 7. Management quality 8. Cost analysis 9. Sustainability 1. The Aga Khan Health Network includes the Aga Khan Foundation, the Aga Khan Health Services, and the Aga Khan University, all of which are involved in the strengthening of primary health care 2. Primary Health Care Operations Research is a worldwide project of the Center for Human Services, funded by the United States Agency for International Development Managers can easily adapt these tools to fit local conditions. Both new and experienced programmers can use them. Government and NGO managers, management teams, and communities can all use the modules to gather information that fits their needs. Each module explains how to collect, process and interpret PHC-specific information that managers can use to improve planning and monitoring. The modules include User's guides, sample data collecting and data processing instruments, optional computer programs, and Facilitator's guides, for those who want to hold training workshops. The health and management services included in PHC MAP are listed below. OTHER HEALTH CARE Water supply, hygiene and sanitation School health Childhood disabilities Accidents and injuries Sexually transmitted diseases HIV/AIDS Malaria Tuberculosis Treatment of minor ailments Chronic, non-communicable diseases HEALTH SERVICES Planning Personnel management Training Supervision Financial management Logistics management Information management Community organisation MANAGEMENT SERVICES Health and management services GENERAL PHC household visits Health education MATERNAL CARE Antenatal care Safe delivery Postnatal care Family planning CHILD CARE Breast feeding Growth monitoring Nutrition education Immunization Acute respiratory infection Diarrhoeal disease control Oral rehydration therapy Several Manager's guides supplement these modules. These are: Better management: 100 tips, a helpful hints book describing effective ways to help managers improve what they do; Problem-solving, a guide to help managers deal with common problems; Computers, a guidebook providing useful hints on buying and operating computers, printers, other hardware and software; and The computerised PRICOR thesaurus, a compendium of PHC indicators. A computerised database with constantly updated information on various households with high-risk members can be a powerful tool to plan and assess health worker activities Photo by Pierre Claquin for AKF 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 QUICK START 1 INTRODUCTION Planning and assessing health worker activities: 3 How Module 3 can help you 4 Some limitations of the module 5 How to use this guide 6 STEPS IN PLANNING AND ASSESSING HEALTH WORKER ACTIVITIES 7 Step 1: Describe and map the catchment area 9 Step 2: Identify community needs and available resources 19 Step 3: Set priorities and identify high-risk groups 26 Step 4: Plan PHC activities 32 Step 5: Develop job descriptions and recruit staff 62 Step 6: Develop individual work plans and schedules 67 Step 7: Assess job performance 75 APPENDICES 81 A. Examples of legends for map making 81 B. Risk factors 83 C. Assessment of community health facilities 91 D. CHW activity register booklet and instructions 95 E. Blank worksheets 101 REFERENCES AND BIBLIOGRAPHY 133 ACRONYMS AND ABBREVIATIONS 134 GLOSSARY 135 Acknowledgements A number of people and institutions have contributed to the development, review, and testing of this module. The first outline was made by Lori DiPrete and Jack Reynolds from the University Research Corporation/Center for Human Services. Drafts of the module were reviewed by a number of PHC experts, including Pierre Claquin, Aga Khan Foundation; Jack Reynolds, Center for Human Services and Jack Bryant, Aga Khan University; and it was then field tested. The module was revised and reviewed by participants at the International Conference on the Management and Sustainability of the PHC Programmes, held in Bangkok in May 1992. The final version was prepared based on that feedback. A number of other individuals deserve special thanks for their contributions to this module. Among these are Neeraj Kak and Maria Franscisco from the Center for Human Services and Sohail Mushtak from the Aga Khan University. Special acknowledgement and deep appreciation goes to Dr. Colin De'ath, Bangkok, Thailand for his extra efforts during the final edits on this edition, all the work at odd hours he has put in on the rest of the series and his continual encouragement while working with a less than harmonious production team. Field tests: Countries, participating organisations, field test facilitators India Junagadh PHC Project, Gujarat, and the Sidhpur Sustainable Health System Project, Gujarat; Aga Khan Health Service, India; Facilitators: Neeraj Kak, Center for Human Services, Vijay Moses, Aga Khan Health Service, India Kenya Mombasa PHC Programme; Kisumu PHC Programme; Facilitators: Maria Francisco, University Research Corporation/Center for Human Services; Inaam-ul-Haq, Aga Khan University, Pakistan PHC MAP MANAGEMENT COMMITTEE Dr. Ronald Wilson Aga Khan Foundation, Switzerland (Co-Chair) Dr. Jack Bryant Aga Khan University, Pakistan (Co-Chair) Dr. William Steeler Secretariat of His Highness the Aga Khan, France (Co-Chair)<%0> Dr. Jack Reynolds Center for Human Services, USA (PHC MAP Director) Dr. David Nicholas Center for Human Services, USA Dr. Duane Smith Aga Khan Foundation, Switzerland Dr. Pierre Claquin Aga Khan Foundation, Switzerland Mr. Aziz Currimbhoy Aga Khan Health Service, Pakistan Mr. Kabir Mitha Aga Khan Health Service, India Dr. Nizar Verjee Aga Khan Health Service, Kenya Ms. Khatidja Husein Aga Khan University, Pakistan Dr. Sadia Chowdhury Aga Khan Community Health Programme, Bangladesh Dr. Mizan Siddiqi Aga Khan Community Health Programme, Bangladesh Dr. Krasae Chanawongse ASEAN Institute for Health Development, Thailand Dr. Yawarat Porapakkham ASEAN Institute for Health Development, Thailand Dr. Jumroon Mikhanorn Somboon Vacharotai Foundation, Thailand Dr. Nirmala Murthy Foundation for Research in Health Systems, India PHC MAP TECHNICAL ADVISORY COMMITTEE Dr. Nirmala Murthy Foundation for Research in Health Systems, India (Chair) Dr. Krasae Chanawongse ASEAN Institute for Health Development, Thailand Dr. Al Henn African Medical and Research Foundation (AMREF), formerly of the Harvard Institute for International Development Dr. Siraj-ul Haque Mahmud Ministry of Planning, Pakistan Dr. Peter Tugwell Faculty of Medicine, University of Ottawa, Canada Dr. Dan Kaseje Christian Medical Commission, Switzerland, formerly of the University of Nairobi, Kenya @FRONTCOV1 = KEY PHC MAP STAFF AT THE CENTER FOR HUMAN SERVICES Dr. Jack Reynolds (PHC MAP Director) Dr. Neeraj Kak Dr. Paul Richardson Ms. Lori DiPrete Brown Dr. David Nicholas Ms. Pam Homan Dr. Wayne Stinson Dr. Lynne Miller-Franco Ms. Maria Francisco Ms. Mary Millar Quick start Basic work planning You may already have done some of the work planning activities described in this module. To find out - and to identify the ones that interest you most - review the following Quick start summary. Check off the sections that you want to read and begin with these. Most of these sections include worksheets and sample forms that can help you develop work planning procedures quickly. Step 1: Describe and map the catchment area Review this step if you need to: 1) define and map the physical boundaries of your catchment (service) area; 2) describe the health services and population contained in that area; and/or 3) develop a register of households and/or individuals located in the area. Step 2: Identify community needs and available resources<%0> Review this step if you need to: 1) identify community health problems and needs; 2) assess the PHC services currently provided by other health providers in the area; and/or 3) identify health resources that you can call on in the area. Step 3: Set priorities and identify high-risk groups Review this step if you need to: 1) identify priority health problems that your programme will address; 2) set up a system for assessing risk factors in your area; 3) identify your primary target groups; 4) identify high-risk groups and individuals in your area; and/or 5) establish a system for monitoring high-risk groups. Step 4: Plan PHC activities Review this step if you need to: 1) identify strategies for providing needed health services to your target groups; 2) develop a plan for community-based and outreach services; and/or 3) develop a plan for clinic-based services. Step 5: Develop job descriptions and recruit staff Review this step if you need to: 1) develop a role and task list for your staff; 2) prepare job descriptions for your staff; and/or 3) make sure that staff job descriptions will produce desired programmatic results. Step 6: Develop individual work plans and schedules Review this step if you need to: 1) develop individual work plans for each staff member; 2) assign work to fit priority health needs and the needs of high-risk groups; and/or 3) schedule work so that staff have a reasonable work load and can complete their assignments on time. Step 7: Assess job performance Review this step if you need to: 1) set up a performance-based system for assessing staff work; 2) set up procedures to compare planned with actual work performance; and/or 3) ensure that staff performance is contributing to programme objective. Photo by Pierre Claquin for AKF In North Pakistan a health worker administers an oral dose of iodinated oil for prevention of iodine deficiency disorders, such as goitre Photo by Pierre Claquin for AKF Introduction Planning and assessing health worker activities One of the major objectives of most PHC managers is to find ways to increase coverage of the target populations with basic health services. One of the major challenges is finding simple, yet effective procedures for getting PHC staff to do that. This module was designed to address this problem. The overall objective of Module 3 is to help your staff develop realistic work plans that will lead to improved coverage, early identification and attention to high-risk women and children, and will not require additional effort to manage. To do this, you will need to set up a system that identifies your various target populations, determines their health needs, sets priorities among those needs, and then assigns staff to provide services on a selective basis. The heart of this system will be information. The system must provide adequate information so that you and your health workers can continually assess needs, adjust plans accordingly, monitor results, reassess needs, readjust plans, and so on. The "system" described in this module is based on some of the best features of several PHC programmes that have been successful in that respect. Through the use of maps, simple registers, risk analyses, prompt feedback, flexible work plans, living job descriptions, supportive performance appraisals, and other simple tools, these programmes have been able to increase coverage, improve health status, and raise job satisfaction at the same time. Module 3 picks up where Module 2 left off. Community surveys provide a broad picture of health needs and program effectiveness in meeting those needs. Module 3 shows how to assess individual needs and develop specific work plans to enable both clinic staff and field workers to meet those needs. The procedures described in this module do not require sophisticated computers or advanced training in management. All of the procedures can be done by hand, and many are designed to be used by front line field workers (CHWs, nurses, midwives, field doctors, and the like). As with the other PHC MAP modules, these tools are illustrative and you are encouraged to adapt them to fit your specific needs. How Module 3 can help you This module is designed to help you to plan your PHC activities. For example, you can use this module to; Identify the populations/individuals to be served. Step 1 will help you to define and describe your programme's catchment area, to develop a map of the area, and to compile information for a household register from a community/village. Identify health problems, risk factors, and available resources as well as assess existing health services. Step 2 will help you to identify health problems, demographic factors, and other risk indicators. It will also help you to assess health services and other resources available to you. Identify those in need of the various types of care and target high-risk clients for intensive care. Step 3 will help you in developing risk factors for the various PHC components. You can use the risk factors to identify individuals or households at risk of getting diseases you are trying to protect them from, and to focus your efforts on these high-risk groups. Plan PHC activities. Step 4 will help you to plan outreach and clinic-based services to accommodate community needs with available PHC resources. Identify needs for additional staff and resources. Step 4 can also help you to identify additional resources that would be needed to improve coverage and to reach those most in need. Improve health worker efficiency. The module will show you and your staff how to set priorities and to develop work plans for their day-to-day activities, to monitor their own performance, and to manage their time effectively. The tools can help your staff accomplish more with no additional effort. Develop job descriptions and individual work plans. Steps 5 and 6 show you how to develop job descriptions and individual work plans that will help your programme meet its overall objectives. Review performance, monitor and support health worker activities, and give them constructive feedback. Step 7 shows how to monitor staff performance in reaching individual, community and programme objectives. And it shows how to set up a system to provide objective and constructive feedback to your staff. Some limitations of the module The module does not deal with the overall planning of a PHC programme. Rather, its purpose is to assist the manager and the team in planning their activities so that the work that each person does contributes directly toward the larger goals of the programme. The module does not discuss specific ways to involve communities in the planning process. However, that is encouraged, and it is not difficult to see how they could be involved in most of the steps, from assessing needs to identifying high-risk children, to providing feedback on CHW performance. The module is not a comprehensive personnel management manual either. However, it does describe ways to focus the health worker on those tasks that will lead to better programme performance. How to use this guide This guide provides instructions for planning and assessing your programme's PHC and health worker activities. By following the instructions and using the worksheets, you should be able to identify the target population, to assess its needs, to plan PHC activities, to determine staffing requirements, to develop individual job schedules, and to evaluate worker performance. You may skip a step or sub-step if you think that the activity is already being undertaken in your programme. However, you may still want to review the skipped step to see if the existing process can be improved. The steps and sub-steps for planning and assessing PHC and health worker activities are summarised on the following page. Steps in planning and assessing health worker activities Step 1: Describe and map the catchment area, +, +, + , Define the catchment area, +, + , Describe the catchment area, +, + , Make map(s) of the catchment area, +, + , Make a register of communities/villages, +, + , Make a household register, +, + Step 2: Identify community needs and available resources, +, +, + , Select indicators, +, + , , Health problem indicators, + , , Demographic indicators, + , , Risk factors indicators, + , , Existing health services and available resources, + , Identify source(s) of information, +, + , Develop a survey instrument, +, + Step 3: Set priorities and identify high-risk groups<%0>, +, +, + , Set priorities among health problems, +, + , Determine the risk factors, +, + , Set priorities for risk factors identified, +, + , Identify main target and high-risk groups, +, + , Use risk factors to monitor high-risk groups, +, + Step 4: Plan PHC activities, +, +, + , List services required,, identify strategies and activities , +, + , Identify and plan outreach and community-based activities, +, + , , Determine number of units to be covered , + , , Determine optimal time interval for each activity, + , , Determine resource requirements, + , , Compare resource availability with requirements and identify an optimal number of visits, + , , Develop tools to plan and monitor community-based and outreach activities, + , Identify and plan clinic-based activities, +, + , , Determine client load , + , , Determine staff capacity, + , , Determine resource requirements, + , , Determine availability of resources, + , , Compare availability with need and identify an optimal solution, + , , Develop tools to plan clinic-based activities, + Step 5: Develop job descriptions and recruit staff, +, +, + , Develop role,, task and skills list, +, + , Prepare job descriptions and do a feasibility check, +, + , Post job announcement,, recruit,, screen,, and select candidates, +, + , Agree with selected candidates on role and task expectations, +, + Step 6: Develop individual work plans and schedules, +, +, + , Advantages of work plans, +, + , Principles of good work plans, +, + , Scheduling of work, +, + Step 7: Assess job performance, +, +, + , Principles of performance assessment, +, + , Continuous performance assessment, +, + , Formal performance assessment, +, + If your programme is new, you will need to go through the following steps. This module can be used for some of these. Other PHC MAP modules can help you with those steps not included in this module. Steps, Module 3 steps, Other modules 1. Define catchment area and target group, 1, 1 2. Identify community needs, 2, 2 3. Set priorities among health problems and identify high-risk groups, 3, 2,4 4. Define goals and objectives, , 1 5. Identify services/components and strategies, , 1 6. Plan activities, 4, 7. Plan resource needs, 4, 8,9 8. Develop job descriptions and recruit staff, 4, 9. Develop work plans and schedules, 5,6, 10. Implement and monitor progress, 7, 4,5,6,7 11. Assess job performance, 7, 5,6,7 12. Assess programme performance, 7, 4,5,6,7,8,9 13. Evaluate, , 2,4,8,9 Step 1: Describe and map the catchment area Skip this step if: Your catchment areas are adequately defined and mapped You already maintain adequate registers of households and/or individuals in these areas Review this step if: You need to define and map the physical boundaries of the catchment area(s) and to describe the services and population contained within it You need to define and develop a register of households and/or individuals located in these catchment area(s) The purpose of this step is to help the manager to define and describe the PHC catchment area or the geographical area surrounding a health facility and the target population it serves. The PHC manager needs to understand the ecology and economy of the local area because both will be reflected in the health needs of the catchment population. In each community, a detailed household listing will have to be developed to identify women, children and other at-risk individuals who may seek or require health services from time-to-time. The sub-steps involved are described below. Define the catchment area(s) Describe the catchment area(s) Draw a map of the catchment area(s) Make a register of villages, communities Make a household register Define the catchment area If you have not already done it, this step can be a major activity, but it is worth it. Most PHC programmes do some sort of assessment at the onset. It is a good opportunity to involve key members of the PHC team and the community. The catchment area is defined as the geographical area surrounding a single health facility or group of health facilities and includes the target population living within it. Catchment areas may be determined by the type of PHC service or by geographical or administrative boundaries. For example, the catchment area of a secondary hospital may be a district serving a relatively large population; a community health centre serving the health needs of one sub district of only five to ten villages; and at the lowest level, a community-based worker with a village or sub-division of the village as part of his or her catchment area. Thus, the boundaries of the catchment area can be defined by: an administrative unit which can be based on area and/or population, e.g., district, sub-district, village, etc; a circle of a fixed distance, e.g. five or eight km around a health facility; an area which includes the target population for a specific PHC service, a socio-economic group, or a geographically defined population; or any practically defined working area, which may include services offered in neighbouring areas or which is based on an assessment of utilisation patterns. A catchment area for a larger PHC programme can be divided into sub-catchment areas for different types of PHC services. For example, the catchment area for a programme's EPI component may be larger than the one for basic curative care if the neighboring health centre does not have electricity so it can provide surgical services. The sub-catchment areas may also be defined by the area where outreach MCH services will be most concentrated. (It may not be possible to provide outreach services to a large area because of transportation problems.) The following is an example of a completed worksheet that can help you define your catchment area. A blank worksheet is provided in Appendix E. Exhibit 1: Worksheet for defining catchment area a) Select criteria to define the boundaries of your catchment area: Fixed distance of kms around health facility _X 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 _X MCH Family planning _X TB Other Describe the catchment area Following the definition of the catchment area, the PHC team must identify the target population residing in the catchment area. For example, at the village level, households or individuals will be identified as the target population for specific PHC components, while at the district level the identification will only include communities. The identification process may involve gathering data from existing sources, such as administrative records or household registers (described later in this module), or may require the collection of data through community surveys (Module 2 and Step 2 of this module). Information for a village or community level catchment area should include: number of households, or individuals residing in the area composition of households (or characteristics of individuals, including age, sex, ethnic group, mortality, morbidity, disablement) such socio-economic factors as occupation, income, education level utilities (water, sanitation facilities, electricity, telephone, TV) social activities size and terrain of area, status of roads and houses Exhibit 2: Worksheet for describing catchment area Level Information Data sources District level No. of facilities Government offices Name of facilities Government offices Facility level Name of villages Village registers No. of villages Village registers Location of facility(s) Village registers Size and terrain of area, Observation Village level No. households Household registers Position of HHs Household registers Source of income Community surveys Educational levels Community surveys Religion/ethnicity Community surveys Status of houses/roads Interviews and observations Distance to health facility Interviews and observations For larger catchment areas, you may need to aggregate data for several villages or communities and include such additional information as: road networks, distances, transport availability and cost social differences among populations (e.g., female mobility) industry, agriculture, and environment listings of communities/villages The preceding is an example of a worksheet that can help you to describe your catchment area. A blank worksheet can be found in Appendix E. The example illustrates the types of information that may be needed to determine target groups and to plan PHC activities for the sub-district catchment area. Make map(s) of catchment area You can use maps for planning work assignments, conducting surveys, monitoring services, and determining the physical parameters of service coverage. Maps can be drawn for different levels of the service delivery system: Map A At the district level, showing boundaries of sub-districts and facility catchment areas, the location of district headquarters and surrounding villages, health facilities and their catchment areas, and other major infrastructure in the district (see Exhibit 3). Map A is often available at government offices and can be used to illustrate an overall scheme for the planning of a PHC programme. Exhibit 3: District level map - Map A District HQ Hospital Health centre Railroad River Highway Highway Map B At the health facility level, showing the catchment area for a single health facility with surrounding communities/villages (see Exhibit 4). Map B is particularly important for planning activities for a community-based health care programme or outreach service. Several maps can be made of the catchment area for a health facility which illustrate sub-catchment areas for different target groups or PHC services. Exhibit 4: Health facility level map - Map B Sub-district HQ Health centre Mill, factory Village, boundary River Highway Map C At the community/village level, showing a single community or village with roads, houses, services such as a health post or private clinic, water sources, waste disposal areas, and schools (see Exhibit 5). If the houses are assigned a number before hand, then these numbers can also be put on the map. Exhibit 5: Community/village level map - Map C House Mill, factory Health centre Sub-district HQ Highway Road Case of malaria Map C should be easy to make and understand. Community workers can often be taught to draw maps of their own villages/catchment areas. However, this often necessitates compromises on the quality of the map. Distances, for example, may not be drawn accurately. Map C is useful at the local level to identify households or individuals in need of particular services and to develop a house-to-house work plan for the community health worker. Again, at this level, it may be helpful to use different maps of the same catchment area to illustrate different needs or services. Health workers could place different coloured pins in this map to indicate high-risk households in order to provide better and more equitable health care. Red pins, for instance, could be used to indicate malnourished children, blue to indicate children with no immunization or an incomplete status, green to show pregnant high-risk women, etc. The markers chosen, however, should be appropriate to the local settings and used in a way that is easy to understand. Effective map-making requires that information on geographic features, location of landmarks or buildings, and distances be depicted as accurately as possible. A scale should be used that indicates the relationship between distances shown on the map and real distances, e.g., 1 cm on the map = 1 km of real distance. In addition, the map legend (symbols and colours representing structures, geographic features, or administrative boundaries) should be recognisable and consistent. You may refer to Appendix A for an illustrative listing of map legends. Often, it may not be possible to get the exact proportions or locations of minor roads or communities. What is more important is that the map be good enough to find the relative location of clusters or groups of communities and their main access roads. Maps should be modified periodically to include new facilities, houses, or other features identified after working for an extended period in an area. Based on the worksheets for defining and describing the catchment area (Exhibits 1 and 2) and Appendix A (examples of legends for map making), you should be able to create a useful map of your catchment area(s). Make a register of communities/villages For a larger catchment area, you should develop a community or village register providing a listing of communities/villages and their population size; ethnic, religious, or social groups; and health facilities which serve these areas. If the person maintaining the register is illiterate, a pictorial register could be developed. The worksheet illustrated in Exhibit 6 can help you to determine what information should be included in a village or community register. A blank worksheet is provided in Appendix E. Exhibit 6: Village register District: Pakhowal Sub-district: Juhu , +, +, +, +, +, +, +, +, +, +, S. No, Village, No. of house-holds, Populatio<%0>n, Local leaders, Health volunteers, Health problems, +, Distance to health facility (Km), Public transport available, Other remarks, + , , , , , , Priority, Being addressed, , , ^, ^ 1., Anderi, 150, 1,000, Nasir, Nazima, Poor sanitation, yes, 10, yes, Education needed, + 2., Balowai, 20, 750, Aziz, Noor, Low immunization, yes, 15, no, CHW inactive, + 3., Sapur, 172, 1,500, Kasim, Roshan, TB,, parasites, no, 5, yes, Educationneeded, + 4., Deogha, 93, 1,200, Ramsan, Amina, Low immunization,, MCH, yes, 8, yes, Need to train local TBA, 5., Jalma, 210, 1,075, Mehndi, Sumi, Low immunization, yes, 2, yes, Household reg. to be updated, 6., Hamsa, 95, 450, Rustam, Naseem, Hepatitis B, no, 5, yes, Education needed, 7., Sahan, 80, 900, Munwar, Bano, Low Immunization, yes, 3, yes, Update HH reg. training CHW, 8., , , , , , , , , , , 9., , , , , , , , , , , 10., , , , , , , , , , , 11., , , , , , , , , , , 12., , , , , , , , , , , 13., , , , , , , , , , , Exhibit 7: Household register Sector # / house # / household #: 02/90/1/2 Registration date: 23/07/1989 Name of head of household: Mohammad Hossain Occupation: Gov't service HH income: 3000 Centre name: Grax ID No, Name, Father's/ husband's name, Date of birth/age*, Sex M/F, Chronic health problem, Date ofDeath Migration out, +, Remarks D2, Bibi Masyam, Hasan Ali, 11-1929, F, , , , F, M. Hussain, Hasan Ali, 30-09-1948, M, , , , M, Sakina, M. Hossain, 23-06-1950, F, , , , C1, Sikundar, M. Hossain, 01-03-1967, M, , , , C2, Laila, M. Hossain, 24-04-1968, F, , , 26-06-1990, Left for Saudi Arabia C3, Zainab, M. Hossain, 19-05-1970, F, , 20-09-1970, 05-04-1989, Left family after marriage C4, Khalid, M. Hossain, 21-01-1974, M, , , , C5, Seema, M. Hossain, 15-02-1976, F, , , , C6, Zahail, M. Hossain, 17-09-1980, M, , , , C7, Naila, M. Hossain, 30-07-1984, F, , 15-08-1984, , C8, Aaman, M. Hossain, 06-02-1986, M, , , , , , , , , Risk profile of household, +, Score if present, Score , , , , , At least 1 child << 1 yr, +, 1, , , , , , >>2 Infant deaths in past 5 years, +, 2, , , , , , >>2 children << 5 yrs, +, 1, , , , , , Illiterate women, +, 2, 2 , , , , , Restriction on mobility of women, +, 1, 1 , , , , , Presence of TB case, +, 1, 1 , , , , , Low family income, +, 1, * List oldest member first and youngest last, +, +, , , Improper /no use of toilet facilities, +, 1, Exhibit 6 Make a household register A household register at the community level can help you or your community health worker to identify individuals or under-served groups in need of a specific type of service (e.g., vaccination for a particular age group). You should collect the following types of information from each household: age and sex of each member, health needs of various members, other characteristics of household members such as education, income, access to water and sanitation, etc. An example of a simple standard household register and the types of information it should contain is presented in Exhibit 7. You can determine the size of the target population for specific PHC services by compiling information from these registers. Using these registers, you should be able to calculate the number of children who need immunization, the number of women who need antenatal care, etc. in a given year. However if you are unable to develop household registers in some areas because of the dispersion of villages and communities, you should estimate the size of the target population. For example, demographic survey or census data of an area or country can be used to estimate the proportion of people in the various age groups and these proportions can be applied to the total population to estimate the population age pyramid of the area. Example: A demographic survey of rural Pakistan provided the following overall estimates for the area: << 5 children = 15% of the total population << 2 children = 6% of the total population married women = 20% of the total population pregnant women = 15% of married women These percentages were multiplied by the population in the catchment area of the Dhabeji health facility (about 25,000). Thus the estimated target population << 5 children = 25,000 x .15 = 3,750 << 2 children = 25,000 x .06 = 1,500 married women = 25,000 x .2 = 5,000 pregnant women = 5,000 x .15 = 750 Step 2: Identify community needs and available resources Skip this step if: Your programme has already prioritised health problems and identified high-risk groups You have already completed Module 1 and/or Module 2 and have identified community needs Review this step if: You have not identified community needs You have not assessed existing health services You wish to determine available resources The purpose of this step is to identify community needs based on information from records and surveys as well as from interviews with community members to determine their perceptions. In addition, this step also addresses the identification of resources that will help in providing better service. These needs and available resources can be ascertained from; the health status of the community in terms of occurrence of disease and death, factors that contribute to these outcomes, e.g., crowding, sanitation, lack of water supply, illiteracy, the quality and adequacy of existing health services being provided in the area, available resources, such as facilities, manpower, transportation, etc., needed for the effective and efficient provision of health care. Sub-steps to identify community needs and available resources are described below. Select indicators Identify source(s) of information Develop a survey instrument Step 1 has helped you to define and describe the catchment area, to develop an area map, and to compile information for a household register from a community/village. This information will help you when you proceed to Step 2. Step 2 will help you to collect the necessary data to determine the health needs of the community and the existing resources which could be used for the provision of PHC services. Select indicators The first thing that you will need to do is to determine which indicators are necessary to assess the health status of the community. This information will help you proceed, together with the PHC team and the community, in setting priorities and determining strategies for the provision of effective and equitable health care. These indicators fall into two broad categories: 1) indicators that reflect the health status of the population and 2) indicators that reflect the perceived needs of the community, which can often prove contrary to what other data will show. A community's perceived needs are often different from what other data indicate. The information which you will need to select pertain to the following: 1. Health problems 2. Demographic information 3. Risk factors 4. Existing health services and available resources. Health problem indicators. This category deals primarily with statistics of disease (morbidity) and death (mortality). You need to characterise health problems in terms of WHO is affected, WHEN the person was affected, and WHERE it happened. These characteristics can be translated into indices to help you analyse the current situation. They also serve as a baseline with which to evaluate future PHC interventions. In addition, this information can be presented in the form of rates (see Module 5 for details of rates, formulae, and examples) to facilitate comparisons over time and between geographical areas. Examples of these indicators are: simple frequencies of those afflicted by a particular disease community perceptions of what they consider to be major health problems prevalence rates, preferably by age and sex mortality rates, e.g., crude death rate (CDR), infant mortality rate (IMR), under 5 child mortality rate, cause specific death rates, etc. If you are interested in setting up a permanent (or temporary) surveillance system to monitor changes in morbidity and mortality, see Module 4. Demographic indicators. This category includes population composition, i.e., the total number of people within the community, preferably with age and sex distribution. Since both age-sex distributions and sex ratios are reflected in reproductive behaviour, disease exposure rates, and death rates, both factors need to be considered in determining community needs. Data should be broken down by age group. Useful categories include: less than 1 year (infants), children aged 1-4 years, persons between the ages of 5-14, 15-44, and those 45 years and above. Data on the number of births and deaths are also important. Birth data are needed to determine the fertility level of the area, whereas the number of deaths reflects the health status and health services of the area. The more important rates are: Crude birth rate (CBR) Crude death rate (CDR) Total fertility rate (TFR). Population growth can be calculated from the rate of natural increase (births minus deaths) and the net migration (migration-in minus migration-out). It calls the attention of a PHC team to future problems due to an increase in population. A note of caution: you need to have a fairly large population - at least 50,000 - to calculate accurate rates. See Module 2 or Module 4 for a discussion. Risk factors. A risk factor is a characteristic pertaining to individuals or groups that is associated with an increased chance of an unwanted outcome such as illness or death. Risk factors may either indicate the possibility of such an outcome or directly cause it and form part of the chain leading to illness or death. These risk factors may be amenable to change in which case the incidence of a disease will drop. However, some risk factors, such as age, cannot be changed and, therefore, require greater care (see Appendix B for details on risk factors). The impact a certain risk factor may have on determining an individual's or community's health status can be measured by comparing the likelihood of the unwanted outcome in the presence of the risk factor with the likelihood of that outcome in the absence of the risk factor. This measure is called the relative risk. Often in health programmes it is also necessary to determine the attributable risk. The attributable risk is the magnitude of risk that can be solely attributed to the risk factor and which would decrease in the absence of the risk factor. In some cases, an outcome for one risk factor may be considered to be a risk factor for another outcome. For example, poverty (risk factor) is associated with low birth weight (outcome). Low birth weight in turn could act as a risk factor for infant death (outcome). A risk factor may also be associated with several outcomes, e.g., low birth weight is a risk factor for infants developing diarrhoea as well as for infant death. Risk factors are thus categorised into the following groups: Environmental: These factors pertain to an individual's surroundings, e.g., poor sanitation, drought, lack of water, lack of access to clean water, type of housing structure. Biological: These factors are intrinsic to the individual, e.g., age, malabsorption, malnutrition, infections, decreased immunity, developmental abnormalities, maternal height. Socio-economic: These factors pertain to income, societal status of women, education, employment, etc. Some of the most important are poverty, illiteracy, large families, and working mothers. Behavioural: These factors are primarily determined by cultural and/or religious beliefs, such as male preference, local beliefs regarding disease causation and management, local nutritional practices, and early marriage. Health care related: Some of the most important are inaccessible health services, improper outreach programmes, poor quality of health care, unavailability and/or high cost of supplies and medicines. Existing health services and available resources. The information included in this section deals with the type and quantity of health services being provided, e.g., curative clinics, number of PHC centres, number of tertiary facilities. In addition, knowledge of the health providers such as the TBAs, doctors, dispensers, etc., helps in determining the ratio of health service providers to population. Included in this section is information on how to assess the quality of health services being provided, access to the health services in terms of distance, and availability of supplies, e.g., vaccines, medicines, surgical supplies. Community perceptions regarding availability, accessibility, quality of services, etc., are also extremely important and cannot be overemphasised, as community members are ultimately the clients for such services. In addition to health care services and providers, it is also important to ascertain other resources such as available transportation and other human resources, e.g., school teachers, that can be utilised for the provision of health care to the community. Identify source(s) of information You need to obtain information for the indices. This information can be found in: 1) existing data sources, 2) interviews with people, and 3) observation. Existing data sources: A large amount of the required data can be obtained from records of hospitals and clinics, national registries, results of previous surveys, household registers (described in Step 1), etc. Interviews: The source in this case is the people of the community, and information can be obtained from them through: surveys conducted through structured interviews of either all or representative samples of the community (see Module 2 for suggestions for designing and conducting community surveys) interviews of a small number of particularly knowledgeable persons from the community (key informants). Observation: To a great extent, data can also be collected from observing the environment and behaviour of the people of the community. This is especially needed for data on sensitive issues like household cleanliness, economic status, etc. The source to be used depends on: 1) resources and; 2) the stage of the programme. For example, if you want to determine community needs but are unable to conduct a community survey, you might use existing records as your data source. If your programme is already in place, you will easily be able to obtain information generated from the periodic reports. Exhibit 8 is a worksheet that can help you to determine indicators and the source of indicators. A blank worksheet form is provided in Appendix E. Exhibit 8: Worksheet for determining indicators and source of indicators INDICATORS SOURCE 1. Health status indicators Clinical morbidity Clinic/hospital records Prevalence rates Community survey Age-specific morbidity rates Community survey Frequency of cause of deaths Community survey Verbal autopsy Cause-specific mortality rate Community survey Verbal autopsy 2. Demographic indicators Age distribution Community survey Village household registers Sex ratio Community survey Village household registers CBR Community survey Village household registers CDR Community survey Village household registers 3. Risk factors Biological malnutrition MCH card immunization status MCH card Environmental water Observation sanitation Observation Socio-economic literacy Community survey Behavioural Community survey 4. Health service-related Quantity Facility survey Quality Facility survey Accessibility distance Community survey cost Community survey Develop a survey instrument You will also require detailed information about the community, the health services provided, and the resources present, which cannot all be obtained from records. For planning PHC programmes, you will need to conduct a survey (see Module 2) to elicit information regarding; the community, and health facilities. Questionnaires, such as those in Appendix C, can be designed to provide information covering the indicators that you have selected. These questionnaires can be modified to suit your needs. Models of questionnaires in Module 2 can be used through a mix-and-match method to provide you with the necessary survey instrument. Module 2 will also provide you with details on how to analyse the data that you obtain from these surveys. Step 3: Set priorities and identify high-risk groups Skip this step if: You know client load per facility or provider You have well planned outreach and clinic-based activities Review this step if: You have not identified priority health problems Your programme does not have a way to identify at-risk individuals or families The purpose of this step is to help in setting priorities among health problems and in the identification of at-risk groups so that the PHC programme can: 1) provide equitable health care, and/or; 2) increase the frequency of services for those in greater need. The sub-steps for setting priorities and identifying high-risk groups are described below. Set priorities among health problems Determine the risk factors Set priorities for the identified risk factors Identify target groups and high-risk groups Use risk factors to monitor high-risk groups Set priorities among health problems Now that you have gone through the process of identifying community health problems (Step 2) you have some basic information in terms of the pattern of disease prevailing in the area and the risk factors that are prevalent. Your next step, therefore, is to work with the PHC team, along with the community, to prioritise the health problems. One method of setting priorities among health problems (Exhibit 9) is based on such criteria as; seriousness of the disease (e.g., in terms of mortality, disability) prevalence of the disease feasibility of control, i.e., available technology, cost, resource constraints community acceptance with respect to their perceptions and demands. Each criterion can be assigned a score from 1 to 4 (or any other scale that you choose). The scores for the different health problems are tabulated using addition or multiplication and then compared and priorities are set. Multiplication may result in a more sensitive score for comparison between health problems if addition results in equal scores for different health problems (e.g., malnutrition, cancer, and AIDS = 10). Thus, according to multiplicative scores in Exhibit 9, diarrhoea is ranked as the highest priority followed by malnutrition, AIDS, and cancer. A blank form of this worksheet can be found in Appendix E. Determine the risk factors You now need to determine the risk factors that are associated with the health problems you selected to emphasise. You will find that identifying the risk factors will help you to develop appropriate strategies for the health promotion, disease prevention, and the reduction of morbidity, disability, and mortality in high-risk groups. In order to use the risk approach in your PHC programme, you can make use of the risk factors determined by: prior research analysing data from your programme site. As mentioned above, many risk factors have been identified and carefully documented and are easily accessible through literature. For example, your survey might have identified malnutrition as a health problem which was later determined to be high on the list of priorities. Data obtained by you from the catchment area might indicate that poverty, illiteracy, poor sanitation, and lack of antenatal care facilities are potential risk factors. A review of the literature and prior knowledge will help you to decide whether these are risk factors that you should consider in the priority-setting process. Appendix B (see also Exhibit 10 for malnutrition risk factors) provides you with risk factors for some health problems. In this appendix, risk factors for selected diseases are tabulated. However, caution must be taken and critical monitoring done when applying them to your PHC programme. In certain situations, you may feel that you are equipped to determine the magnitude of risk associated with a factor. In this case you may wish to calculate the Relative Risk (RR) and Attributable Risk (AR) (see Appendix B). Because risk factors vary among communities, information should be collected (see Module 2 and Module 3 þ Step 2) that identifies the relevant risk factors. Exhibit 9: Worksheet for setting priorities among health problems , +, +, +, +, +, + Health Problems, Prevalence, Seriousness, Feasibility of control, Community acceptance, Additive scores, Multiplicative scores (x) Malnutrition, 3, 3, 3, 2, 11, 54 Diarrhoea/dehydration, 3, 4, 2, 4, 13, 96 Cancer, 1, 4, 1, 4, 10, 16 AIDS, 2, 4, 1, 3, 10, 24 Exhibit 10 Exhibit 10: Malnutrition risk factors Biological, Environmental, Socio-economic, Behavioural, Health care-related Malnutrition, +, +, +, + Age, Unsanitary conditions, Poverty, Feeding boys before girls, Lack or improper antenatal care Malabsorption, Drought, Illiteracy, ^, ^ Infections, Desertification, Large family, Preference of adults in food distribution, Distant health care facility Pregnancy-related nutritional disorders, , Working mothers, ^, ^ ^, , Violence/war, Unwillingness to weigh children due to belief in evil eye, Drugs Infections and disease during pregnancy, , Unwillingness to weigh children due to belief in evil eye, ^, Lack of drugs and diagnostic equipment Decreased gut immunity due to lack of breast feeding, , ^, Attributing malnutrition to supernatural causes and not food-related, Other diseases which are untreated ^, , , ^, Inadequate use of services , , , Breast feeding boys longer than girls, ^ , , , ^, ^, , , Diet, , , , Inactivity,, smoking,, etc., , , , Dietary beliefs, Set priorities for risk factors identified You will now have to set priorities for the identified risk factors through a process similar to the one you used when you set priorities among health problems. The same criteria can also be used here with a few modifications; seriousness of the factor in terms of magnitude of risk (i.e., relative risk and attributable risk) prevalence of the risk factor feasibility of control (i.e., available technology, cost, resource constraints) community acceptance with respect to their perceptions and demands. Here, too, you will need to assign each risk factor a score for each criterion and then to calculate total scores either by addition or multiplication. You will then compare the scores to obtain priorities for the risk factors. Identify main target groups and high-risk groups After health problems and the risk factors for your catchment population are defined, you will need to identify the individuals or households in the catchment area who will be the target of your PHC services, as well as those who are at greater risk of disease and death. Identification of priority target groups and high-risk groups is very much related. Target groups are determined in order to focus on persons who will require services. Identifying high-risk groups helps to recognise those individuals (households/communities) most at risk of disease or death, whose potential for these outcomes can be decreased if they are targeted through specific strategies aimed at reducing risk factors. For example, the target groups identified may be mothers with children under five who are most vulnerable. In this case the high-risk group would be those children under five who have been losing weight for three consecutive months. You will find that the identification of all individuals/households in the target groups is relatively easy if these groups are defined by age, sex, location, or other commonly known demographic criteria. You can obtain this information through the household registers maintained by community health workers or village leaders. In case there are no household registers, other means, such as surveys, reviewing administrative records, or interviewing key-persons, can be used. You can use risk factors in several ways to identify individuals or households. For example, the maternal health record card of Pakistan has an in-built risk-identifying mechanism to track high-risk pregnant women and children under three years. MODEL OF MCH CARD IN PAKISTAN The MCH card being designed for use in Pakistan, is action-oriented and focuses on risk identification. It uses the risk approach while monitoring the individual. One side of the card has information on the pregnant woman and the reverse for the child from that pregnancy. The Maternal side of the card has four panels, one each for general information, past history, present pregnancy/labour, and outcome. Each entry has a built-in alert signal which is a shaded area and points to a risk factor. An entry in this area anywhere on the card makes the card holder a high-risk case and requires action. The reverse of the card is devoted to the child from that particular pregnancy and has a panel for general information regarding the child, some of which is similarly designed to show risk factors (areas shaded in red). The rest of this side has a growth chart showing a cut-off for normal growth and undernutrition. Below this are shaded areas to mark bottle feeding and early weaning, which are both risk factors for poor growth. Use risk factors to monitor high-risk groups You can assign households a risk score based on a "risk profile" which indicates the risk of high morbidity and mortality of its members. This score will help in the identification and follow-up of "risk households." The basis for creating the risk profile is a list of risk factors. The list can be based on literature, prior knowledge or experience, and local perceptions. A value is assigned on the basis of whether the risk factor is absent (0) or present (1). A total score is calculated and compared to a rating scale which was designed earlier. Weights can be used for risk factors when present, if deemed necessary. For household no. 1, which has one infant death, three children under the age of five, an illiterate mother who is not allowed out of the house, low family income, and low use of toilet facilities, the risk score is 8. This household would be considered to be in the high-risk group. Household No. 4 has one child under five, an illiterate mother, and low family income but is included in the low-risk category because the risk score is 3. Once these high-risk individuals, households, or communities are identified, PHC services can be organised according to the special needs of the high-risk groups. Exhibit 11: Worksheet to develop risk profiles of households CONDITIONS, SCORE IF PRESENT, HOUSEHOLD NO., +, +, + ^, ^, 1, 2, 3, 4 Number of infant deaths in past 5 years, *, 1, 1, 1, 0 Number of children under the age of 5, *, 3, 1, 1, 1 Illiterate mother, 1, 1, 1, 0, 1 Cultural/religious restriction on mobility of women, 1, 1, 1, 1,0 Presence of infectious diseases (e.g.,, TB), 1, 0, 1, 0, 0 Low family income (below locally accepted level), 1, 1, 1, 1, 1 Improper/no use of toilet facilities*, 1, 1, 0, 1, 0 Total risk score, , 8, 6, 5, 3 * Weights determined by number of children Rating scale: Low risk Moderate risk High risk 0-3 4-6 >>7, Step 4: Plan PHC activities Skip this step if: Your programme is already set up and you have job descriptions Review this step if: You want to plan community-based, outreach, and/or clinic-based activities You do not know client load in your facility The purpose of this step is to develop a community-based outreach and centre-based activities plan for delivering services. In Step 2, you identified community need and available resources. In Step 3, you determined the number of households and/or individuals who are at-risk or afflicted by health problems. At this point, you need to use Module 1 to determine your goals and objectives and the type of services required to meet the health needs of the target population. After deciding the type of service, you must decide what strategy will be used to provide the service, the community-based outreach, and the centre-based activities that will need to be performed. You will also need to know the type and amount of resources that will be required to provide the services. If you foresee that your existing resources cannot fulfill the need in an appropriate manner, then you will have to decide either to mobilise additional resources or to relocate existing resources to improve efficiency. To carry out this step, PHC teams with large catchment areas must have assessed community needs (Module 2 and/or Step 2 of this module), identified priority or high-risk groups (Step 3), defined programme goals and objectives based on the needs of the community (Module 1), selected PHC services (Module 1), and identified strategies for providing the services. The manager, the PHC team, and the community leaders should together plan PHC services and activities. The following section will focus on how to plan community-based, outreach, and clinic-based activities to deliver services. The following sub-steps will need to be modified depending on the nature of the activity. List services required by the community and identify the strategies that will be used and the activities that will need to be performed to provide these services Identify and plan community-based and outreach activities Identify and plan clinic-based activities List services required, identify strategies and activities In Steps 2 and 3, you identified the community needs and the priority groups. You, the PHC team, and the community leaders will now need to work together to identify (use Module 1) and list the services that should be provided and the strategies for delivering those services. For example, you may have decided that you need to provide antenatal care, growth monitoring, immunization, and basic curative care services. You now need to decide how you will provide these services. You need to determine: the overall strategy that you will use to provide each service. which activities are needed to provide the service. You may need several. who will perform the activities, how, and at which level (community vs. health centre). The activities needed to provide a service may be activities done by different people at different levels. Exhibit 12 is an example of a worksheet that can be used to list services, strategies, activities, those who should do the activity, and where and how it should be done. A blank form is provided in Appendix E. Once you have listed the activities, identify which are community-based, outreach, and/or centre-based activities. A community-based activity is performed at the community level by community members. An outreach activity is performed at the community level by the health centre staff. A centre-based activity is done at the centre by health centre staff. Organising and conducting clinics is a major centre-based activity. The first column of Exhibit 13 shows an example of activities that can be done at the different levels. You can use the first column of the worksheet provided in Appendix E for listing your activities in the appropriate category. In the following sub-steps you will be asked to plan for each activity separately. However since many of the attributes involve the same resources, it is important to look at the package of activities as a whole when assessing the availability of resources. Resources should be allocated to reach an optimal level of services for those at risk and to maintain equity. Exhibit 12: Worksheet for identifying services, strategies and activities Service/component, Strategy, Activities, +, +, , , List, Who will do it, How and when, Immunization, Will be provided regularly at the health centre and periodically in the villages through camps., Motivate mothers, CHW, Home visits, , , Maintain cold chain, Vaccinator, At health centre and during transportation with proper carriers, , , Vaccinate, Vaccinator, Centre and camps, , , Maintain records, Vaccinator /CHW, Centre,, camps and home visits, Basic curative care, Will be provided regularly at the health centre., Identify and refer cases fromcommunity, CHWs and LHVs, Home visits, , ^, Provide treatment, CHN and CHD, In health centre, , , Maintain reports, CHN and CHD, In health centre, Community organisation, Motivate community members to participate in improving their own health through regular interaction with them., Dialogue with community members, COs and CHDs, Visits to villages-COs, , ^, Form village committees, , Visit to villages, , , Select volunteers, Community members and COs, Meeting with village committee, , , Form area health committees, COs and CHDs, Visit to villages and meeting at health facility, , , Have regular meeting with:, , , , , village committees, COs, Village health centre, , , area committees, COs and CHDs, , CO = Community organiser TBA = Traditional birth attendent Vac. = Vaccinator CHW = Community health worker CHN = Community health nurse AA = Administrative assistant LHV = Lady health visitor CHD = Community health doctor SP = Security person Exhibit 13: Worksheet for planning PHC activities (continued, page 37) Services / activities needed, +, +, Manpower, +, +, Logistics / supplies, +, +, Optimal level of services givenresource constraints, A. Community- based, Target group, Frequency, Required, +, Available, Required, +, Available, ^, , , , Type, Number(FTEs), , Type, Amount, , ^, Home visits for:Growth monitoringBuild awareness of ORS for diarrhoeaMotivate for FPMotivate for immunization and ANCFollow-up of high riskReferraletc., 1,000 HHs , Regular 1/monthHigh-risk 1/week more if needed , CHWs , 6 , 4, Weighing scaleORS packetsRegistersStationary, 10, , Visit HHs with no women and children quarterly,, the rest monthly, Community meetings for health education, Mothers of 10 villages , 1/month, CHW, 1.5, , Flip Charts, , , , Deliveries, Women delivering, 30/month, TBAs, 1 , , TBA kit, 10, , , B. Outreach, , , , , , , , , , Community organisation activities, 10 Villages, 1/two weeks, CO, 1, , Bus fare, , , , Vaccination, 300 women and children , 1/month per village, Vac., 0.5, , VaccinesCarriersSyringesVan, 10 days/month, , , Supervision/support , CHWOthers, 1/month per CHW regular, LHVCHN, 0.40.1, , Van, 15 days/month, , , CO= Community organiser TBA = Traditional birth attendent Vac.= Vaccinator CHW= Community health worker CHN = Community health nurse AA= Administrative assistant LHD= Lady health visitor CHD = Community health doctor SP = Security person Exhibit 13: Worksheet for planning PHC activities Services / activities needed, +, +, Manpower, +, +, Logistics / supplies, +, +, Optimal level of services givenresource constraints, C. Clinic-based, Target group, Frequency, Required, +, Available, Required, +, Available, ^, , , , Type, Number(FTEs), , Type, Amount, , ^, Curative care , 1000/month(20% ref. to CHD), Every day, LHVCHNCHD, 0.70.650.2, 0.55, Drugs (by type)EquipmentVan, 2 days/ month, , May need to bring a volunteer from time to time, Antenatal care, 80/month (20% ref. to CHD), 1/week, CHNCHD, 0.150.03, , , , , , Vaccinations, 200/month, 1/week, LHVVac., 0.20.4, , VaccinesSyringesRefrigeratorEquipment, , , , Family planning, 200/month, 1/week, LHV, 0.5, 0.40, CondomsPills,, etc., , , May need to bring a volunteer in to help with FP, 6PTRIGHT, Supervision/support, Staff a centre, Regular , CHNCHD, 0.10.3, , , , , , Management activitiesmeetings, , 1/month1/month, CHWLHVCHNCHDVac., 1.50.30.10.40.1, , StationeryRegister and - Form, , , , Administration, , , AAHelperSP, 111, , Van StationeryCleaning supplies,, etc., 2 days/month, , , Total, , , CO CHWsTBAsVac.LHVsCHNCHDAAHelperSP, 1 10112.11.11111, 1810 for 10%1211111, Van Cost of other equipment and supplies, 1, , , Identify and plan outreach and community-based activities In developing countries, community-based activities play an important role in ensuring that large populations have access to basic health care, both curative and preventive. A number of health services originate from clinics, but frequently community-based workers play an important role as a source for referrals and for the provision of basic health care and education. The planning of some of the community-based activities, such as selection of CHWs, home visits, and monitoring of CHWs, should be conducted by the community members themselves with some technical assistance from the health centre staff. Community-based workers need to be trained and supported by the clinical staff. Clinical staff often also monitor the high-risk individuals in the community identified by the community health workers. Outreach activities are very important for the success of the community-based programme and can be done through meetings with community-based workers, community meetings, immunization or growth monitoring camps, educational sessions with school children, and home visits. Therefore, PHC teams need to plan their clinic staff's outreach activities as well as to participate in the planning of the activities that are to be carried out by community-based workers. The sub-steps to plan and carry out community-based and outreach activities are described below. Determine number of units (individuals/households/villages) to be covered for each activity Determine optimal time interval for each activity Determine resource requirements Compare resource availability with requirements and identify an optimal number of visits Develop tools to plan and monitor community-based and outreach Determine number of units to be covered. For activities like health education you will have to target the entire village while for others, such as immunization, ORT, etc., you may target specific households or individuals. You will have to review the household or village register or a map of your catchment area to determine the size and location of the target populations for various activities. If you do not have a household or a village register or a map, you should review Step 1 for how to develop them. Determine optimal time interval for each activity. You will need to decide an optimal time interval for each activity. For example, you may decide to conduct a community-wide health education session once every three months, while immunization services will be offered in a village once a month. In some communities, monthly home visits may be needed, while in others, quarterly visits may be enough. Information from past experience, literature reviews, and/or operational research could be used to determine the frequency of visits that would be required to meet community needs. Determine resource requirements. For each activity, you should determine the type and quantity of resources required. For example, health education may be provided by a community nurse, while contraceptive supplies could be provided by community health workers. In this section we will focus on how to determine staff requirements; however, the same method can be used for other resource requirements (for example a vehicle). Exhibit 14 formulae can be used to determine the level of staff effort required for each type of activity (for example, home visits) over a specific time period. Exhibit 14: Worksheet to determine staff requirements 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 unit for that activity and travel time if needed. Before you do the next step, you need to determine the availability of resources. When calculating availability, keep in mind other activities which need the same resources. For example, a health worker may need to conduct community meetings, health education sessions, and immunization sessions in addition to home visits (see Exhibit 13). Personal leave and administrative duties should also be considered when determining availability. Since you need to see the whole package of activities when allocating available resources, it may be a good idea for you to do the first three sub-steps for all activities before you do the next step. An example of the results of this process is shown in Exhibit 13. A blank worksheet form has been provided in Appendix E for you to use. For example, if you were planning LHVs 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 of 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 Compare resource availability with requirements and identify an optimal number of visits. In the last sub-step, you determined the number of staff needed to perform a particular activity in a specific time period. If the existing staff is unable to cover every unit (village/household/individual) during the time interval, then you should: increase the time allocated for doing the activity; hire additional staff; or substitute resource intense activities with less resource intense activities. For example, use group sessions as a substitute for frequent home visits. However, focus on high-risk groups/individuals should not be neglected. You can use the following formula to determine the total time (in months) needed to cover every unit in the catchment area: No. units/(staff capacity x No. of staff available) frequency of doing the activity If the total is one, all units can be covered every month. If it is more than one, a special strategy is needed. For example, for planning home visits if: Number of households = 600 Days/month = 20 Number of households that can be visited per day per worker = 5 Capacity per month per worker = 20 x 5 = 100 Available health workers = 4 Time to complete routine visits = 600/(100 x 4) = 1.5 months Therefore, with the existing number of workers, it would take 1.5 months to visit every household. In the example above, if each household could be visited quarterly instead of once in 1.5 months, the remainder of the outreach time could be used for high-risk cases, which could be followed up monthly or weekly. However, if it is felt that regular monthly visits are essential to meet the needs of the community, two more workers will need to be identified and trained. In some situations the above method may not be useful for community-based workers since they are often volunteers and are not always available. In such a case, each worker should be asked how much time she/he would be able to give. This will help you to determine the number of households/individuals she/he can monitor and the total number of workers that will need to be selected and trained. If there are not enough available volunteers, then the frequency of visits/service may have to be decreased. Develop tools to plan and monitor community-based and outreach activities. This step is the basis for developing individual work plans in Step 6 and for assessing performance in Step 7. Activity registers or lists of target groups can be used to plan community outreach services and to follow up high-risk cases. Some activities which are done once a month, such as community meetings, may not need a separate tool. A work schedule (see Step 5) can be used to plan such activities. Activities such as immunization camps need a list of villages, a map, and a schedule. Supervisors can use supervisory checklists (Modules 5 and 6) to identify gaps in the quality of services being provided by the service providers and to identify training needs. Five models of tools for planning and monitoring community-based and/or outreach activities will be presented in this section as examples. CHW activity register þ- used by the Urban PHC Programme of the Aga Khan University in which families are visited on a monthly basis (see Exhibit 15). Pictorial CHW activity record þ- a part of it is extracted from the record used by the Mombasa PHC Programme of the Aga Khan Health Service, Kenya (see Exhibit 16). Pictorial TBA activity record þ- not tested anywhere as of yet (see Exhibit 17). LHV activity register þ- not tested anywhere as of yet (see Exhibit 18). Target lists of women who need immunization þ- used by the Aga Khan Community Health Programme in Bangladesh (see Exhibit 19). These formats can be adapted and used in various situations. MODEL 1: AKU URBAN CHW ACTIVITY REGISTER FOR MONTHLY HOME VISITS At present, the CHWs in AKU's Urban PHC programme focus their attention on married women with children less than three years old. Growth monitoring of children less than three years is done every month. The CHWs list all the households, children, and married women in their target area in the household register once a year and update it during their home visits. The CHW also records information about their activities (households visited, children weighed) and target population (births, deaths, age, weight change, nutrition status, immunization status, diarrhoea cases of children under five years, last menstrual period, pregnancies, use of family planning, and immunization status of married women) during home visits. The CHW uses the register to: plan her home visits and monitor the health status of the target population, identify and monitor the high-risk women and children record and aggregate information to see if changes are occurring over time and thus, revaluate her own performance. The supervisors use the register for identifying problems and for supporting the CHWs. The register is also used for summarising information and preparing quarterly reports for management purposes. The CHW has visited (columns 11-13) all seven families, 12 children, and eight women listed on this page in January and March. In February, she visited six out of the seven families. She weighed and recorded weight change from one month to the other (+ = increase, 0 = table, and þ = decrease) of children less than three years of age in January, February, and March (columns 6-8). She must focus her attention on two childrenþ child C2 in House No. 245 has lost weight three times in a row and child C4 in House No. 248 has not been putting on weight and is a second degree malnourished child. Household 248 seems to be a problem household as all the children seem to have nutritional problems and immunization does not seem to be given importance. Three of the married women are pregnant (Household Nos. 243, 245, and 248). One woman has delivered a baby (house No. 243) during the month of March and may need follow-up by a nurse. Her other child seems to be neglected. A model of the CHW activity register with instructions on how to fill it is provided in Appendix D. MODELS 2 AND 3: PICTORIAL CHW AND TBA RECORDS In some rural areas the TBAs and the CHWs are illiterate or semi-illiterate. In such cases, these workers can use pictorial records to plan and monitor their activities. However, recording should be kept to a minimum, and only those indicators that can be used by the workers themselves or the community should be on the record. An example of a pictorial CHW record is presented in Exhibit 16, and a TBA record in Exhibit 17. In developing pictorial records, the end users should be involved because pictures should be culturally sensitive and should be understood by the local people. MODEL 4: LHV ACTIVITY REGISTER LHVs need a tool to plan their outreach services. Their outreach activities often include support visits or training sessions for community workers, meetings with CHWs or other community members to plan community-based services, home visits to high-risk individuals, and group health education, growth monitoring, and immunization sessions. An example of a register she can use to monitor and plan her outreach activities has been provided in Exhibit 18. MODEL 5: COMPUTER-GENERATED LISTS In project areas where it is feasible and cost-effective, computer-generated lists of default or high-risk cases can be used for planning and conducting outreach services. Exhibit 19 shows a list of women who need tetanus toxoid immunizations. This format is currently being used by the Aga Khan Community Health Programme in Bangladesh. Some advantages of computer lists include the following: 1) they eliminate the burden of having to create the lists manually and maintenance can be relatively simple, 2) the accuracy of the information may improve because computers can reduce human error in the manipulation of data, and 3) computers can also aggregate information and generate different types of indicators for the different levels of workers and managers. Identify and plan clinic-based activities The planning of clinics is an essential part of a PHC programme. It serves the purpose of supplementing field-based preventive services by providing a back-up referral together with centralised preventive services. It is also important to determine the types of services which are or will be in demand. Examine the services which are offered at the clinic and compare them to survey results. Are the community's perceived needs being met by the services offered? Are there other services/schedules that would better serve the population? You should use the second half of the worksheet (Exhibit 13) to complete this step. The sub-steps to plan clinics are listed below. Determine client load Determine staff capacity and resource requirements Determine availability of resources Compare availability with need and identify an optimal solution Develop tools to plan clinic-based activities Exhibit 16: CHW activity record (continued, page 48) Name of CHW: _____________ Village: ______________ Month:________ Homes visited this month,mmmmmmmmmmmmmmmmmmmmmmmmmmm Meetings attended this month,mmmmmmmmmmmmmmmmmmmmmmmmmmm Children who have completed vaccination, mmmmmmmmmmmmmmmmmmmm Children who have not had a single immunisation,mmmmmmmmmmmmm Children suffering from diarrhoea,mmmmmmmmmmmmmmmmmmmmmmmmmmm INSTRUCTIONS: Fill one circle for every case seen. Exhibit 16: CHW activity record Name of CHW: _____________ Village: ______________ Month:________ Children identified malnourished this month,mmmmmmmmmmmmmmmmm Children suffering from ARI,mmmmmmmmmmmmmmmmmmmmmmmmmmm Number of referrals made, mmmmmmmmmmmmmmmmmmmmmmmmmmm Children born this month, mmmmmmmmmmmmmmmmmmmmmmmmmmm Children who died this month,mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm Mothers who died this month, mmmmmmmmmmmmmmmmmmmmmmmmmmm INSTRUCTIONS: Fill one circle for every case seen., + , mmmmmmmmmmmmmmmmmmmmmmmmmm Meetings attended this month, Children who have completed vaccination, Low birth weight Postnatal visits Full term Deliveries assisted Family planning accepted Abortions Antenatal visits Antenatal referral Exhibit 17: TBA monthly record (continued, page 50) Year: ________ Month: _________ Division:___________ TBA name:__________ mmmmm, mmmmmmmmmmmmmmmmmmmmmm, mmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmm, mmmmmmmmmmmmmmmmmmmmmm, mmmmm mmmmmmmmmmmmmmmmm, mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm, mmmmmmmmmmmmmmmmmmmmmm, mmmmmmmmmmmmmmmmmmmmmm, mmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmm, mmmmmmmmmmmmmmmmmmmmm INSTRUCTIONS: Fill one circle for every case seen. INSTRUCTIONS: Fill one circle for every case seen. Postnatal referral Normal labour Pre- term Referral in labour Prolonged labour Still births Puerperal fever First week deaths Exhibit 17: TBA monthly record Year: ________ Month: _________ Division:___________ TBA name:__________ mm, mmmmmmmmmmmmmmmmmmmmmm, mmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmm, mmmmmmmmmmmmmmmmmmmmmm, mmmmm mmmmmmmmmmmmmmmmm, mmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmm, mmmmmmmmmmmmmmmmm mmmmm, mmmmmmmmmmmmmmmmmmmmmm, mmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmm, mmmmmmmmmmmmmmmmmmmmmm, mmmmm mmmmmmmmmmmmmmmmm, mmmmmmmmmmmmmmmmm mmmmmmmmmmmmmmmmm, mmmmmmmmmmmmmmmmm INSTRUCTIONS: Fill one circle for every case seen. Exhibit 18: LHV activity register Name of LHV: Naseem Ali Hyder Month: November Date, Village, Purpose of visit, +, +, +, +, +, +, +, +, , +, +, Actions taken ^, ^, Support visit, Training session, Meeting, +, Visit high risk, Sessions on, +, +, Others (specify), No. of participants or persons visited, +, +, ^, ^, ^, ^, CHWs, Com-munity, ^, IMM, GMP, Health education, ^, ^, ^, ^, CEN, CEN, CEN, 6PTITALIC, 6PTITALIC, 6PTRIGHT, 2, Mosa Goth, , , X, , X, , , , , MCHWVHR, ==, 93, Health talk given to pregnant women and diet info to III degree malnourished child's mother 3, Babu Jo Goth, , X, , , , , X, , , TSSCMP, ==, 12 7, 4, Ali Goth, X, , , , , , , , , SV, =, 3, 5, Allah Goth, , , , X, , , , , , CM, =, <%-4>10<%0>, 6, Nathan G., , , , , X, X, , , , VHRSI, ==, 211, Full term pregnant with fits,, refer to hospital 9, Palijo Goth, , , , , , , , X, , SHE, =, 12, 10, Shahjo G., , X, , , , , , , , TSMTBA, ==, 10 6, 11, Juman Jo Goth, X, X, , , X, , , , , SVTSVHR, ===, 313 3, 12, Shahi Goth, , , X, X, , X, , , , MCHWMCSIMM, ===, <%-2> 9<%0> 815, Immunized women who were present in the session and had not rec'd any 13, Shams Goth, , X, , , X, , , X, , TSVHR, ==, 10 3, Gave health talk to pregnant women 16, Mhmd Goth, X, , , , X, , , , Meeting with TBA and teachers, MTBAVHRMT, ===, 6 3 5, Prepared and gave food to the III degree malnourished child in front of his mother Exhibit 19: Target list of women to be immunized Reg.#, Name, Age, Preg-nant, TT1, TT1 Date, TT2, TT2 Date, Booster, Booster Date 90001A, Shahida Akhtar, 18, , N, / /, , / /, , / / 90002F, Shohida, 36, , N, / /, , / /, , / / 90008F, Husnera, 15, , N, / /, , / /, , / / 90009A, Fatema Begum, 25, , N, / /, , / /, , / / 90012C, Nurjahan, 27, , N, / /, , / /, , / / 90013A, Razia, 18, , N, / /, , / /, , / / 90014F, Monni, 19, , N, / /, , / /, , / / 90015A, Nayama Chowdhary, 45, , N, / /, , / /, , / / 90016D, Mazeda Chowdhary, 34, , N, / /, , / /, , / / 90017C, Halima Karim, 25, Y, Y, 02/31/91, N, / /, , / / 90018D, Ruma, 27, , N, / /, , / /, , / / 90019A, Runa, 23, , N, / /, , / /, , / / 90020A, Rita Ahmad, 45, , N, / /, , / /, , / / 90021A, Arifa Ahmad, 34, , N, / /, , / /, , / / 90022C, Jiauan Naher, 24, , Y, 15/01/92, N, / /, , / / 90024F, Rupaili, 34, , N, / /, , / /, , / / 90025A, Meheri Banu, 23, , N, / /, , / /, , / / 90031A, Nagwa Mata, 33, , N, / /, , / /, , / / 90035A, Fatema Bebum, 23, , N, / /, , / /, , / / 90037A, Jesmin Sultanta, 34, , N, / /, , / /, , / / 90038A, Hushneara, 19, Y, Y, 01/01/90, Y, 10/01/90, Y, 15/02/92 90043S, Rezia, 17, , N, / /, , / /, , / / 90047S, Jaahanara, 23, , N, / /, , / /, , / / 90048S, Bebum, 24, , N, / /, , / /, , / / 90049A, AImina Arahiim, 16, , N, / /, , / /, , / / 90050A, Shilashen, 23, , Y, 20/03/91, Y, 30/06/91, Y, 01/10/92 90051A, Farhana Karim, 19, , N, / /, , / /, , / / 90052A, Afsana, 34, , N, / /, , / /, , / / 90055D, Shana, 27, , N, / /, , / /, , / / 90059A, Rubina, 46, , N, / /, , / /, , / / 90067A, Shanjida, 19, , Y, / /, Y, / /, , / / 90070S, Momitaz, 17, , Y, 01/01/89, Y, / /, N, / / 90073A, Peyara, 25, , N, 10/06/91, , / /, N, / / 90075A, Shahida, 31, , Y, / /, , / /, , / / Determine client load. You should project utilisation or demand for various PHC services for a specific time period (month, year, etc). You can base your projections on clinic records from recent years or on community surveys. Keep in mind that demand for services can be influenced by many factors internal and external, to the PHC programme. For example, a new mass media initiative, a social marketing programme, the establishment or closure of another nearby clinic, or a new market place can all positively or negatively influence demand in your area. Some influences cannot be foreseen, so you should plan within a range. Once you are satisfied that your range realistically reflects the current situation and foreseeable influences, this information can be used to estimate requirements for manpower, equipment, and supplies. You can calculate demand for services or project client load using the following two methods: Method 1 - The average number of patients/clients expected to come for the various services in a given month can be determined from past records and/or community surveys (Module 2). Example: If there are 200 pregnant women in a catchment area and past records show that 30% of them come for ANC on a monthly basis, 10% come occasionally, and the rest do not come, the expected ANC visits for the month would be between 60 to 80. Method 2 - Some people recommend that an arbitrary figure of one adult visit and three child visits per person per year can be used to calculate the clinic load. Example: If the catchment area population consists of 9,000 adults and 1,000 children, the total number of visits at the clinic per year would be: 9,000 adults x 1 visit/person/year 1,000 children x 3 visits/child/year Total clinic load (#visits/year) Look for patterns of fluctuations in client load by days of the week, months, or seasons. For example, market days, religious periods, or planting seasons may prevent clients from seeking service. You should make optimum use of your resources by making them most available when demand is highest. Try to plan other nonservice activities, such as training or inventory, during these low demand periods. Determine staff capacity. Looking at past experience, one can determine on an average how many patients/clients can be seen by the service provider on any one day for the various services. Using this average, the number of clinic days needed for the services can be calculated. Example: If from past experience we see that a CHN or an LHV takes about 15 minutes to see one ANC case, and that 20% of the ANC cases seen by an LHV or a CHN have to be referred to a doctor, and that the doctor takes about 10 minutes to see a referred cases, then to see 80 cases in a month we would need; LHV/CHN's time: 4 cases/hour at 15 minutes/case 4x8 hours = 32 cases/day 80/32 = 2.5 days Doctor's time: 6 cases/hr at 10 minutes/case 20% of 80 = 16 patients 16/6 = 2.7 hours Determine resource requirements. The average yearly requirements for drugs, supplies, and other resources can also be determined using past experience. You should determine the average requirement per case and then determine the current year's requirements based on your projection of client load, which was calculated in the previous step. For example, if you determine that the clinic will receive an average of 200 family planning clients per month who require (based on last year's demand) 144 condoms per client per year, your projected yearly requirement would be about 2,880 (200 clients x 144 condoms/client/year). Again, keep in mind other factors that which could increase or decrease your estimated demand. Determine availability of resources. When determining availability of resources, keep in mind all health services as they often involve the same resources. For example, besides seeing patients, a nurse may supervise/support field workers, make reports, etc. Different clinics often must be run in the same limited space, making lack of space a problem. Therefore, different clinical services (ANC, immunization, curative care, etc.) may have to be provided on separate days and the availability of resources may have to be determined by the day of the week. Compare availability with need and identify an optimal solution. The optimal solution is one that best addresses the service need, given the resources available. You should not expect to meet 100% of the need but should look for ways to adjust your service delivery to meet as much of the need as possible without sacrificing the quality of your programme. These adjustments may be long-term (if funds are not available), while others may be short-term (if, for example, trained workers are not available and the training can be done in a few months). Example: In the example shown in Exhibit 13, 80 ANC cases per month are expected, and if staff capacity is as shown, 15% (three days) of the CHN's time and 3% (five hours) of the doctor's time will be needed to see these cases. Looking at all the other activities of the staff, the CHN is available for three days and the doctor for five hours in a month to see ANC cases; therefore, there is no problem. However, if they were not available, the reasons would have to be identified and the solutions found. Funds may be available to hire only one LHV rather than two, and the CHN may have to spend time supervising the CHW; therefore, compromises would need to be made. Outreach programmes could be decreased, volunteer manpower could be identified, or curative care clients could be referred to other centres, etc. If trained manpower is not available, local manpower could receive more training, etc. Develop tools to plan clinic-based activities. The final step in the planning process is to develop tools to record information which can help in the monitoring process as well as in the making of future decisions. The information needed for clinic-based services could contain: A weekly timetable: (See Step 6). This can be developed based on expected patient load for a particular service and the availability of personnel. Individual medical records: The record gives the health provider the information he needs for patient care. It often has two formats. The first is for each encounter (see Exhibit 20), and the second summarises all of an individual's encounters (see Exhibit 21). Blank forms are provided in Appendix E. Daily clinical treatment record: (See Exhibit 22). This can be designed to show the general profile (age, sex, diagnosis, etc.) of all clients who visit a clinic each day. It helps to determine client load in a specified period. The pattern of diseases or the services that people require will be demonstrated through this format. A blank form is in Appendix E. Drug dispensing form: (See Exhibit 23). This lists the drugs available at the centre at the the beginning of the month (which is the balance left over from the previous month), the amount received during the month, the amount dispensed on each day of the month, and the balance at the end of the month. A tabulation at the end of the month would help to determine the type of drugs and quantity needed for the following month (see Appendix E for a blank form). A similar format can be used as a daily record with the amount dispensed against each patient if needed. Similarly, records could be developed for other issues that the PHC team or manager identify as crucial to setting up and monitoring a programme. Exhibit 20: Individual medical record INDIVIDUAL MEDICAL RECORD, + (Fill this form for every encounter), + Name: , Date of visit: 1. History: , 2. Physical examination: T: P: BP: R: , + 3. Assessment:, 4. Plan: Investigation:, Treatment: Exhibit 21: Individual medical record Household #: Individual #: Medical record#: (for unregistered only), +, +, +, +, +, +, +, +, +, +, +, +, +, +, +, +, +, +, Patient Name: Father/husband name:, +, +, +, +, +, +, +, +, +, +, +, , , , , , , , Date of birth: Sex (M/F): Height: Weight:, +, +, +, +, +, +, +, +, +, +, +, +, +, +, +, +, +, +, + Past history: Diagnosis Hospitalisation Medication, +, +, +, +, +, +, +, +, +, +, +, +, +, +, +, +, +, +, + , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , Drug allergies: Y/N (specify):, +, +, +, +, +, +, +, +, +, +, +, +, +, , , , , , Family history (check appropriate boxes):, +, +, +, +, +, +, +, +, +, +, +, +, , , , , , , Personal history (check appropriate boxes):, +, +, +, +, +, +, +, +, +, +, , , , , , , , , Smoking Alcohol Drug use Occupation, +, +, +, +, +, +, +, +, +, +, +, +, +, +, +, +, , , ^, ^, ^, ^, ^, ^, ^, ^, ^, ^, ^, ^, ^, ^, ^, +, +, +, +, + , VISIT DATES, , , , , , , , , , , , , , , , , , 1, Tuberculosis, , , , , , , , , , , , , , , , , , 2, Polio, , , , , , , , , , , , , , , , , , 3, Diphtheria/pertussis/tetanus, , , , , , , , , , , , , , , , , , 4, Measles, , , , , , , , , , , , , , , , , , 5, Mumps, , , , , , , , , , , , , , , , , , 6, Malnutrition, , , , , , , , , , , , , , , , , , 7, Diarrhoea/dysentary, , , , , , , , , , , , , , , , , , 8, Intestinal parasites, , , , , , , , , , , , , , , , , , 9, Hepatitis/jaundice, , , , , , , , , , , , , , , , , , 10, URTI, , , , , , , , , , , , , , , , , , 11, Pneumonia/bronch. (LRTI), , , , , , , , , , , , , , , , , , 12, Other LRTI/asthma, , , , , , , , , , , , , , , , , , 13, Skin problems, , , , , , , , , , , , , , , , , , 14, UTI, , , , , , , , , , , , , , , , , , 15, Fever >> five days, , , , , , , , , , , , , , , , , , 16, Pregnancy-related problem, , , , , , , , , , , , , , , , , , 17, Anaemia, , , , , , , , , , , , , , , , , , 18, FP complications, , , , , , , , , , , , , , , , , , 19, Gynaecological problems, , , , , , , , , , , , , , , , , , 20, Hypertension/ischaemic, , , , , , , , , , , , , , , , , , 21, Diabetes, , , , , , , , , , , , , , , , , , 22, Musculoskeletal disorders, , , , , , , , , , , , , , , , , , 23, Mental illness, , , , , , , , , , , , , , , , , , 24, Dental problems, , , , , , , , , , , , , , , , , , 25, Eye problems, , , , , , , , , , , , , , , , , , 26, Errors of refraction, , , , , , , , , , , , , , , , , , 27, Ear problems, , , , , , , , , , , , , , , , , , 28, Accidents/injuries, , , , , , , , , , , , , , , , , , 29, Handicaps, , , , , , , , , , , , , , , , , , 30, Other, , , , , , , , , , , , , , , , , , Exhibit 22: Daily clinical treatment record Name of clinic: Mt. Vernon Date: 28 Nov,, 1992 MO/CHN: Pamela, +, +, +, +, +, +, +, +, +, +, +, + Registered, +, +, +, +, +, +, +, +, +, +, +, + , , 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, Total Household No./Reg. No. , +, 146, 128, 62, 243, 416, 24, 518, 661, 84, , ID #: , +, 238, 216, 45, 306, 610, 47, 618, 721, 96, , M=4 Sex: M/F, +, F, M, M, M, F, F, M, F, F, , F=5 Age Years >> 1, +, , , X, , , , X, , , , 2 1-5, +, , X, , , X, , , X, , , 3 6-15, +, , , , , , , , , , , 16-49, +, X, , , , , X, , , X, , 3 Over 49, +, , , , X, , , , , , , 1 Routine ANC, +, X, , , , , X, , , X, , 3 Routine well-baby, +, , , X, , X, , X, , , , 3 1, Tuberculosis, , , , , , , , , , , 2, Polio, , , , , , , , , , , 3, Diphtheria/pertussis/tetanus, , , , , , , , , , , 4, Measles, , X, , , X, , , X, , , 3 5, Mumps, , , , , , , , , , , Other diseases, +, , , , X, , , , , , , 1 6, Malnutrition, , , , , , , , , , , 7, Diarrhoea/dysentary, , , , , , , , , , , 8, Intestinal parasites, , , X, , X, , , , , , 2 9, Hepatitis/jaundice, , , , , , , , , , , 10, URTI, , , , , , , , , , , 11, Pneumonia/bronch. (LRTI), , , , , , , , , , , 12, Other LRTI/asthma, , , , , , , , , , , 13, Skin problems, , , , , , , , , , , 14, UTI, , , , , , , , , , , 15, Fever >> 5 days, , , , , , , , , , , 16, Pregnancy-related problem, , , , , , , , , , , 17, Anaemia, , , , , , , , , , , 18, F. P. complications, , , , , , , , , , , 19, Gynaecological problems, , , , , , , , , , , 20, Hypertension/ischaemic, , , , , , , , , , , 21, Diabetes, , , , , , , , , , , 22, Musculoskeletal disorders, , , , , , , , , , , 23, Mental illness, , , , , , , , , , , 24, Dental problems, , , , , , , , , , , 25, Eye problems, , , , , , , , , , , 26, Errors of refraction, , , , , , , , , , , 27, Ear problems, , , , , , , , , , , 28, Accidents/injuries, , , , , , , , , , , 29, Handicaps, , , , , , , , , , , 30, Other (Specify), , , , , , , , , , , Exhibit 23: Drug supply record (continued, page 61) Name of centre:, +, +, Previous balance, Rec'vd, Total, Date, +, +, +, +, +, +, +, +, +, +, Issued, Balance, Cost 1 , Acetyl Salicylic Acid Tab. 300 mg, +, , , , , , , , , , , , , , , , , 2 , Aluminum and Magnesium Hydroxide Tabs., +, , , , , , , , , , , , , , , , , 3 , Aminophyllin Tab. 100 mg, +, , , , , , , , , , , , , , , , , 4 , Benzyl Benzoate 25% solution, +, , , , , , , , , , , , , , , , , 5 , Betamethasone Cream, +, , , , , , , , , , , , , , , , , 6 , Buscopan 10 mg Tabs., +, , , , , , , , , , , , , , , , , 7a, Chloramphenicol Eye Ointment, +, , , , , , , , , , , , , , , , , 7b, Chloramphenicol Syrup, +, , , , , , , , , , , , , , , , , 7c, Chloramphenicol Capsule, +, , , , , , , , , , , , , , , , , 7d, Chloramphenicol Eye Drops (Btls), +, , , , , , , , , , , , , , , , , 8a, Chloroquin Syrup, +, , , , , , , , , , , , , , , , , 8b, Chloroquin Tab. 250mg, +, , , , , , , , , , , , , , , , , 9a, Cotrimoxazole (Double strength), +, , , , , , , , , , , , , , , , , 9b, Cotrimoxazole Syrup, +, , , , , , , , , , , , , , , , , 10 , Chlorpheniramine Tabs. 4 mg, +, , , , , , , , , , , , , , , , , 11 , Diazepam 5 mg. Tabs (Relaxipam), +, , , , , , , , , , , , , , , , , 12a, Ferrous Sulphate Tabs. 200 mg , +, , , , , , , , , , , , , , , , , 12b, Ferrous Sulphate Syrup, +, , , , , , , , , , , , , , , , , 13 , Folic Acid Tabs. 5 mg, +, , , , , , , , , , , , , , , , , 14 , Gradinal Sodium Tabs. (Phenobarb), +, , , , , , , , , , , , , , , , , 15 , Gentian Violet 1% Aqueous Solution, +, , , , , , , , , , , , , , , , , 16 , Mefanamic Acid Tabs. (Ponstan), +, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , +, Previous balance, Rec'vd, Total, Date, +, +, +, +, +, +, +, +, +, +, Issued, Balance, Cost 17 , Metronidazole Syrup, +, , , , , , , , , , , , , , , , , 17a, Metronidazole Tab. 200 mg, +, , , , , , , , , , , , , , , , , 18 , Neomycin and Bacitracin Oint. Skin 15 mg, +, , , , , , , , , , , , , , , , , 19 , Nystatin Vaginal Pessaries, +, , , , , , , , , , , , , , , , , 20 , Nystatin Oral Drop (Nilstat), +, , , , , , , , , , , , , , , , , 21 , Otosporin Ear Drops, +, , , , , , , , , , , , , , , , , 22 , Oxytetracycline Tab. 250 mg, +, , , , , , , , , , , , , , , , , 23a, Paracetamol Tab. 500 mg, +, , , , , , , , , , , , , , , , , 23b, Paracetamol Syrup, +, , , , , , , , , , , , , , , , , 24a, Phenoxymethyl penicillin Tabs. 250 mg, +, , , , , , , , , , , , , , , , , 24b, Phenoxymethyl penicillin Syr. 250 mg, +, , , , , , , , , , , , , , , , , 25 , Pyrantel Pamoate susp., +, , , , , , , , , , , , , , , , , 26 , Theophyllin Syr. 150 mg/ 5 ml, +, , , , , , , , , , , , , , , , , 27 , Whitefield's Ointment in kg, +, , , , , , , , , , , , , , , , , , , +, , , , , , , , , , , , , , , , , , SIGNATURE OF ADMINSTRATIVE ASSISTANT/CLINICAL ASSISTANT:, +, +, +, +, +, +, +, +, +, +, +, +, +, +, +, +, +, +, + Step 5: Develop job descriptions and recruit staff Skip this step if: Your programme is already set up and you already have work plans for each staff member Review this step if: Your job descriptions are out of date They are not on a programme list The purpose of this step is to translate the plan for PHC activities (developed in Step 4) into roles and responsibilities for individual staff. This is done by first developing a "role and tasks" list from the service plan. This list describes the tasks for each staff position and the experience and skills required. Next, the "role and tasks" list is used to develop job descriptions for each position. After these job descriptions are reviewed and approved, they can be "posted" or advertised as "job announcements." Candidates can then be recruited, interviewed, screened, and selected according to your organisation's regular procedures. The purpose of a job description is to: Describe the roles and tasks that staff need to carry out to help the programme achieve its objectives; Identify the experience, skills and knowledge needed to carry out the tasks; and Ensure that management and staff have a mutual understanding of these expectations. Sub-steps for developing a job description and recruiting staff are listed below. Develop a "role and tasks" list Identify programme activities/tasks for each staff position Identify skills/experience needed for each staff position Prepare job descriptions Assignments, tasks Personal skills/experience requirements Post job announcement and recruit, screen, and select candidates Agree with selected candidates on role and task expectations Develop role, tasks and skills list The first step is to translate the programme plan for clinic and outreach services into staff assignments. Programmes are usually subdivided into components (ORT, ANC, planning, etc.), which are subdivided into activities and tasks. These tasks are the basis for developing job descriptions. Exhibit 24 illustrates a role and tasks list that management can use to produce this information. Notice how it includes the programme's goals, service objectives, and service strategies. This is included to ensure that management defines roles and tasks that are consistent with the programme's goals, objectives, and strategies. A blank worksheet is found in Appendix E. Exhibit 24: Role and tasks list PHC programme goals: , +, , , 1., To improve the health status of mothers and children of under five years of age., +, +, + 2. , To reduce the IMR by 10% in two years., +, , Service objectives: , +, , , 1. , To increase the children in the normal category by 20% in two years., +, +, + Strategies: , +, , , 1. , Growth monitoring during monthly home visits., +, +, + 2. , Vaccination of children and married women. , +, +, + 3. , Provision of health education on family planning,, breast feeding,, control of diarrhoeal diseases., +, +, + Position title, Role, Tasks , Experience, Ability/skills CHW, To provide services and monitor women and children in her assigned target area., During home visits and at PHC educate and promote health by: >> growth monitoring >> health education:, Not necessary but know community dynamics , Communication skills. Interest in conducting health education sessions , , nutrition, , , , use of ORS solution, , , , breast feeding, , , , immunization, , , , family planning, , , , personal/public cleanliness, , , , identifying at-risk patients and referring to PHC programme, , , , >> recording/compiling info on:, , , , family folder, , , , growth cards, , , , CHW daily activity register, , , , >> attending ongoing education classes on health, , , , , , , , , , , , , , CHN, Training,, super-vising and sup-porting the CHW in providing both preventive and curative health care and assisting them in providing basic health services, Provide services:, Two years experience in community work, Conduct health education. Know local languages , ^, * vaccination * family planning * basic curative care * antenatal care, ^, ^ , ^, Supervise CHWs and TBAs by doing home visits, , , ^, Assist in continuing surveillance through MIS, , , ^, Provide on-the-job training and continuous education to the CHWs and mother, , , , , , CHD, Co-ordinate and monitor the performance of the entire PHC programme and formulate action plans, Provide integrated maternal health care, 6 month house job in * medicine, Conduct health education. , ^, Identify and analyse the present health problems of the community, paeds obs/gyn, Attend community meetings ^, Set goals,, prepare plan of action and implementation strategies, Some experience working with community, , , Liaison and maintain co-ordination with the community leaders,, govt. and non-govt. agencies for designing,, implementing and maintaining community-based primary health care, , , , Monitor progress by using information collected through the MIS and prepare annual progress report., , , , Provide ambulatory care, , , , Organic continuing education programmes , , Exhibit 25: Job description and announcement 1. POSITION TITLE, 2. POSITION STATUS, DATE OF PREPARATION CHW, 2.1 Full-time a. Permanent 2.2 Part-time b. Temporary, 25 Feb. 1992 4. POSITION SUMMARY To provide services and monitor the women and children in designated areas, +, + 5. REPORTS TO Community health nurse, 6. POSITIONS DIRECTLY SUPERVISED BY INCUMBENT None, + 7. SPECIFY REQUIREMENTS:, +, + 7.1 Education/professional qualifications, +, + , +, + 7.2 Experience and training, +, + Not necessary,, but a knowledge of community dynamics would be desirable, +, + 7.3 Knowledge,, skills,, ability, +, + Communications, +, + Ability to conduct health education sessions, +, + , +, + 8. DESCRIPTION OF DUTIES/RESPONSIBILITIES:, +, + , +, + List duties under two separate headings: REGULAR DUTIES and PERIODIC DUTIES:, +, + ^, ^, ^ During home visits and at PHC,, educate and promote health through:, +, + A. REGULAR DUTIES/RESPONSIBILITIES, +, + Growth monitoring, +, Health education on nutrition,, use of ORS,, breast feeding,, immunization,, family planning personal/public cleanliness,, identifying at-risk patients and referring them to PHC programme, +, + Recording and compiling information on family folders,, growth cards,, CHW daily activity register, +, + , +, % TIME SPENT B. PERIODIC DUTIES/RESPONSIBILITIES:, +, 30% GM Attend ongoing education classes on health, +, 30% Health education 9. PREPARED BY: , 10. REVIEWED BY:, 20% Recording Jazmi Hosein, Izhar Sheraz, 20% Ongoing education Prepare job descriptions and do feasibility checks The next step is to develop individual job descriptions for each position, drawing on the roles, tasks, experiences, and skills summarised in the role and tasks list. Most agencies have their own formats for job descriptions, and the roles, tasks, experience, and skills can be adapted to fit within any particular format. Exhibit 25 illustrates an example of a job description for a CHW position ( see Appendix E for a blank form). Before these job descriptions are finalised and submitted for approval, it is a good idea to conduct a "feasibility check" to make sure that the tasks are feasible and the requirements are realistic. Some test questions are shown below. Does the job description adequately reflect programme needs? Does the job description include all necessary activities/tasks? 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? If any problems are identified that would make the job description unfeasible then it should be altered accordingly or the problems should be dealt with before candidates are recruited. Post job announcement and recruit, screen, and select candidates After the job description has been approved according to the agency's procedures, a job announcement can be posted or advertised. That announcement should be based on (or be identical to) the job description itself. Recruitment, screening of candidates, and selection would follow normal agency procedures. Agree with selected candidates on role and task expectations One step that is very important is for the manager and immediate supervisor to sit down with the selected candidate and discuss the job description openly and frankly. The purpose of this meeting is to clarify expectations on both sides: what management expects from the staff member, and what the staff member understands to be the role and tasks of the job. This will lead to the next portion of the process, described in Step 6: Develop individual work plans and schedules. Step 6: Develop individual work plans and schedules Skip this step if: Your programme already uses a performance-based assessment system Review this step if: Your staff work plans are out of date They are not based on priority project tasks, or You have household registers, but no system for setting priorities. The purpose of this step is to translate the individual job descriptions (developed in Step 5) into specific work plans for each staff member. Individual work plans should be based on: 1) the programme's clinic and outreach service plans (Step 4) and: 2) each person's job description (Step 5). Work plans list all planned activities, their sequence, the time when they should begin and end, the resources that will be needed to carry them out, and the person responsible for each task. Step 4 showed how valuable information on service demand and needs could be compiled in registers. It also showed how targets could be computed for field workers. That information is used to identify the numbers of people who will probably need services, and those who are high-risk and deserve special attention. It can also be used to estimate the numbers of people who will need to be served each week or month. Individual work plans would take that information into account in determining how much time each staff person would spend on each task, at the site, and with each targeted individuals. In most cases, each staff member should develop an annual plan that coincides with the programme's annual plan, and a second plan that is used to schedule monthly, weekly, or even daily activities. These plans may be developed individually, or in a group, depending on how much one person's plans affect another's. Often, the process of planning is as important as the plan. Work planning helps everyone to know what everyone else is doing and can be an effective tool for building team spirit and co-operation. Advantages of work plans There are many advantages to work planning, for the project, the team, and the individual: To make sure that planned project activities are carried out To make sure that they are carried out in the correct sequence To make sure that priority tasks are carried out first To help the staff manage its time efficiently To maximise programme impact To enable staff to coordinate their work with one another To facilitate monitoring of programme and individual performance. Step 7 in this module describes how performance assessment can help to improve a programme's effectiveness. Good, realistic work plans are the key ingredient of successful performance assessment. That is because the plan is an obvious and convenient tool for monitoring progress, identifying problems, determining needs for change, and replanning. Work plans usually list tasks in some sort of order of priority. This allows the supervisor and worker to agree on high-priority tasks and to focus more attention on monitoring those tasks. The key concept here is to always focus attention on those tasks that are essential to the programme's objectives. Principles of good work plans Good individual work plans include the same elements as good project plans: A clearly stated purpose or objective A list of all activities or tasks that must be carried out to achieve the objective Specification of the priority tasks and activities A specific time frame for starting and completing all tasks Clear indicators for measuring progress Specification of resources needed to carry out the work. Work plans should be written out. That increases commitment to, and understanding of, the work to be carried out. It also helps to summarise the plan in a chart, calendar, or graph that reflects the passage of time. That makes it easier to monitor progress. Exhibit 26: Excerpt from a staff work plan WORK PLAN Name of person preparing workplan: Josephine Baker Performance period: November 1, 1992 - October 31, 1993 Task No. 1 of 3 Statement of task assignment: Conduct routine and special home visits to all eligible households in areas C and D. Key Sub-tasks and deadlines: 1. Build awareness of PHC services, advantages, how to get to them 2. Motivate eligible women to accept and use GM, immunization, ANC, FP, ORT 3. Identify and follow-up high-risk mothers and children 4. Refer pregnant women, malnourished children and others as approriate to the health centre 5. Conduct village meetings on PHC Performance expectations, standards of performance: 1. Awareness will increase to 90% of households by the end of 1993 2. Acceptance and continued use of PHC services will reach the same level as for the programme 3. All high-risk mothers and children in the area will be identified and referred - no avoidable deaths will occur 4. All high-risk mothers and children will be visited at least monthly 5. At least one community health meeting will be held each week. Name of supervisor on this task: Mustafa Bustamante Workplan approved by supervisor: M. Bustamante Date:1/11/92 Prepare a workplan with your supervisor. Prepare a separate plan for each task. List the major sub-tasks and performance expectations for each sub-task. There are no set number of sub-tasks, but 3-5 is common. Each time you are given a new task, you should prepare one of these work plans. Scheduling of work There are hundreds of variations of work plans, most of which include the elements described above. The difference is usually in formatting and emphasis. Some plans emphasise time, others emphasise tasks. The following examples illustrate both approaches. Gantt charts The Gantt chart is one of the oldest and most useful tools for summarising work plans. In PHC it is especially useful for summarising an annual, semi-annual, or quarterly plan. All major project activities can be displayed together with a schedule and persons responsible. These charts are also useful for special projects, such as research and training projects. An example is shown below. Exhibit 27: Gantt chart of research project , Months, +, +, +, +, +, +, +, +, + Baseline studyactivities, Jan, Feb, Mar, Apr, May, Jun, Jul, Aug, Sep, Oct 1. Plan survey, XXXXX, +, +, , , , , , , 2. Design forms, , , XXXXX, +, , , , , , 3. Recruit interviewers, , , XXXXX, +, , , , , , 4. Train interviewers , , , , XXXXX, +, +, , , , 5. Conduct survey , , , , , XXXXXXXXX, +, +, +, , 6. Data entry and analysis, +, +, , , , , XXXXXX, +, +, 7. Feedback to team, , , , , , , , XXXX, +, 8. Final report, , , , , , , , , XXXX, + Time and task charts These charts are especially useful for short-term planning of a week or month. Both charts are self-explanatory. The first emphasises time. The left column lists the hours in a day, and the rows show the days in a week or month. The chart can be modified for any time schedule: 1/4 hour, 1/2 hour, etc. on the vertical axis; Monday-Friday, Sunday-Saturday, Day 1-31, etc., on the horizontal. Exhibit 28: CHN weekly workplan and schedule Time, Monday, Tuesday, Wednesday, Thursday, Friday 07:00, , , , , 08:00, Gen clinic, Community , Prenatal, Immuniz., Com ed 09:00, , health ed, , , 10:00, , , , , 11:00, Reports, , Reports, Reports, 12:00, Lunch, Lunch, Lunch, Lunch, Lunch 13:00, PHC meet, Continued, Home visit, Lane meet, Reports 14:00, , , , , 15:00, Home visit, Home visit, Home visit, Home visit, Home visit 16:00, (#6-17), (#18-29), (#30-41), (High-risk), (#42-50) 17:00, End, End, End, End, End 18:00, , , , , 19:00, , Community, , , 20:00, , Meeting, , , The second version shows the tasks on the vertical axis instead of time. The days are placed on the horizontal axis, as before. Exhibit 29: Biweekly CHN workplan and schedule Tasks: July 1-12, +, Days, +, +, +, +, +, +, +, + , Mo, Tue, We, Th, Fri, Mo, Tue, We, Th, Fri Gen clinic, 8-11, , , , , 8-11, , , , Community ed, , 8-12, , , 8-12, , 8-12, , , Prenatal, , , 8-11, , , , , 8-11, , 8-11 Immunization, , , , 8-11, , , , , 8-11, Reports, 11-12, , 11-12, 1-12, , 1-12, 1-12, 1-12, 1-12, 1-12 PHC meeting, 13-15, , , , , , , , , Lane meeting, , , , , , , 3-15, , 13-15, Continuing ed, , 13-15, , , , 3-15, , , , Home visits, 15-17, 15-17, 13-17, 3-15, , , , 13-17, , High-risk visits, , , , , , , , 15-17, , 15-17 Lane meeting, , , , , , , , , , Com. meetings, 19-21, , , , , 19-21, , , , Routine scheduling of CHW household visits is especially important, and the above tools can also be used for that. The following example from Pakistan illustrates how a supervisor and four CHWs might develop a coordinated schedule. Example: A CHW in charge of monitoring the health of 200 families who live in four lanes (L) also conducts lane health education sessions in her area. These are informal gatherings held outside, often in someone's front yard. It is a good way to reach small groups of neighbours. Exhibit 30: Coordinated schedules of several workers MONTH, CHW A, CHW B, CHW C, CHW D , , , , January, L1, L1, L1, L1 , Jan 5, Jan 12, Jan 19, Jan 26 , , , , February, L2, L2, L2, L2 , Feb 2, Feb 9, Feb 16, Feb 23 , , , , March, L3, L3, L3, L3 , Mar 3, Mar 9, Mar 16, Mar 23 , , , , April, L4, L4, L4, L4 , Apr 6, Apr 13, Apr 19, Apr 27 , , , , May, L1, L1, L1, L1 , May 4, May 11, May 28, May 25 There are four CHWs in the programme who conduct these sessions. The supervisor is required to be present to assist in answering questions. Thus, the supervisor and CHWs need to coordinate their schedules. The chart shows that CHW A will hold a lane session in the first week of the month, CHW B in the second week, and so on until all four CHWs have held a session in a lane. This process is repeated until all lanes have been covered. Many projects assign CHWs to cover a certain geographic area. Typically, they are expected to visit periodically all of the households in that area. What often happens is that they visit homes that are close more frequently than those that are far away. Some homes are never visited. The following schedule, which is adapted from the Swarnivar Project in Bangladesh, illustrates one way to ensure that all houses are covered on a regular basis. Assuming that the area has been mapped and each house given a number, the work plan can specify which houses to visit each day. The example shows the schedule of one CHW who visits 15-20 houses each workday. Time is also allocated staff meetings and other activities. This type of schedule can also be used to schedule selective visits to high-risk women and children, as described in Step 4. Exhibit 31: Simplified CHW monthly workplan Workplan fo