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 Editor: Jennifer Sharples, Bangkok, Thailand Design & Layout: Helene Sackstein, France Desktop Publishing: Amornphan Thongpanang, Marilyn J. Murphy, Somboon Vacharotai Foundation, Bangkok, Thailand Printing: Thai Wattana Panich, Bangkok, Thailand Published in 1993 by the Aga Khan Foundation USA, Suite 700, 1901 L Street N.W., Washington DC and the Aga Khan Foundation,P.O. Box 435, 1211 Geneva 6, Switzerland. Additional copies are available at the Aga Khan Foundation Canada in Toronto; Aga Khan Foundation (United Kingdom) in London; and AKF offices in Dhaka, Bangladesh; Delhi, India; Nairobi, Kenya; Karachi, Pakistan; Lisbon, Portugal;and Dar-es-Salaam, Tanzania; the Aga Khan University Faculty of Health Science in Karachi, Pakistan; the Somboon Vacharotai Foundation and the ASEAN Institute for Health Development in Thailand Dedicated to Dr. Duane L. Smith (1939-1992), Dr. William B. Steeler (1948-1992) and all other health leaders, managers and workers who follow their example in the effort to bring quality health care to all in need. 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 and PRICOR2. Anexperienced 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 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. 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 INTRODUCTION 1 Common problems in primary health care 3 Community organisation 3 Information, education, and communication 3 Information systems and record keeping 4 Personnel and training 4 Logistics 5 Supervision 6 MANAGEMENT FUNCTIONS: Community organisation 6 Information, education and communication 13 Information systems and record keeping 21 Personnel and training 28 Logistics 34 Supervision 35 THE PROBLEM-SOLVING PROCESS 42 Step 1: Identify select and define the problem 42 Step 2: Learn everything about the existing problem 45 Step 3: Determine the basic causes of the problem 45 Step 4: Identify all possible solutions 46 Step 5: Choose and implement a solution 47 REFERENCES 51 ACRONYMS AND ABBREVIATIONS 54 Acknowledgement The idea for this guide came from PHC managers, who requested a supplement to the PHC MAP modules that would provide practicalsuggestions for solving problems. Jack Reynolds developped the desingn for the guide, contributed the first examples, and oversaw the project throughout. Gael Murphy compiled the first material prepared by a number of URC/CHS staff. Maria Francisco and Neeraj Kak prepared a revised draft. Which was reviewed by participants at the International Conference on the management and sustainability of PHC programmes in, May 1992. They worked on revisions together with Martine Hilton to complete the final draft. Special thanks are due to Pierre Claquin of the Aga Khan Foundation,Geneva, for his support and interest; several participants of the 1992 PHC MAP Conference including Peter Mabonga and Jeddah Katimo (Mombase PHC Programme, Mombasa, Kenya), and Vijay Moses (aga Khan Health Services, India) for their suggestions on how to improve the guide; and Julia Friend for conducting the background research We wish to thank all of the managers, consultants and others with first-hand PHC experience who generously contributed their experiences and guided us to other sources. The material for the problem-solving process is based on previous material developed by URC/CHS's PRICOR and Quality Assurance projects. Introduction "There are no problems, only opportunities." As a member of a primary health care (PHC) management team, you probably encounter a number of problems that demand innovative thinking and flexibility. Many of these managerial problems willbe identified through the tools and techniques in the PHC MAP modules. The modules will also help you identify most of the solutions, as well. Many will be obvious, but sometimes it may be a real challenge to identify an effective solution that will work in your situation. As the PHC MAP modules were being reviewed and tested, many PHC management teams asked for guidelines for problem-solving. This problem-solving guide is our response to those requests. The guide has two principal sections. The first is a compendium of common problems and solutions that come from PHC managers. These are ideas and strategies that they implemented and which worked. We have arranged them under six management headings: community organisation information, education and communication information systems and record-keeping personnel logistics supervision Each topic is first described briefly, together with some key lessons learned. Then a common problem is described, followed by one or more suggested solutions and some examples from field experience around the world. Several problems are presented for each topic, and as mentioned, several solutions are usually presented for each problem. Altogether, there are 29 problems discussed in this guide. The following table shows how they are distributed across management topics, and the specific services from which the examples were drawn. Obviously, the problems and solutions described could apply to a number of services. General Immunisation ORT Family planning Growth monitoring Breast feeding nutrition Community organisation 1,2,3, 4 Information education, communication 5 6 7 8,9,10 11,12 Information systems and record keeping 13,14,15 16 17 18 Personnel and training 19 20,21 Logistics 22 23 Supervision 24,25,26 27 28,29 Numbers in the chart correspond to the number assigned to each problem in this guide. A summary listing of these problems is at the beginning of the next section. The suggestions and solutions presented in this guide come from a number of sources, including operations research studies, PHC consultants and teachers, case studies, articles, and trial-and-error experience of PHC managers. Number in parentheses refer to the sources of the information, which are listed in the References at the end of the guide. The second section describes a general approach that managers can use to analyse problems, identify root causes, and develop appropriate solutions to address these causes. This section builds on the problem identification and analysis process embodied in the PHC MAP Modules. It also includes some simple tools that you and your team can use,such as brainstorming, nominal group techniques, cause-effect analysis, flowcharts, and fishbone diagrams. In presenting these problems, suggestions and practical solutions, it is our hope that programme managers, outreach, clinic and hospital-based health care providers, planners will be able to use the suggestions offered as a "springboard" for their own ideas, inspiring them to develop appropriate solutions to their own problems. Common problems in primary health care The following list summarises the problems discussed in this guide, arranged according to the six management functions described in the Introduction. This list is followed by an in-depth discussion of each problem, suggested solutions, and examples from PHC managers. Community organisation Problem 1: Even though project interventions are acceptable to individual community members, they do not want to join in activities that would support those interventions, since they perceive that they will enjoy the same benefits whether or not they themselves participate. Problem 2: Patients tend to bypass peripheral health units and seek care directly at the hospital outpatient department. Problem 3: Utilisation and support of health programmes are low. Problem 4: Family planning activities are hindered by a lack of support from influential village members who hold negative impressions of family planning based on reports from dissatisfied clients. Information, education and communication Problem 5: Parents do not recognise the need for immunization. Problem 6: Despite high recognition of ORT among mothers, key messages about preparation and administration are not being conveyed to mothers. Problem 7: Family planning messages are not well received because of strong religious influences. Problem 8: Heavy case loads limit the opportunities for education in the health centre. Problem 9: Mothers are not alert to changes in their children's weights that may signal the initial stages of malnutrition. Problem 10: Mothers do not recognise the importance or utility of growth monitoring. Problem 11: Health workers have difficulty convincing mothers of the importance of breast feeding. Efforts are often undermined by perceptions and media messages that bottle feeding is "modern" and "better." Problem 12: Supplementary feeding programmes do not reinforce behaviour change or independence. Information systems and record-keeping Problem 13: Referring providers do not learn from their referrals. Problem 14: Semi-literate CHW's cannot easily record and report information, identify needed information, or use health records to determine major health problems and the families affected by each. Problem 15: Record- keeping and reporting requirements are time-consuming. Problem 16: Poor record keeping by field workers. Problem 17: Performance records show wide variations among field workers. For example, in the same period of time, some recruit over 100 family planning adopters, while others recruit fewer than 20. Problem 18: CHW's involved in growth monitoring programmes lack interpretative skills and the supportive technical standards needed to properly respond to questions. They are not able to record weights correctly on chart and have difficulty counseling mothers effectively. Personnel and training Problem 19: High attrition rates among CHW's who suffer from a general lack of motivation and incentive to do their work, and often do not feel appreciated by the community. Problem 20: Family planning workers are not accepted by the community. Problem 21: There are not enough health workers to provide effective coverage. The programme is not having a strong impact on family planning acceptance, or on reductions in fertility. Logistics Problem 22: Refrigerator records show storage temperatures are above those required for vaccines. Problem 23: Weighing data are often inaccurate because of such factors as using inappropriate scales (such as bathroom scales). Scales are not calibrated before each weighing session, and are not set to 0 before each weighing; children are rarely fully undressed when weighed. Age reporting as well as growth plotting are often inaccurate. Supervision Problem 24: Ineffective and infrequent supervision of CHW's. Problem 25: Staff have a limited amount of time to perform duties. Coverage, and hence prevalence of family planning use, for example, suffer as a result. Problem 26: Too many tasks are assigned to CHW's. Tasks do not have a clear priority. Problem 27: Opportunities for immunization are often missed, even when a child does make contact with a health facility that is prepared to vaccinate. Problem 28: Lack of supervisory control in growth monitoring and counselling activities. Problem 29: Lack of organisation in growth monitoring/supplemental feeding projects. Management function: Community organisation Community organisation addresses the processes and institutions through which community members organise for participation in health promotion, including involvement in the decisions related to the planning, financing, construction, operation, and maintenance of a project. It emphasises the group process for learning and collective action, and is in contrast to the rapid installation approach in which groups outside the community make the majority of decisions related to the project. The benefits of this group process are not confined to improved PHC project performance or reduction in mortality and morbidity rates. The communities learn to apply lessons that they have learned to other development opportunities. 15 Programmes must involve the community in health activities to ensure that services reflect community needs and desires. In the process, it can also provide individuals with organisational and planning skills that they can apply to other development areas. As a management function, the process of community organising will vary quite extensively from one programme to another, and from one community to another. Participation in health activities is a natural outgrowth of efforts at community organisation. Throughout the modules, "community participation" has been defined as the involvement of the community in the design, planning, promotion, or delivery of health enhancing activities (see Module 7, p-11). This definition can be expanded to include not only the contributions made to establish and sustain services, but also the acceptance and utilisation of services. Successful programmes have found that the first and most essential step in initiating health programmes is to establish a positive rapport with the intended beneficiaries, keeping in mind that prior negative experiences with the health system may predispose individuals to reject new programmes.30 Increasingly, programmes are understanding the need for community participation at all levels of planning, implementation, and evaluation in order to have successful projects and outcomes. The more a community feels a sense of ownership of project activities, the more likely that project will be successful. Problem 1: Even though project interventions are acceptable to individual community members, they do not want to join in activities that would support those interventions, since they perceive that they will enjoy the same benefits whether or not they themselves participate. Suggestion A: Don't expect people to join voluntarily in health activities that benefit the community as a whole. Develop or point out appropriate incentive(s) for either community leaders, residents, or organisation members. Incentives could include such things as monetary pay, prestige, power, extra privileges, better health, and increased economic productivity. For example, a water sanitation project might expect that every family in a village would benefit if each built a latrine, ending pollution of the village water supply. But no family is likely to build a latrine by itself, and the effect on water quality would be too small. In fact, each family has an incentive not to build a latrine. An individual fanily is best off if everyone else builds one, while it retains old waste disposal practices. Such a family is a "free rider" -- it gets the benefits of cleaner water without having to bear the costs of providing it. If the latrine is seen as a source of prestige for the household, more households may aspire to having one. 17 Example: The Indonesia Rural Water Supply Project installed 100 gravity water supply systems, and a few rainwater catchment systems. The implementing agency was CARE-USA, whose development strategy stresses community involvement and fits well with Indonesia's national philosophy of self-help. CARE employed and trained Indonesian project workers who lived in the village during the construction phase, and participated in village life to draw political, religious, and other leaders into the planning and implementing activities. In each village, the details of implementation were set by a subgroup of the village community endurance institution (VCEI), a voluntary civic body found in most Indonesian communities. By tying water project. Responsibitities to the indigenous organisation, project workers encouraged the VCEI subgroup to organise neighborhoods and involve villagers in the project. In addition, the VCEI subgroups enjoyed added prestige and power. The success of the CARE community participation approach is explained largely by this strategy of using existing decision-making infrastructures, rather than creating a mechanism which would compete for human resources and power.15 Problem 2: Patients tend to bypass peripheral health units and seek care directly at the hospital outpatient department. Suggestion A:  Offer outpatient consultations only to patients who are referred by a health centre or CHW linked to that hospital. Example: In the Bwamanda Health Zone in Zaire, the zone hospital practised this policy. It had no general non-referral dispensary, for patients from the town in which the hospital was located, a separate health centre was provided 0.5 km from the hospital.34 Example: At the village health centre in a Somali project,priority was given to patients who had been referred by CHW's. This enhanced the CHW's importance in the eyes of the community, and served as a valuable teaching tool for CHW's on their referrals.3 Problem 3: Utilisation and support of health programmes are low. Suggestion A: Public displays, such as community charts and blackboards placed in a prominent location showing project achievements, can generate interest and awareness. Suggestion B: Encourage involvement in the health programme from active organisations from as many different sectors as possible, including non-health organisations that contribute in some form to the advancement of PHC. This approach could include involvement of some less obvious groups, such as school children, through school programmes. Successful projects have been those in which the community had a particular interest and a high perception of benefits. Community contributions to projects are most often in-kind services such as: provision of labour and materials for health centres, latrines, sanitation projects, constructing wells, training visits; provision and selection of volunteers to serve as CHW's; compensation of some form for CHW's; organisation and support of health committees.2 In general, projects successful in involving communities have been those: in which the major capital-investment costs of health improvement were carried by either the government or the project, but not the community; which were small scale or locally implemented, and which tended to involve one-time efforts requiring little involvement once completed; which emphasised the generation of community support and which linked the problem of sustained community participation to supervision; and in which the community perceived the health benefits to be high.2 Example: In its seven years of operation, the Togo Rural Water Supply Project installed nearly 1,000 tube wells in 745 villages and towns. A unique feature of this project was its socio-health component, which integrated community organisation and health education activities to involve villagers in installing,operating, and maintaining their wells. The field workers initiating these activities were Togolese social affairs agents. The final evaluation attributed a large part of the project's success to its community participation approach and to its careful training of the social affairs agents in health education and community organisation, of the village development committee (VDC) members in local management, and of villagers in hygiene education. In its last three years, the project broadened community participation to involve more women in decisions about the operation and maintenance of the water system. It established the position of "pump minder," in which a woman living near the well was made reponsible for oveseeing the proper use of the system and monitoring the operation of the pump. The pump minders were not only appointed by the VDC's but also became full VDC members. During the final year, an ORT project was started in villages with completed well installations. The VDC selected five women, who thereby became full VDC members, as ORT volunteers. These five women and one VDC member were then trained to give demonstrations and provide individual counseling to mothers in the preparation and administration of sugar-salt solutions for children with diarrhoea."15 Example: In the Ivory Coast, a school health education programme was initiated to improve public participation in immunization activities. A simple lesson plan was distributed to primary school teachers. Pupils were taught the need for their younger siblings and neighbourhood infants to be immunized against childhood diseases. After completing the lesson plan, the pupils carried it home together with appointment slips to have the target children immunized.16 Example: In Bangladesh, district family planning management teams consisting of health and family planning officials, community leaders, and district heads visited Indonesia's successful family planning board. These teams then designed and managed community action plans themselves. In some district programmes contraceptive prevalence rates have increased dramatically and community participation and leadership have increased. 33 Example: A research project in Bombay assessing how effective children could be as agents of change, found that children were quite successful in offering ORT in diarrhoea cases and in motivating families to accept immunization. The children organised a procession in the streets and enacted a play about the consequences of not being vaccinated. A UNICEF sticker was put on the door of each house where there was a baby up to a year of age, and the mother was encouraged to take her baby to the immunization centre. Coverage of 85% was achieved for third doses.22 Suggestion C: Reorganise the programme to intensify home visiting, making sure that support services are in place to support the anticipated increase in utilisation. Example:In the rural health zone of Katana in Zaire, a management team addressed the problem of under-utilisation, on the proviso that the solution require no new financial resources. After collaboration with local nurses, the team suggestedintensive home visiting by VHWs living in six villages. By asking the VHWs to identify women who were not in the habit of using clinic services for curative care, and then confirming the selection by consulting clinic records, 25 mothers from each village were selected to participate. A one-week training reviewed the goals and strategies, and offered a refresher course in health education techniques and messages. The nurses were advised on techniques for supervising the VHWs and were provided a newly formulated supervisory checklist to guide them in evaluating performance and offering feedback. Over the course of six months, the mothers received one home visit per month by a VHW. Each visit began with the completion of a brief questionnaire to survey the mother's current understanding of health related topics and to assess her recent participation in child survival services. Then, the VHW counseled the mother on topics such as the completion of the vaccination series, management of diarrhoea, treatment of fever, and prevention of malnutrition. Throughout the period, the local nurses conducted weekly supervisory visits to the VHW making home visit rounds. Over this six-month period, mothers' knowledge of childhood illnesses and the utilisation of child survival services improved dramatically. Utilisation of preventive services rose from 33% in the first month of the study to 88%. Similarly, utilisation of curative services rose from 26% to 72%.9 Suggestion D: Disperse service sites to increase outreach efforts. Example: In the health zone of Zongo (Zaire), an alternative strategy for increasing utilisation rates was tested. After consulting local officials, and health personnel, the zone medical officer decided to test the impact of dispersing the sites of growth monitoring and vaccination sessions. At least once a month, these services were offered by local nurses at a distance of five km or more from the health centre and from all other outreach sites. A total of 202 mothers in the catchment area of two separate health centres were surveyed both before and after the 9-month intervention period. The intervention led to increased participation in the immunization programme: from 39% to 61%. Furthermore, the outreach effort was also associated with an increase from 44% to 61% in the use of clinical services for curative care in the event of an episode of childhood illness. Finally, the dispersion of preventive services also provided additional opportunity for the identification and referral of sick children requiring treatment.9 Problem 4: Family planning activities are hindered by a lack of support from influential village members who hold negative impressions of family planning based on reports from dissatisfied clients.4 Suggestion A: Examine the quality of services and determine where they can be improved. Quality of care is increasingly being recognised as an important determinant of contraceptive acceptance and continuation. One framework for quality of family planning services emphasises six basic elements: Choice of methods: number and variety of methods offered Information given: methods available, their use, potential side effects, service arrangements, etc. Technical competence: providers' competence at performing clinical family planning services Interpersonal relations: clients' perceptions of their interactions with service providers Mechanisms to encourage continuity: media campaigns, home visits, appointments, etc. Appropriate constellation of services: convenience and acceptability of services to clients Example: A study was conducted on the impact of information given to clients on IUD continuation in Mysore, India. Women who had accepted the IUD at the Mysore branch of the Family Planning Association of India during the period from 1983 to 1986 were followed and interviewed in 1986 and 1987. Continuers and discontinuers exhibited differences that have important implications for the quality of care delivered by clinics: IUD continuers were more likely than discontinuers to have received information on side effects prior to acceptance; continuers were more likely than discontinuers to have received information on alternative methods. The 12-month continuation rate was 63% among women with incomplete information, compared with 71% among those with more complete information.29 Suggestion B: Identify dissatisfied clients and visit with them to discuss problems and provide advice or education where needed. Example: In a district of the Indian state of Andhra Pradesh, dissatisfied clients were identified and met with. Problems were discussed and resolved, when possible. Village leaders were informed of the action taken. Opposition to the programme declined over time. 26 Management function: Information, education, and communication Good communication and rapport with clients can stimulate use of services. People respond positively when they receive privacy and respect, are treated with empathy, and have their questions answered. Communication involves the sharing of ideas, knowledge, attitudes, and feelings. If efforts to communicate health messages do not achieve the results intended it may be for one of the following reasons: The message may reach only some of the target audience because few communication channels are used. For example, some health programmes may rely heavily on printed materials such as posters and leaflets, or on radio and television to reach people who have no access to these media. The message may be received but not understood. For example, the message may be expressed in the wrong language or dialect, or use inappropriate or technical terminology. The message may be received but misinterpreted and applied incorrectly. For example, mothers who are taught to use ORT may use too much water, which makes the solution ineffective, or too little, making the solution potentially dangerous. The people may receive and understand the new information but be unable to act upon it because of their poverty, or because basic services are not available. For example mass media campaigns can increase community demand for packets of ORS, but if the packets are too expensive or unavailable from the health services or private pharmacies, the money spent on such campaigns is wasted. The people may receive and understand the information, and learn a new health action correctly, but the knowledge may conflict with existing attitudes and beliefs. For example, mothers who are taught to continue feeding a child with diarrhoea may not act on this information because it conflicts with traditional belief that the stomach needs to be rested during diarrhoea. The people may receive the information but change their behaviour only temporarily because of disappointment with the results. For example, mothers may learn to prepare and administer ORT correctly but lose faith in the therapy because what they want is a treatment to stop diarrhoea quickly rather than prevent dehydration. Communication breakdowns of this kind are not inevitable. They can usually be avoided if communicators first try to understand the attitudes, beliefs and social factors that determine people's health behaviour.41 Problem 5:  Parents do not recognise the need for immunization. Suggestion A: Education campaigns can help raise awareness. In agricultural societies, one could try to educate by creating a parallel between the effort put into land or livestock and the health of their families. Example: In Yemen, there were difficulties in getting villagers to accept the need for immunization of their children. However, villagers were concerned about a sudden attack of Rinderpest disease in their cattle. Health workers recognised this concern and made arrangements for the cattle to be immunized. Once the villagers recognised the value of immunization for their cattle, there was a much greater interest in immunization for children. Example: A similar situation arose in Guatemala, where the community was more concerned about an illness among the chickens than about an illness among the chickens than about the need for medical care. Once the poultry problem was diagnosed as Newcastle disease and veterinary treatment was made available, the community became interested in its own health problems and developed its own community health programme.1 Problem 6: Despite high recognition of ORT among mothers, key messages about preparation and administration are not being conveyed to mothers. Suggestion A: Re-examine the quality and effectiveness of techniques being used to teach mothers about preparation and administration of ORT. Encourage mothers to put into practice what they have learned. Go beyond evaluating only inputs and coverage, to more thoroughly assessing and monitoring the process of service delivery. Extensive field experience with ORT has demonstrated that programme success depends on effective communication between the mother and health worker to ensure that behaviour changes. Systems analysis data revealed that health workers, whether in the home or in the health centres, frequently did not convey key messages, and that encounters were generally not used to encourage mothers to put into practice those messages that they did understand. Operations research has shown in many countries that while mothers know of ORT, few can prepare and administer it correctly. Example: An ORT programme in The Gambia used mass media to promote the use of a home-make salt-sugar solution. A common container suitable for measuring ORS ingredients was found, and mothers were told how to prepare the solution. Mothers were also told how to administer ORS, how to determine if their child was improving, and to seek help if the child did not get better. Experienced mothers who had been trained in ORT techniques flew "happy baby" flags over their homes. Mothers were told that they could go to the flag holders for help with ORT. Complementary (and pre-tested) radio, print, and face-to-face instructions reinforced one another to have maximum impact. A contest was launched, in which mothers could win small household items if they mixed the solution correctly. The names of winning mothers were entered in a grand prize drawing for 15 radios. The village turning out the most mothers for the contest each week received a 50-kilo bag of sugar and a 100-kilo bag of rice. Unlike other programmes in which the incentive was given to health workers, in this one it was given to mothers. After eight months ofpromotion and training, the number of mothers reporting using ORT climbed from 3% to 48% of all diarrhoea episodes. The number of mothers who could recite the formula rose from 1% to 64%.27 Problem 7:  Family planning messages are not well received because of strong religious influences. Suggestion A: Combine family planning efforts with other helpful information about health promotion or other health topics, such as nutrition, which may be perceived as more relevant. By demonstrating a practical link between the two topics, family planning messages may be made more "palatable." Integration of services has been shown to be more cost effective than delivery of separate services. Example: The Second Population Project, servicing 26% of the Egyptian population, integrated family planning and MCH service delivery in order to work towards its goal of reduced fertility rates. It developed an implementation strategy rooted in the Qur'an, using a combination of birth spacing and breast feeding messages with underlying health rationales. It relied upon Qur'anic injunctions requiring a woman to breast feed two full years. The project presented modern contraception as a means to ensure the necessary spacing of births. A combination of written and broadcast media as well as outreach activities were used to communicate its message, many of which indirectly introduced the concept of family planning while addressing directly the issues of the Islamic family in maternal and child health. Using a non-confrontation manner, their message was not confined to the traditional target population as defined in terms of fertility but was also directed to militant fundamentalists who might not otherwise be viewed as relevant to reproductive decision-making. Overall, the problem of implementation was approached at two levels: 1) the operational level, considering the determinants of use with their associated functional details, such as personnel, logistics, etc., and 2) the external environment, which conditions the kinds of programme implementation choices implied in the operational level of planning. 23 Problem 8:  Heavy caseloads limit opportunities for education in the health centre. Suggestion A: Institute a triage system to streamline the process and reduce "dead time." Example: A national project in Zaire, the SANRU project, developed various modifications to the Pre-school Clinic (PSC) System to allow the nurse to increase the time allotted for the examination of malnourished children and the counselling of the mothers. Two changes were proposed: 1) begin the weightings as soon as mothers arrive at the PSC session, to eliminate the "dead time" spent waiting for mothers to assemble and to ensure greater participation in the health education session, and 2) institute a system of triage, whereby nurses examine only the children whose weight had failed to progress. As part of the solution,volunteer community health workers were trained to assist with the weightings, allowing nurses to spend more time counseling the mothers of malnourished children.They found that placing the health education session in the middle of the PSC session decreased long waiting lines and improved attendance at the health education lessons. The triage of the malnourished children allowed nurses to triple the time they spent with malnourished children. Furthermore, there was a substantial augmentation in the proportion of mothers who correctly understood whether their child's weight had increased. In addition to improving the quality of services, the modifications had the surprising effect of actually reducing the average length of PSC sessions by 90 minutes.11 Problem 9: Mothers are not alert to changes in their child's weight that may signal the initial stages of malnutrition. Suggestion A:  Use cultural or traditional indicators to encourage awareness of growth. Emphasise size, using clothing as a useful indicator. With poor growth, clothes become loose around the body or are still a good fit many months later. A survey in India found that mothers used indicators for growth such as the child being heavier to lift or outgrowing her clothes. As malnutrition is not always evident to mothers, give her mental checklist of four or five key signs and symptoms to look for that serve as a cue to bring the child to the health centre such as: poor appetite, listlessness, not urinating enough, repeated colds or infections, etc. Example: It is customary in central Ghana, as in many cultures, to make a string of beads for a new-born and put it around the waist, wrist, or legs. It is intended for decoration but used by many parents to assess growth. One mother explained that by the time the child had reached the age of five months, the bead string around the waist should have been changed or adjusted five times. Other items mentioned included metal bracelets, necklaces, and finger rings.5 Problem 10:  Mothers do not recognise the importance or utility of growth monitoring. Suggestion A:  Growth monitoring activities may be too focused on weighing and plotting growth charts for data collection. There may not be enough feedback and education for the mother. Tell the mothers the results; whether their child has gained, remained the same, or lost weight. Discuss the reasons for the child's failure or success in growing. Give concrete and understandable recommendations. Involve the mother interactively in the process by: Encouraging the mother to weigh her baby herself, keep the growth monitoring card, interpret the child's growth, and act on the results. Basing interpretation and action on weight change. Weighing frequently, as often as every month or two, if feasible. Feeding back monitoring results to the mother immediately, so she can take effective action and see the impact of her actions.5 Example: Mothers often leave growth monitoring sessions without knowledge of their child's status or specific action to take. Focus on counseling skills that involve the mother to the greatest extent possible, possible. These skils can be taught in training, or by supervisory example and guidance on the job. Supervisors themselves often fail to discuss and explain issues and information with workers, setting a negative example for worker about communication and information sharing. Those responsible for growth monitoring can make it a point to provide each mother with information about her child's growth and some concrete piece of advice to follow until the next session. Several countries have successfully implemented school programmes to teach students about nutrition and growth monitoring. Students monitor their siblings' growth and help mothers adopt good nutritional practices. Problem 11:  Health workers have difficulty convincing mothers of the importance of breast feeding. Efforts are often undermined by perceptions and media messages that bottle feeding is "modern" and "better." Suggestion A:  Communicate and reinforce health messages in terms of traditional beliefs and value systems. Avoid paternalistic or threatening messages; use a positive psychology to educate. It pays to take the trouble to find areas of agreement between the various knowledge systems. Adopting new ideas is easier and more dignified if they relate to existing knowledge systems. Example: A nurse in the maternity ward in a hospital in the Yemen Arab Republic was trying to convince a mother who had just given birth, of the benefits of breast feeding. Breast milk, she explained, contained antibodies against diarrhoea, did not cost any money, was cleaner and easier than bottle feeding, and was a gift from God. The mother was bottle feeding her child and believed she did not have enough milk to breast-feed her child. At this point, another nurse came over and said to the mother, "You know, nowadays children are growing up without close bonds with their mothers because they were not breast-fed." The mother's attitude changed instantly, and she began to take an interest in the benefits of breast-feeding her child. Problem 12:  Supplementary feeding programmes do not reinforce behaviour change or independence. Suggestion A Involve mothers by setting up a nutrition fund, training them as peer counsellors, etc. Remove elements in your programme that encourage them to be passive recipients. Example: An innovative activity in a programme in Thailand has been the establishment of a nutrition fund at the village level. Each project village is given a start-up fund about US $150.00 in materials and foodstuffs to start producing supplementary food. Community members are given the opportunity to buy shares to add to the starting capital, which then entitles them to the profit generated by the sales of the supplementary food (about US $0.10 per 100-gram package). In this scheme, third degree malnourished children receive the package free. Example: A study in Togo selected mothers from among the regular participants at growth monitoring sessions at a nutrition centre group to be trained as peer counsellors. They conducted home visits to other mothers to reinforce health education messages. Prior to beginning their home visiting activities the mothers participated in a 2-day training session which covered procedures for conducting home visits and basic techniques in health education. They also learned the use of pictorial guides to help record information about messages communicated during the visit. It was concluded that mothers could help extend nutrition centre services effectively. Furthermore, mothers reported that they were more comfortable being visited by other mothers rather than by clinic staff. Suggestion B:  Recommend appropriate local foods which are already in popular use for other nutritionally susceptible groups, such as the elderly. Example: The Sarbottam Pitho Weaning Foods Project in Nepal began as a supplementary feeding programme for mothers and pre-school children. The programme was costly, experienced several distribution problems, and created undesirable dependencies. A nutrition survey was conducted to identify appropriate local foods and current infant feeding practices. The survey of weaning age children showed that all were breast feeding but that many were malnourished because they did not receive enough well-balanced supplemental foods. The investigators noticed that almost all mothers knew how to prepare a nutritious and popular traditional snack of beans and cereal grains, which were sometimes ground and mixed with milk or water to prepare a gruel for elderly people. Staff believed that a low-cost weaning food could be made in the same way. A nutritious mixture was developed, and education on its preparation and use was included in an integrated campaign to reduce malnutrition via promotion of weaning foods, ORT, and growth monitoring. Evaluations suggest there have been positive changes associated with this intervention.5 Suggestion C:  Separate food distribution activities from growth monitoring. Experience has shown that if food distribution is combined with monitoring, it will tend to take "centre stage," diverting attention from preventive/promotive aspects of the intervention. Example: The Tamil Nadu Integrated Nutrition Project (TNINP) in India experimented with innovative methods for providing food supplements, when necessary, but with a preventive emphasis. It focused on early detection of growth faltering. Monitoring was followed by various promotive activities, as well as food supplements when appropriate. Rather than focusing on older children who are easier to find but among whom malnutrition is often far advanced, TNINP concentrated on children from birth to 36 months in order to prevent poor growth. Feeding was considered to be primarily the parent's responsibility. Participation in feeding was limited to 90 days for each "admission." The food served as a supplement to help young children with faltering growth, and also provided an educational experience for the parents. The project was able to economise significantly on food costs by limiting the frequency of participation and by more selective targeting. A mid -term impact evaluation showed that during the first 3.5 years of operation, third and fourth degree malnutrition in the project block had declined 23%, while in the control block the percentage had increased 19%.27 Management function: Information systems and record keeping Management information systems provide workers, managers, donors, and community members with the information they need to plan, implement, and monitor service deliver and support activities. It is a systematic way of collecting, reporting, and using data at all programme levels, and is organised around key indicators that measure a programme's progress toward its goals. Better record keeping promotes effective supervision and monitoring, can aid in the evaluation of worker's performance, and can help monitor progress and identify problem areas. Problem 13:  Referring providers do not learn from their referrals. Suggestion A: Adapt referral forms contain a space for the hospital physician to write a brief note on the diagnosis and treatment that the patient received at the hospital. Each month, when a staff member from each health centre visits the hospital, he/she collects the accumulated forms, which have been kept separately for each clinic and distributes them to the provider who initiated the referral.34  Problem 14:  Semi-literate CHW's cannot easily record and report information, identify needed information, or use health records to determine major health problems and the families affected by each. Suggestion A:  Prepare "rainbow" family cards with coloured tabs across the top, each in a distinct colour. Example: Each coloured tab corresponds to a different condition, such as pregnancy, need for vaccination, malnutrition, etc. If a given condition is present, the corresponding tab is folded up. Otherwise, it is folded down. The cards are stored in a file box. Each month, the tabs are counted. The count indicates the relative magnitude of the problem and trends from previous months. In addition, the families with unfolded tabs can be identified for visitation by the health worker each month. This system was developed by Fondacion CIMDER, Universidad del Valle, Cali, Colombia. Suggestion B:  Make charts easier for CHW's and mothers to use and understand. Many forms are difficult to plot, read, or understand. In Mombasa, an AKF programme introduced an innovative "pictorial register" to deal with this problem. Example: In Thailand, the PHC programmc developed coloured stickers that CHWs could stick onto family folders to identify a pregnant woman, an underweight child, a with diarrhoea, etc. Example: Kenyan students were assigned to help CHW's with their recording and reporting. They also helped in case-finding and follow-up. This study fund collaboration between schools and CHW's to be the most cost-effective team arrangement for basic preventive services. School children, in addition to learning about health, helped monitor siblings and mothers needing growth monitoring and immunization. 28 Problem 15:  Record-keeping and reporting requirements are time-consuming. Suggestion A:  CHW's should collect only data that will be useful to them in performing their job. As a rule of thumb, CHW's should spend about 15% of their time on record keeping and reporting. Example:An evaluation of a programme in Karachi, Pakistan, found that health workers were spending up to 49% of their time on record keeping and reporting. The programme simplified the MIS by reducing the number of indicators to be reported on, the frequency of data collection, and the frequency of tabulation and reporting. This made information collected more useful and has significantly reduced the amount of time health staff spend on management information activities.28 Example: In India, a village record keeping and monitoring system is kept in a loose-leaf notebook. Included in the notebook are: a map of the village individual family cards, listing family members by age, occupation education and immunization status pregnancy chart for each woman receiving antenatal care weight charts for all children under five Health workers have service delivery targets, and work with their supervisor each month to prepare a report comparing actual service with targeted service. Managers are trained to look for unquantified events affecting health, such as: local employment patterns local food prices and availability localised disease outbreaks changes in the physical and/or natural infrastructure the existence of other governmental or private programmes affecting nutrition They also use monthly and quarterly reports to identify villages that: deviate from norms established by other villages, deviate substantially from their own established trends, or fail to exhibit positive improvements over a substantial period of them. Managers then visit exceptional villages to better understand successes and failures. In addition, every village conducts an annual review to asses programmes, review programme operations, and set goals and operating procedures for the coming year.24 Suggestion B: Reduce reporting requirements to include only key indicators. Example: An analysis of Thailand's PHC management system revealed that most of the PHC information from the provinces was sent to the Health Statistics Division (HSD) through a 10-page form consisting of over 200 service activities for each province. This cumbersome and expensive system of paperwork placed the greatest reporting burden on peripheral facilities. More importantly, the information flow tended to go in one direction only, from the periphery to the central level. Finally, there was little analysis of the information and therefore limited use of the data for planning or policy making and almost no feedback to the periphery. After several workshops with division managers and provincial-level staff, a provincial-level analysis of project information flow and needs was completed and several changes were made: 1) the use of coverage rates (versus counts) was endorsed as the most appropriate PHC indicators, 2) reporting frequency was reduced to no more than every four months, 3) the list of essential coverage indicators for PHC/child survival elements was reduced to seven, 4) a format for feedback reports was agreed upon, which would provide national, regional, and provincial coverage rates for all of the indicators in the system thus allowing for comparisons among provinces and within geographic regions, and allowing overall progress toward national service coverage goals to be estimated.10 Problem 16: Poor record keeping by field workers. Suggestion A:  Often data collection forms do not have enough space to write in. Some CHW's find them difficult and frustrating to use. Have forms with wider spaces to write in. Simplify record keeping to the minimum information necessary for day-to-day decision making. Example: In Honduras, it was found that not only illiterate but also literate mothers could not understand the vaccination card being used by the MOH. The script was too small, the graphics looked like a complex crossword puzzle, and some of the nurses had used roman numerals to write the dates. Even literate mothers could not tell the name or number of doses of each vaccine that had been given to her own child or that needed to be given to complete the series. When the MOH launched a new immunization campaign, it was decided that this old vaccination card should be replaced. Questions posed and answered in designing the new card were: 1) how to represent the kind of immunization needed 2) how to represent the number of doses needed 3) how to indicate when a dose had been received 4) how to indicate the date to return 5) what size should the card be. Participant observation in rural clinics and in-depth interviews with mothers helped planners understand that Honduran mothers identified the vaccine by the way it is given: if given orally, it is against polio; if a deep shot in the arm, it is against measles; if a superficial shot in the arm, it is against TB; if a shot in the hip, it is for tetanus. Of the three diseases DPT prevents, tetanus it the one most Honduran mothers remember. A new, easy-to-understand, 6-page card was designed with illustrations for each immunization, showing where the vaccination is given and the number of doses for each. On the line provided next to the illustration, the nurse now fills in with ink the date a dose is received and prints in with pencil the date the mother should return. To determine the optimal size, vaccination cards were collected from public and private institutions. The vaccination cards used by private institutions were four times larger than the card used by the MOH; about 5" x 5" versus 2" x 5." The reason given was to avoid loss of the card. To decide what size was best, the project planners following social marketing principles, turned to the consumer, mothers. Three different models were prepared for pre-testing by rural women. Both illiterate and literate mothers understood the new design, whereas only a few of the literate mothers understood the old MOH card. The mothers overwhelmingly preferred the smaller size, however, as it is easier to carry while also being easy to comprehend. Rural women in Honduras, as in many countries, carry money and valuables in a plastic bag in their brassiere where they feel it is safe. They also preferred the smaller card because it presented only one, rather than two, vaccines on a single page. Coverage for children under five for DPT III and polio increased in two years from about 55% to an impressive 78%. The new graphics of the vaccination card are believed to have contributed significantly to this increase.27 This experience suggests the following guidelines for vaccination cards elsewhere: The card must be able to stand on its own. Even if health staff have time to do a good job of explaining it at the time of vaccination, the mother must be able to comprehend it once she has returned home and time has passed. The card should show clearly four types of information: 1) which vaccines are needed, 2) the necessary number of doses for each vaccine, 3) how many of these doses have been received, and 4) when to return for the next immunization. The card should be attractive. Illustrations make the card both more attractive and help it communicate the information. The card should be culture-specific. It should be in the local language and illustrations, if used, should look like local people and adhere to cultural standards. The size should be neither too small nor too large: large enough to comprehend easily but small enough to carry easily. Problem 17:  Performance records show wide variations among field workers. For example, in the same period of time, some recruit over 100 family planning adopters, while others recruit fewer than 20. Suggestion A:  Examine the factors that could account for the variations in performance, and develop and implement changes that would raise overall project effectiveness. Example: A family planning project in rural Bangladesh, SOPIRET, conducted an OR project which identified some differences in practices between high- and low-performing field workers: high performers tended to carry more supplies with them, spent more time with non-users, were more likely to check client supplies, and visited clients more often; the low performers reported encountering considerably more religious opposition in their areas, did not cover their prescribed catchment areas, only visited current users, did not contact younger women, and did not discuss side effects. In light of these findings, SOPIRET decided to implement the following changes: provide field workers with messages and materials to respond to religious concerns, emphasise discussions of side effects, implement a uniform weekly work plan, and ask low performers to set targets for new adopters. Despite external disruptions to the programme, modest results were obtained: the CPR rose, use continuation improved, reported pregnancies dropped, and the low performing field workers halved the difference between themselves and the high performers in the frequency of visits. 37 Problem 18: CHW's involved in growth monitoring programmes lack interpretative skills and the supportive technical standards needed to properly respond to questions. They are not able to record weights correctly on charts and have difficulty counseling mothers effectively. Suggestion A:  Conduct a skills assessment of CHW's. Develop a list of skills needed. Design training to emphasise skill development (as opposed to teaching information). Provide training individually or in small groups using scenarios and role plays. Then conduct on-the-job training until skills are demonstrated properly. Have CHW's practice skills such as correct use and reading of scales, use and interpretation of growth charts, maternal counseling with actual clients. Example: The National Family Nutrition Improvement Programme in Indonesia used training techniques that involved repeated practice of the actual skills needed. It was reported that after three or four weighing sessions, community health workers with minimal education levels could accurately weigh a child in very little time. The use of the local market scale helped make this possible, as it was a familiar and appropriate technology for the workers concerned.6 Suggestion B: Develop simple job aids that will help CHW's recall points which must be discussed during counselling sessions. Example: After research and testing, the Northwest Frontier Provincial Health Service in Pakistan developed two memory aids to guide service delivery in key interventions. These aids would assist health workers to remember the relatively large number of procedures to be followed in delivering a given intervention. One of these aids consisted of a series of reference guides for each of the interventions, which were placed beneath the Plexiglas covers of examination tables. A modified outpatient dispensary slip served as a second memory aid. On this slip, health workers were to fill in or check such key tasks as taking a history, conducting a physical exam, providing treatment, and counselling patients. Follow-up study that health workers carried out diagnostic procedures with greater frequency. Counselling also seemed to improve in both content and technique. Clearly, memory aids such as these should not be construed as a panacea for resolving service delivery problems. While improvements can be made, other problems will remain. Detailed information about the types of problems that impede effective service delivery enables decision makers to implement simple corrective measures that make a difference. 12 Management function: Personnel and training Personnel management ensures that the organisation attracts and retains competent people, that staff can be productive and efficient in their jobs, and that they are recognised appropriately by the organisation for their service. Training serves to continually improve upon the knowledge, skills, and competencies of health workers so that service delivery or management activities can be carried out correctly. Problem 19:  High attrition rates among CHW's who suffer from a general lack of motivation and incentive to do their work, and often do not feel appreciated by the community. Suggestion A:  Examine locally available alternatives to increase CHW motivation and incentives. Upgrade other benefits such as opportunities for growth, increased responsibility, time off as a reward, travel to a conference, public recognition for their accomplishments, etc. CHW attrition occurs for a variety of reasons. Among them are: Low or irregular salaries. Studies of attrition rates from six USAID-supported projects suggest that attrition rates among CHW's who depend on community financing are approximately twice the rates of CHW's who receive a fixed government salary. Displeasure with limited curative role, i.e., not allowed to give injections. Community acceptance of CHW's can be strained because, while communities generally desire and expect curative care, CHW's are trained for preventive care. Lack of community respect and support. Address how CHW's are chosen, and their roles defined. Too often a CHW is imposed on a community, or a community selects one for the wrong reasons. Involve the community in choosing CHW's: make sure they understand what the CHW's role will be, and the CHW understands what the community expects. Few opportunities for training, upgrading of skills. Lack of support from the project, i.e., travel, regular visits from central staff, regular feedback, etc. Inadequate frequency and/or effectiveness of supervisory visits. Some countries have found that having the community discuss and implement financing mechanisms before the CHW is selected helps address the problem of CHW sustainability and attrition. A project in Mauritania, for example, requires villages to work out a villages to work out a viable financial plan before a selected CHW can receive training. 2 Non-material incentives are also effective: Create recognition for CHW's in their villages by having a health day at the school or church and recognise them and their efforts publicly. In some areas of Honduras, the Ministry of Health gives CHW's picture I.D. cards. These help create a sense of belonging to the institution as well as increasing their respect and position in the community. Possession of charts, pictures, and simple equipment can help CHW's communicate better as well as enhance their status. Another possibility is to routinely collect contributions to pay the CHW from the community. This can take the form of produce or in-kind services. In Swaziland, for example, the community plowed the CHW's field. At monthly meetings, teach CHW's a new concept or skill, conduct refresher courses to review knowledge and improve skills. In one case, interviewing of CHW's, community members, and supervisors led to identification of factors leading to attrition. Among them was a desire to learn more about curative services, which was incorporated in training. Career ladders are important for job satisfaction and retention. Some CHW's in Northern Pakistan have gone into training as Lady Health Visitors, while in other countries, some have become "senior CHW's" and trainers after two or three years service. When they reach this level, communities may be more willing to pay them a stipend, since this requires more work, but also because it provides them with more prestige. Provide free medical care to the CHW and his/her family. Exemption from military service. 28 Many countries also finance CHW's (partially) through: Use of drug profits; this can be problematic - profits are too small and irregular, and it encourages prescriptions Fee for service; in Bolivia and Kenya, some projects allow the CHW to charge a small fee for curative care and MCH services. Social events can help develop a sense of camaraderie and show that efforts are appreciated. Arrange to give out awards at a social event to family planning field workers with the longest continuous acceptors, or who have the most new acceptors who have been educated appropriately, or for the health worker whose clients can correctly describe how to mix ORT. Post the award in the health centre for all to see. Example:Lack of funds is obviously problematic. Ideas from a project in North-western Somalia offer some low-cost alternatives: Water tax on the village pump; a certain amount per household pays for a CHW, pump maintenance. Shop and tea shop cash collection; travellers from outside the village indirectly support community health. Insurance type collection; payment of a small fee Payment-in-kind; once-a-year livestock or grain collection. Waived village fees, e.g., for water.3 Example: A Kenyan study provided different sets of incentives to three groups. One received token payments and a newsletter, the second received community recognition and lapel pins, and the third group received all of the above as well as diplomas for "healthy households." A healthy household was defined as one in which all children under five years were fully immunized, which had a clean water supply, which maintained adequate nutritional status for children under five, and which practised family planning. The study found no difference in the performance of the different incentive groups, but all group areas showed improvement in health status.25 Suggestion B:  Keep in touch with field workers not only at regular meetings/visits but by commenting on their reports, offering praise where it is due. At monthly meetings encourage a two-way flow of information. Give feedback on the results of their work to encourage commitment to the organisation and job. Discuss performance and problems and, where possible, develop new strategies together. Feedback to workers is critical, not only to improve their morale and effectiveness, but also to give them an incentive for reporting correctly. Feedback can include: suggestions for improving record-keeping information that might be helpful in preventing or solving problems results of home visits to patients (or referrals) congratulations on doing a good job in delivering a service36 Feedback should be task-related, prompt, action-oriented, motivating, and constructive. 42 Example: Profamilia, a successful family planning project in Colombia, addressed this issue by rotating field workers into the health centre for a day so they could experience the health project from the manager's perspective and gain an understanding of the system and organisation. Problem 20:  Family planning workers are not accepted by the community. Suggestion A:  Examine recruitment procedures. People hired as field workers should be credible and acceptable to family planning acceptors. Known characteristics of the community should be considered when recruiting family planning workers. Recruitment should be done using a job description outlining what the responsibilities will be and the skills and qualifications necessary to accomplish them. Include attitudes and personal qualities you think the person should have. This will ensure that you hire someone who can do the work and with whom you can work. 42 A PHC project in two Bangladeshi upazilas found the following selection criteria of CHW's useful: CHW's should be permanent residents of the village. Avoid temporary residents and job seekers. CHW's should have good reputation in their area and be acceptable to the people in their locality. Preference should be given to traditional birth attendants, traditional healers,women, retired officers, and those who are already doing social work. Some basic education preferable. However, enthusiastic individuals active in community service can be selected even if they are illiterate. Preference is given to married women above 20 years of age. 40 Example: In Bangladesh, field workers whose characteristics are closer to those of the eligible couples in their area were found to be more effective in promoting family planning. Important characteristics matched were language, socio-economic status, and residence in the local area. Credibility is extremely important. In general, female field workers were better able to motivate and serve female clients than male clients. Projects that follow formal procedures for recruitment, promotion, and termination perform much better than those that do not follow such procedures. 38 Example:In Indonesia, it was found that at the province level, midwives were more accepted as providers of family planning services, although they needed general managerial and salesmanship training. 37 Suggestion B:  Encourage satisfied users to advocate contraceptive use. They can be especially effective as family planning promoters and contraceptive distributors. Project experience has shown that women counseled by satisfied acceptors are less likely to discontinue use than those counseled by a midwife alone; satisfied users are better able to reduce the fears of side effects. 31 Often, the adoption of a method by a charismatic and respected local person can lead to rapid dissemination of the same method in a village. Example: In Sri Lanka, satisfied acceptors with high community standing were encouraged to motivate other mothers. This approach was found to be successful and cost-effective. Satisfied acceptors were effective in counseling women who believed temporary modern methods have too many negative side effects. 37 Problem 21:  There are not enough health workers to provide effective coverage. The programme is not having a strong impact on family planning acceptance, or on reductions in fertility. Suggestion A:  Help CHW's take a selective approach to serving clients. Example: Field workers should give maximum time to top priority couples, those with three or more children, the wife being under age 35. Such couples could be marked in red on target couple registers for easy visual identification. This plan was implemented in a project in India and made a considerable contribution to the success of the project.26 Suggestion B:  Reduce client-worker ratios to increase frequency of contact. Field workers should spend more time with new acceptors. Example: In a project in rural Bangladesh, reducing the client-worker ratios enabled field workers to complete their visits on time and allowed more time to be spent with each couple. Increased home visits have been associated with increased contraceptive prevalence.21 Suggestion C:  One very effective way to increase coverage is to authorise paramedic personnel to distribute contraceptives. The use of paramedics to distribute contraceptives is beneficial for several reasons. In developing countries, they already offer fairly wide coverage of the population. Thus, once they are trained, they provide an extensive base for contraceptive service delivery. Physicians generally leave their villages to work in the cities, where the pay is usually higher, but paramedics tend to live and work in the vicinity in which they were raised. Also, because they work in the same area in which they live, paramedics often have long-standing relationships with their clients, which contributes to improved contraceptive use and longer continuation rates. Paramedics can do much to extend contraceptive use and thereby reduce the incidence of unwanted pregnancies. This, in turn, reduces medical complications, unsafe abortions, and maternal deaths. Such benefits greatly outweigh the risks attendant upon contraceptive use. Example: A pilot study in Thailand demonstrated the safety and effectiveness of allowing paramedics to dispense oral contraceptives, using a simple checklist for contraindications. Following the success of this trial, the Ministry of Public Health ruled that all auxiliary nurse midwives who had received basic family planning training were authorised to distribute the pill. This immediately increased the total number of providers offering the pill from approximately 350 to 3,500. The number of acceptors rose from only 25,000 in the three months prior to the ruling to over 35,000 in the three months afterward. One and a half years later, over 80,000 women accepted the pill in a single three-month period. 29 Management function: Logistics Logistic systems deal with the procurement, storage, and tracking of supplies and equipment in order to ensure that drugs, materials, equipment, and transportation for service delivery and support services are available. Problem 22: Refrigerator records show storage temperatures are above those required for vaccines. Suggestion A:  Have only one person be in charge of monitoring the temperature. Provide supervision to ensure this is done every day. Make sure health centre staff understand the importance of the cold chain. Have a plan for each centre to follow for power outages. Have a kerosene supply for gas refrigerators. Make one person directly responsible for cold chain maintenance. Problem 23:  Weighing data are often inaccurate because of such factors as using inappropriate scales, such as bathroom scales. Scales are not calibrated before each weighing session, and are not set to zero before each weighing; children are rarely fully undressed when weighed. Age reporting as well as weight plotting are often inaccurate. Suggestion A:  Review equipment maintenance procedures and weighing protocols. Example: In the Philippines, modest improvements were observed after maintenance procedures were developed for scales and a manual prepared for staff at health units. In-service training was conducted to improve workers' weighing technique as well as refresher training to improve weighing skills and ability to calculate age correctly. 35 Mangement function: Supervision The supervision of personnel serves many critical purposes. It ensures that staff perform their duties effectively, through support, guidance, on-the-job training, and assistance in identifying and solving problems. It is a means to motivate and boost the morale of staff; to provide continuing education and advice; to enhance field worker's credibility in the eyes of community members; to assess quality and quantity of staff efforts; and to gather other information which can be fed back to programme staff and community members. Fieldworker performance has improved when supervisors make home visits with workers and question clients about the worker's activities in the presence of the field worker, when supervisors discuss the client's problem with the field worker, and when the supervisor visits clients' homes.31 Some general strategies to consider to improve supervision: A regular village visitation programme where staff spend one full week every two months - nearly six weeks per year - in each community can be an essential part of efforts to reinvigorate health workers and restart health-related activities in the villages, if they have slackened. Regular meetings with CHW's ensure that potential problems can be handled early on. Use two-way radios, especially in isolated areas, to supervise, inform, and motivate.2 Problem 24:  Ineffective and infrequent supervision of CHW's. Suggestion A:  Supervisors should use guidelines and checklists for actual tasks performed by staff and field workers. Have supervisors emphasise feedback on technical skills rather than on administrative ones. Staff should have a job description and performance objectives to know what is expected of them and how their performance will be appraised. Conduct periodic performance appraisals to make sure objectives are met and to discuss any problems CHW's are having.42 "CHW's have been found to benefit from high quality and frequent supervision and from unusually motivated community organisations; where these have been lacking, CHW's have poor morale and high dropout rates."28 "When supervision is ineffectual or focused on clerical matters, an increase in frequency had no effect on performance." 31 Some simple tasks that can improve supervision include: revising guidelines for content and frequency of supervisory visits; identifying appropriate personnel for supervision; using standardized checklists for monitoring and forms for inventory control. Example: An operations research project in Bangladesh found that high performing supervisors: visited more homes with the field workers; asked clients whether they were screened for contraindications and had side effects explained to them; had more extensive and frequent contact with field workers; and checked on client's contraceptive supplies. Field workers in high performing programmes followed a regular visiting plan, visited homes more often, visited non-users more often, varied messages to suit the listener, promoted the advantages of contraception more forcefully, and provided more thorough information on method use and on possible side effects.37 Example: In Guatemala, the major factors for high turnover rate among CHW's and ensuing loss of community confidence were irregular and insufficient provision of drugs and lack of supervision. The dropout rate was two to three times higher among unsupervised CHW's than among those with regular supervision. In the eyes of the community, the supervised CHW seemed to enjoy increased status because of the evident link to outside expertise. Projects in Mali and Niger have also noted that for illiterate CHW's, more personal contact is indicated and that literate CHW's can be effectively supervised with a mixture of personal contact and correspondence. 2 Problem 25: Staff have a limited amount of time to perform duties. Coverage and hence prevalence of family planning practice, for example, suffer as a result. Suggestion A: Work with the staff to help them allocate their time better. Help them organise their time and maximise their efforts, including targeting of high-risk groups. Suggest that for certain activities, the CHW meet with specific groups of mothers to provide education on a common problem to save time. This will also provide an opportunity to learn different teaching skills. Example: In Bangladesh, a community-based service project active in 24 urban areas identified problems in client coverage, record keeping, planning and supervision. Three management interventions (work plans for field workers, a reduced client-worker ratio, and a simplified record-keeping system) helped improve coverage, supervision, and services, The most effective of these interventions was thought to be the work plan. Work plans expanded coverage. The new work plans set up a schedule for field workers to visit specific clients and ensured that all would be visited during a 1-2 month cycle. Most project staff and field workers understood the rational for the work plan and prepared them on a monthly basis. The main advantages were: 1) they systematised the activities of the workers; 2) they ensured regular visits to MWRA's; and 3) they facilitated supervision. The main disadvantage was "serial visiting." All women had to be visited in turn, which precluded revisits to those women who needed to be seen sooner. Better record keeping and improved monitoring. The new system was simpler and less time-consuming. The main advantages: 1) it systematised record keeping; 2) helped promote effective supervision and monitoring; and 3) helped in evaluating field worker performance. The main drawback: it didn't produce all the data needed for reports to donors. Thus, both the new and the new and the old system operated side by side, which increased the workload. Reduced client-worker ratios improved coverage. Two of the three projects that implemented this intervention hired additional field workers and adjusted some of the catchment areas to reduce the client-worker ratios. The third project increased the number of assigned couples per field worker, thus increasing the ratio. Where the ratios were reduced, staff reported that the main advantages were that: 1) field workers completed their visit cycles on time; 2) more time could be spent with each couple; 3) more low-parity women could be recruited; and 4) new acceptor targets could be more easily met. 39 Problem 26: Too many tasks are assigned to CHW's. Tasks do not have a clear priority. Suggestion A:  Institute work plans for field workers to help systematise activities and establish priorities. An effective work plan minimises travel time, maximises client contact, and systematically covers all eligible clients in the assigned catchment area. Example: A project in Bangladesh found that the work plans allowed for better supervision and organisation. A schedule was set for field workers to visit specific clients on the same day of the week at the same time. The clients can be expected to be there and they, in turn, will know when their field worker should be with them. Regular visits to clients are ensured, and supervisors know where their subordinates will be on any day of the year, providing a strong incentive for workers to make their rounds. Supervisors should occasionally accompany field workers on visits to verify that work plans are being followed and to provide guidance and on-the-job training.39 Problem 27: Opportunities for immunization are often missed, even when a child does make contact with a health facility that is prepared to vaccinate. Suggestion A: Try to identify reasons for missed opportunities. Ask yourself some questions: Is the health centre to busy? Do health personnel have to review each patient file to examine the immunization record? Do waiting times and case loads preclude attention to immunization? Can patient intake procedures be better structured to help minimise the chances of a missed opportunity? What is the best time in the visit for a child to receive immunization? Use answers to these kinds of questions to reorganise your clinic's system for immunization and patient attention. More sophisticated studies might include in-depth interviews at a clinic, health workers' interpretations of national EPI policies, observations about how health workers calculated ages and dose schedules, and observations of clinic organisation and supply systems. Example: In Lagos, Nigeria a paediatric clinic reorganised itself to reduce waiting times by setting up a separate vaccination station and then vaccinating all sick children after they had received treatment for illness. Coverage rates accelerated with no increase in cost, and staff work load decreased because staff no longer had to do a full medical history and examination to prepare for vaccinations. Waiting time for sick patients fell as the ones coming for vaccinations only were served separately. 19 Example: The EPI in Mozambique reclassified its immunization schedules and reorganised its clinics so that vaccinations are now given at the time a child registers; seriously sick children are vaccinated before leaving the clinic or soon after a required hospitalisation.19 Example: The village health centre personnel in some rural health centres in Honduras will not provide consultations unless the mother presents the child's vaccination card for verification. Children who are missing vaccinations are easily identified, and the importance of immunization is emphasised at each visit. Example: At a health centre in Manila, a campaign was started that introduced changes designed to reduce missedopportunities:1) measles vaccination was made available for use at least once a week in every health facility, and the health facility remained open until 8 p.m. to allow working mothers to bring their children, 2) there was a relaxation of wastage allowances so that the health workers could open a new vial for only one child, and 3) a communications programme was initiated among health centre staff about the importance of measles immunization. A survey performed after the introduction of these interventions showed that missed opportunities for measles decreased by 20 percentage points.19 Problem 28:  Lack of supervisory control in growth monitoring and counseling activities. Suggestion A: Consider using protocols that divide the growth monitoring process into discrete tasks and specific actions to be performed. Once developed, they can be extremely helpful throughout the training, implementation, and evaluation process. Supervision systems that use this system and provide direct and concrete feedback to workers on how they can improve have been found to be quite effective. Many project reviewers have emphasised the importance of developing and using performance guideline that divide the growth monitoring process into at least five discrete tasks (motivating, weighing, recording, interpreting, and taking action) and then clearly describe the specific behaviours or actions that need to be completed at each step. They may be developed initially for a variety of purposes, such as training, to serve as checklists for supervisors or workers or to serve as tools for systems analysis, project monitoring, and assessment.27 When developing a supervision strategy also consider including the following elements: targeted supervision schedules supervision forms task performance norms training of supervisors improved supervision "style" time available calculations number of supervisors available35 Example: A study in Togo had supervisors spend more time at health centres. A day's activities were observed rather than just the growth monitoring session. Feedback was provided to staff at the end of sessions. Supervisors focused on skills such as balancing the scale, reading and plotting weight, communicating results to the mother. Findings were used to train personnel in calculating a child's age, interpreting the growth curve, tailoring individual recommendations. Supervisors also took note of counseling, observing whether mothers received specific messages, whether the chart faced the mother when she was receiving feedback, and whether mothers were able to interpret the chart. Supervisors identified and corrected mistakes and interacted directly with the staff and mothers. Staff showed increased motivation and made fewer errors. Mothers became more active in interacting with staff in identifying and resolving problems related to their children's growth.8 Problem 29: Lack of organisation in growth monitoring / supplemental feeding projects. Suggestion A:  Implement new selection criteria to focus the programme. Select those children who are most malnourished and those whose growth is faltering. Weigh these children each month and provide specific steps and strategies for the mothers to understand and resolve the problem. Organisational problems can be related to the size of the session and the amount of time available for weighing and examining, interpreting growth charts, receiving information from the mother, and providing results and advice. Programmes in Togo and other countries have reorganised clinics so that mothers distribute food, increasing counseling time and reducing overall session length. Example: The Kasa Project in India makes sure that those children who are nutritionally at risk - those who have low nutritional status fail to gain weight every tree months, lose weight over two months, or are sick - are weighed every month. Other children are weighed every tree months. Example: In the Dominican Republic, participation criteria include both age and nutritional status. All children under five are weighed once ever six months in order to compile a community profile; then high-risk children are selected and weighed monthly. These children include all those under one and children three to five who are classified as malnourished or who have not gained sufficient weight.18 Suggestion B:  Limit the number of children in one weighing group. Often weighing groups have fifty or more children in them. Divide weighing groups so that each has no more than 40 children. Have these groups come in for weighing on different dates. Example: A health centre in Honduras divides groups by degree of malnutrition, thus allowing specific and targeted communication with mothers. Problem-solving process* Frequently we talk about identifying, analysing, and solving problems. But there are also "opportunities for improvement;" areas where there may not be obvious problems but where a process or procedure could be improved. Don't overlook them. Problems and opportunities can be thought of as the "gap" between what is happening and what is desired. By correcting problems and making improvements you will close that gap. Step 1: Identify, select, and define the problem Begin seeking out potential problems or areas for improvement through existing information or data. Many teams have begun this process be brainstorming to list known areas of problems and frustrations. If the team members do not have ideas on potential problems, then you need to gather more information from other staff. As you develop your list of problems, there are some dangers. You should be aware of them so you can avoid them or take corrective action when they are discovered: You can become overburdened with problems; identifying more than you can handle. You can raise your people's expectations so that they believe the you or someone else will fix their problems immediately. You can get side-tracked and identify others' problems but not your own. The problem-solving process Problem: A gep between what is happening and what you want Identify, selest, and define the problem and clarify the desired results Seek out ppotential problems or areas for improverment. Define criteria for selecting the most important problems. Define the selected problem operationally: how do we know it is a problem? Determine how we know when the problem is solved by defining criteria for success. This is NOT the same thing as defining the solution. Choose a team to work on the problem. Learn everything about the existing process Determine where and when the problem is occurring. Understand the process in which the provlem occurs. Determine the basic causes of the problem or wherw the process is flawed Determine the factors that contribute ti the problem. Use tools to generate and test hypotheses about possible causes of the problem. Collect data to test hypotheses and determine which causes are the "critical few." Identify all possible solutions Think creatively about how the critical causes might be addressed. Choose a solution to implement Analyse the possible solutions against their ability to meet your criteria for success, the costs involved, the feasility of implementation, or other criteria. Pilot test the solution and evaluate its effectiveness This is the plan-Do-Check-Act cycle. It involves planning out the steps of implementation (including addressing resistance to ckange), doing it (implementing the solution), checking out ehether it had the desired effect (monitoring the Results), and avting on what you found (modifying the solution, changing to another solution, extending implementation). Selecting a problem You cannot work on all problems at the same time. The list is usually long and needs to be narrowed to the most important areas. For initial problem-solving activities, it is best that the problem is a small or a well-focused issue, emotionally appealing, one that others can readily see the value of solving, and one where data are relatively easy to obtain. Other criteria are needed to narrow down the list. The problem should be considered to be important to the people working on it. It should be feasible (size and complexity are manageable), the benefit of solving the problem should be worth the cost and effort required, and there should be support for changes and improvements in the current process. Define the problem operationally Many problem-solving efforts go astray because the group does not have a clear and common understanding of what it is supposed to solve. It is best to develop a statement of the problem in specific and observable terms. The answers to the following questions will assist in defining the problem: What do you think is the problem? How do you know it is a problem? What are the effects of this problem? How long has this been a problem? How frequently does it occur? How will you know the problem is solved? Where do you want to begin looking at the problem? And where do you want to end looking (boundaries of the problem)? The problem statement should answer these questions, be measurable, and be process-oriented. It should never give or imply any preconceived indication of what the cause might be, state or imply a particular solution, or affix or imply blame for the problem. Choosing a team Problem solving is most effective when those involved in the problem participate in analysing it and developing solutions. Once the problem statement is written, the next step is to answer the question, "Who knows about the process where this problem is found?" To answer this question you may need to do a flow chart that identifies the major steps in the process and helps you to focus on the key problem area. Once you know the key problem area(s), ask yourself the following questions: Who is experiencing difficulty because of this problem? These are the people who are experiencing the problem's symptoms. Who do you think may contribute to the problem? It is important not to blame these individuals. Who might help solve this problem? Who can help you understand this problem? These people will provide special knowledge, insights, and services during your problem-solving journey. Some you will work with closely, others you may just call on when you have a specific need. Step 2: Learn everything about the existing problem Start with what you know about the problem: clarify your understanding of what is presently happening. Analyse the data that you already have to see if you can answer the "who, what, when and where" of the problem. Very often people do not have a clear picture of the process, especially the links between what they do as individuals and the work of others in the process. A flow chart is a useful tool to help you understand how the process operates. If you use a flow chart, be sure that it reflects the process as it actually functions so that everyone is working within the same context. Step 3: Determine the basic causes of the problem Effective problem-solving involves identifying and understanding the root causes of the problem so that an appropriate solution can be chosen. There are three steps to identifying root causes; 1) identify all potential causes, 2) develop theories of cause, and 3) collect data to test theories of cause. Identify possible causes In order to identify the root cause, you should generate a list of as many potential causes of the problem as possible. An excellent tool for helping to organise and sort your ideas and to begin creating theories is the cause-and-effect analysis. A cause-and-effect analysis helps you to look beyond the symptoms of the problem, which reflect the manifestation of the cause but do not necessarily indicate the specific cause. A cause-and-effect analysis pushes you to ask, "What causes that and what is behind it?" It is also designed to broaden your thinking about causes and explore other areas that might be contributing to the problem. Develop hypotheses of cause When you have finished identifying all possible causes and displayed them, you may find that you have more causes than you could possibly investigate. You now need to narrow down and develop some hypotheses about what might be the root cause. This can be done by various decision making methods: expert opinion, voting, etc. The point here is to produce a limited number of options from the vast array of possible causes you have identified. The narrowing process will produce your group's hypotheses of causes. Collect data to test hypotheses of cause It is important to remember that all the causes you have generated are only theories. Now it is time to collect data to prove or disprove these theories: specifically, the goal of data collection is to test theories of cause. Data collection is the key component to making improvements. Your picture of what is going on must be based on facts, not opinions or assumptions. Data collection can also be used to reveal areas for process improvement, verify the existence of a problem, assess the effectiveness of a solution, and prevent problems. Step 4: Identify all possible solutions Once the root causes of the problem have been identified, it is time for the group to think creatively about how they can be addressed. Selecting a good solution involves having a range of good options from which to choose. The following are suggestions concerning how to ensure that as many solutions as possible are considered: Review steps 1-3 (defining the problem, learning about the existing process, determining the basic causes). Once again look at the precise problem, the unfulfilled need, and the people involved. Brainstorm to get ideas. Be sure to consider conventional, minor, and unconventional solutions. Don't forget your past experiences! Clarify each suggested solution. Involve people outside the group. Look for those who may be doing similar tasks, even if they are not in the same business. This is referred to as bench marking. You can find out what others are doing through interviews or surveys. The important thing to remember when you are developing solutions is "to think outside the box," to get ideas from other sources, to avoid evaluation, and to ensure that everyone has a common understanding of the suggested solutions. Step 5: Choose and implement a solution Once you have identified as many solutions as possible, it is time to analyse them to determine which is the best one to implement. As in Step 1 (selecting the problem), you must determine the choice by examining criteria and constraints. Criteria Typical criteria for solutions include: Costs of the solution Technical difficulties of implementation Potential side effects Resistance to change Time required to implement the solution It is also important to distinguish between which criteria are a "must" in order to be considered and which are only "wants." Constraints Constraints are unchangeable factors that will limit the options you can realistically consider. It is important to note that these constraints should be challenged and tested prior to acceptance, for many times things that are considered "unchangeable" are, in fact, flexible. Decision making Once you have identified the criteria and constraints, discuss each potential solution in light of them . During this discussion phase, identify positive and negative consequences of the alternatives. Essential to effective decision making is the amount of time spent in active discussion as everyone must feel free to present his or her individual point of view. Once the team reaches a point where the members feel that they have sufficient information to make a decision, it can employ various tools for decision-making. These decisions can be made by an expert or by using rank ordering, multivoting , and/or matrices. Step 6: Implementing quality improvement solutions There are four steps to effective implementation of solutions: plan the implementation do the implementation check the results of implementation act on what you find, by either continuing implementation, modifying the solution, or returning to look for a better solution Plan: Before you start implementing the solution, you need to determine the objectives and criteria for success. You must also decide who, what, where, when, and how the solution will be implemented. It is important to clarify your assumptions at this stage and to think about possible resistance you might encounter. Finally, you need to decide what data to collect to monitor implementation. Do: Implementing the solution often involves providing training and always involves collecting information to monitor ongoing changes and ease of implementation. Observe how implementation is being carried out. Document anything that goes wrong: Every problem or error is an opportunity for improvement. Check: Observe the effects of implementation and draw conclusions about "lessons learned." Act: Take action on what was learned: Adopt the solution, abandon it, or go through the cycle again to test modifications. References 1. Aga Khan Health Services. Planning and managing PHC programmes, report of a workshop . Kenya, 1984. 2.American Public Health Association. Primary health care: Progress and problems and analysis for 52 A.I.D.-assisted programs. Washington, DC, August, 1982. 3. Bentley, C. "Primary health care in north-western Somalia: A case study." Social science and medicine, Vol. 28, No.10, 1989. 4. Blumenfeld, S.N. Operations Research Methods: A General Approach in Primary Health Care. PRICOR Monograph Series: Methods Paper 1. 5. Brownlee, A. Breastfeeding, weaning and nutrition: The behavioral issues. Monograph No. 4, International Health and Development Associates, Washington, D.C., July, 1990. 6. Brownlee, A. Growth monitoring and promotion: The behavioral issues. Monograph No. 6, International Health and Development Associates, Washington, D.C., July, 1990. 7. Center for Human Services. "The challenge for ORT programs: Increase effective use." PRICOR Child Survival Report, Bethesda, Maryland, May, 1988. 8. Center for Human Services. "Child survival report: Supervisors improve growth monitoring sessions through operations research." PRICOR Child Survival Report. Bethesda, Maryland, May, 1991. 9. Center for Human Services. "Improving utilisation rates of child survival services through operations research." PRICOR Child Survival Report, Bethesda, Maryland, November, 1990. 10. Center for Human Services. "Revising national reporting systems to reduce paperwork and track impact." PRICOR Child Survival Report. Bethesda, Maryland, May, 1989. 11. Center for Human Services. "Using operations research to develop practical solutions for improving health worker performance." PRICOR Child Survival Report. Bethesda, Maryland, June, 1990. 12. Center for Human Services. "Using operations research to increase the effectiveness of growth monitoring at preschool clinics." PRICOR Child Survival Report. Bethesda, Maryland, June, 1990. 13. Chowdhury, M. "Evaluating community ORT programmes: Indicators for use and safety." Health policy and planning: A journal on health in development, Vol. 1, No. 3, September, 1986. references 14. Delp, Peter, A. Thesen, J. Motiwala and N. Seshadri. Systems tools of project planning. International Development Institute, Bloomington, Indiana, 1977. 15. Eng. E. "Community participation in water supply project and ORT activities in Togo and Indonesia." WASH Field Report No. 260, Rosslyn, Virginia, 1989. 16. Favin, M. Information for action issue paper:Immunizations. UNICEF, May, 1984. 17. Goldsmith, A. B. Pillsbury and D. Nicholas. Operations research issues: Community organisation. PRICOR, May, 1985. 18. Griffiths, M. Information for action issue paper: Growth monitoring. UNICEF, September, 1985. 19. Grabowsky, M. Missed opportunities for immunization. REACH, Rossyln, Virginia, March, 1991. 20. Hendratta, L. Consultant report for Thailand. International Nutrition Communication Service, January, 1983. 21. Koblinsky, M., et al. "Helping managers to manage: Work-schedules of field workers in rural Bangladesh." Studies in family planning, Vol. 20, No. 4, July/August, 1989. 22. Kowli, Shobha, et al. "Community participation boosts immunization coverage." World health forum.Vol. 11,No. 2, 1990. 23. Longworthy, N. and H. Fierman. "Family planning in Egypt: A planning response to an Islamic environment." The international journal of health planning and management, Vol. 3, No. 2, April-June, 1988. 24. Miller, R. I. and D. F. Pyle. Toward a monitoring and evaluation system for Pl 480 title II maternal child health programs in India. Ann Arbor, Michigan, Community Systems Foundation, 1981. 25. Maximizing results of operations reserach project summaries of family planning research studies. TvT Associates, Washington, D.C., 1991. 26. Murthi, M. N. "Participative style of management in a family planning program." Studies in family planning. Vol. 7, No.2, February, 1976. 27. Pillsbury, B., A. Brownlee and S. Sukkary-Stolba. Behavioral issues in child survival: A synthesis of the literature with recommendations for project design and implementation. Logical Technical Services Corp., April, 1988. 28. Reynolds, J. and W. Stinson. Lessons learned from primary health care programmes funded by the Aga Khan Health Foundation. Geneva, Switzerland, 1992. 29. Ross, J. A., M. Rich and J. P. Molzan. Management strategies for family programs. Center for Population and Family Health, New York, 1989. 30. Roy, S., A. Bardhan, D. C. Dubey and P. Dougherty, (eds.). Case studies in health management. National Institute of Health and Family Welfare, New Delhi, 1987. 31. Seidman, M. and M. Horn. Operations research: Helping family planning programs work better. Wiley-Liss, 1991. 32. Scholtes, P. R. (ed.). The Team Handbook:How to use teams to improve quality. Joiner Associates Inc., Madison, Wisconsin,1988. 33.Seims, S. Personal communication. Maryland, February, 1992. 34.Shepard, S. Personal communication. February, 1992. 35. Stinson, W. and P. Sayer. "Growth monitoring and promotion:a review of experience in seven countries." PRICOR service quality assessment series. Bethesda, Maryland, August, 1991. 36. UNICEF. Information for management of primary health care. July, 1984. 37. University Research Corporation. Family planning operations research/Asia: Lessons from the field. Bethesda, Maryland, April, 1991. 38. University Research Corporation. "Lessons learned from the field." Proceedings of the 1990 Singapore Regional Conference. Bethesda, Maryland, 1991. 39. University Research Corporation. Work plans for field workers improve performance. Project Abstract No. 3, August, 1988. 40. WHO. The experiences of primary health care intensification, Kalihati and Sreepur Upazila:Role of women. Dhaka, Bangladesh, n.d. 41. Williams, G. All for health: A resource book for facts of life. UNICEF, New York, n.d. 42. Wolff, J., L. Suttenfield, and S. Binzen. "Family planning manager's handbook." Management Sciences for Health. Kumarian Press, 1991. 43. World Bank. Adapting the training and visit system for family planning, health and nutrition programs. Staff working papers. No. 662, Washington, D.C., n.d. Acronyms And Abbreviations A.I.D. (United States) Agency for International Development AKF Aga Khan Foundation CHS Center for Human Services CHW Community health worker CPR Contraceptive prevalence rate DPT Diptheria, pertussis and tetanus vaccines EPI Expanded Programme for Immunization HSD Health statistics division I.D. Identification IEC Information, education, communication IUD Intra-uterine device MCH Maternal and child health MIS Management information system MOH Ministry of health MWRA Married women of reproductive age OR Operations research ORS Oral rehydration salts ORT Oral rehydration therapy PHC Primary health care PHC MAP Primary Health Care Management Advancement Programme PSC Pre-school clinic TB Tuberculosis TBA Traditional birth attendant TT Tetanus toxoid URC University Reseach Corporation VCEI Village community endurance institution VDC Village development committee VHW Village health worker WHO World Health Organization 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) 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 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