Manager's Guide - Problem-Solving

THE PHC MAP SERIES OF MODULES.
GUIDES
AND REFERENCE MATERIALS
Each module includes:

o a User's guide
o 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
o Better management: 100 tips
o Problem-solving
. Computers
o The computerised PRICOR thesaurus
Production Managers: Ronald Wilson, Aga Khan Foundation, Geneva, and

Thongchai Sapanuchart, Somboon Vacharotai Foundation,
Bangkok
Design & Layout: Helene Sackstein, France
Desktop Publishing: Marilyn J. Murphy, Suracha Suntarasut, Somboon Vacha-
rotai Foundation, Bangkok, Thailand and Atthapon Tanoi,
Dept. of Medical Sciences, Thailand
First Printing: In 1993 by Thai Wattana Panich, Bangkok, Thailand
Second Printing: ln 7997 by Veteran Organization Printing Co.,Ltd, Thailand
Published by the Aga Khan Foundation USA, Suite 700,1901 L Street N.W., V\hshington
DC, USA. Additional copies are available at the Somboon \lacharotai Foundation, 101
Boromratchonanee Road, Glingchan, Bangkok 10170, Thaland Fax. (662) 44'&.66f,2
ISBN : 1-882839-19-6
Library of Congress Catalog Number :93-70732
Dedlcated to
Dr. Duane L. Smlth (7939'1992),
Dr. Willtam E. Steeler (7948-1992)
and all other health leaders, managers and wotkers
who follout thelr example tn the effott to btlng quallty health
care to all In need.
i
, :.i'tit*iiliiiit-\.ii!F.ii.{€ ;ii:,:,ri*
An overvi€w of PHC MAP

The maln purpose of the Prlmary Health Care Management Advance-
ment Programme (PHC MAP) is to help PHC management teams collect,
process and analyse useful management information.
Initiated by the Aga Khan,Foundatior\ PHC MAP is a collaborative programme of
the Aga Khan Health Network'and PRICOR'. An a<perienced design team and equally
experienced PHC practitioner teams in saneral counhieg including Bangladesh Chile
Colombi4 the Dominican Republig Guatemal4 Haiti, India Indonesi4 k
yq Pakistarq
Senega[ Thailand arflTane"ha',e urcrked together to der.relop, test and refine the PHC
MAP materials to make sure that they are understandable, easy to use and helpfirl"
PHC MAP includes nine units called modules These modules focus on essential
information that is needed in the traditional management cycle of planning{oing-anl-
uating. The relationship between the modules and this cycle is illustrated below
PHC MAP modules and the
planning-evaluation cycle
PHC MAP
MODULES
l. Information needs
2. Community needs
3. Work planning
4. Surveillance
5. Monitoring indicators
6. Service quality
7. Management quality
8. Cost analysis
9. Sustainability
1. The Aga.Kha3. Health Network__ includes_ the Aga Khan Foundatiorl the Aga Khan Health Services,
'
and the Aga Khan University, all of which are in',rolved in the strengthening of primary health care
2. Primary Health Care Operations Research is a uprldwide project of the Center for Human Services,
funded by the United States Agency for International Development
u
Managers can easily adapt these tools to fit local conditions. Both new and
experienced programmers can use them. Govemment and NGO managers,
management teams, and communities can all use the modules to gather
information that fits their rreeds. Each module explains how to collect, process
and interpret PHC-specific information that managers can use to improve
planning and monitoring. The modules include User's guides, sample data
collecting and data processing instruments, optional computer programs, and
Facilitator's guides, for those who want to hold training workshops.
The health and management services included in PHC MAP are listed
below.
Health and management services

MANAGEMENT
HEALTH SERVICES
SERVICES
GENERAL OTHER HEAI.IH CARE Planning
PHC household visits Water supply, hygiene and Personnel management
Health education sanitation 'Iiaining
School health Supervision
MATERNAL CARE Childhood disabilities Financial management
Antenatal care Accidents and injuries Logistics management
Safe delivery Sexually transmitted diseases Information management
Postnatal care HIV/AIDS Community organisation
Family planning Malaria
Tuberculosis
CHILD CABE 'Iieatment of minor ailments
Breast feeding Chronic, non-communicable
Growth monitoring diseases
Nutrition education
lmmunization
Acute respiratory infection
Diarrhoeal disease control
Oral rehydration therapy
Several Manager's guides supplement these modules. These are: Better

management:7}}tips,a helpful hints book describing elfectlve ways to help
managers improve what they do;Problem-soluing a guide to help managers
deal with common problems; Computers, a guidebook providing useful
hints on buying and operating computers, printers, other hardware and
software; and The computerised PRICOR thesourus, a compendium of
PHC indicators.
The Primary Health Care Management Advancement
Programme has been funded by the Aga Khan Foundation
Canada, the Commission of the European Communities, the
Aga Khan Foundation U.S.A., the Aga Khan Foundation's
head office in Geneva, the Rockefeller Foundation, the
Canadian International Development Agency, Alberta Aid,
and the United States Agency for International Develop-
ment under two matching grants to AKF USA. The first of
these grants was "Strengthening the Management, Monitor-
ing and Evaluation of PHC Programs in Selected Countries
of Asia and Africa" (cooperative agreement no. OTR-0158-
4-00-8161-00, 1988-1991); and the second was "strength-
ening the Effectiveness, Management and Sustainability of
PHC,zMother and Child Survival Programs in Asia and
Africa" (cooperative agreement no. PCD-0158-A-00-II02-
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.
Problem-solving
Contents
1
INTRODUCTION
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 5
MANAGEMENT FUNCTIONS: Community organisation """ 6

Information,education and communication ' ' ' '13
Information systems and record-keeping " " "2L
Personnel andtraining.... '"""28
Logistics ''""34
Supervision ' "35
PROBLEM-SOLVINGPROCESS ....42
Sa"p It ldentify, select and define the problem
Step 2: Learn lverything about the eiisting pronlem ' ' ' ' ' ' '45
Step 3: Determineihe blsic causes of the problem " '45
SaA 4t ldentify all possible solutions " "46
Step 5: Choose and implement a solution ' ' " '47
Step 6: Implementing iuality improvement solutions ' ' " ' "47
REFERENCES ..... ".51
ACRONYMS AND ABBREVIATIONS
Acknowledgements
The idea for this guide came from PHC managers, who requested a
supplement to the PHC MAP modules that would provide practical
suggestions for solving problems. Jack Reynolds developed the design for
the guide, contributed the first examples, and oversaw the project through-
out. Gael Murphy compiled the first draft from material prepared by a
number of URC/CHS staff. Maria Francisco and Neeraj Kak prepared a
revised draft, which was reviewed by participants at the International
conference on the management and sustainability of PHC programmes, in
May L992. They worked on revisions together with Martine Hilton to
complete the final draft. special thanks are due to Pierre Claquin of the
Aga Khan Foundation, Geneva, for his support and interest; several
participants of the 1992PHC MAP conference including Peter Mabonga
and Jeddah Katimo (Mombasa PHC Programme, Mombasa, Kenya), and
Mjay Moses (Aga Khan Health services,lndia)for their suggestions on how
to improve the guide; and Julia Friend for conducting the background
research.
we wish to thank all of the managers, consultants and others with
first-hand PHC experience who generously contributed their experiences
and guided us to other sources. The material for the problem-solving
process is based on previous material developed by URC/GHS'S pRICoR
and Quality Assurance projects.
Problem-solving
Introduction
"There are no problems, only opportunities."
As a member of a primary health care (PHC) management team, you
probably encounter a number of problems that demand innovative thinking
and flexibility. Many of these managerial problems will be identified
through the tools and techniques in the PHC MAP modules. The modules
will also help you identify most of the solutions, as well. Many will be
obvious, but sometimes it may be a real challenge to identify an effective
solution that will work in your situation.
As the PHC MAP modules were being reviewed and tested, many PHC
management teams asked for guidelines for problem-solving. This prob-
lem-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:
. communityorganisation
. information, education and communication
. information systems and record-keeping
. personnel
o logistics
. supervision
Each topic is first described briefly, together with some key lessons
learned. Then a common problem is described, followed by one or more
suggested solutions and some examples from field experience around the
world. Several problems are presented for each topic, and as mentioned,
several solutions are usually presented for each problem. Altogether, there
are 29 problems discussed in this guide. The following table shows how
they are distributed across management topics, and the specific services
Problem-solving; introduction
2
General Immunisatlon ORT Famtly Growth Breast

planning monitoring feeding
nutrition
Community L,2,3 4
organisation
Information, 5 6 7 8,9,10 II,L2
education,
communication
Inlormation 13,14,15 16 L7 18
sptems and reord
keeping
Personnel and t9 20,2r
tralning
Logistics 22 23
Superuision 24,25.26 27 29,29
from which the examples were drawn. obviously, the problems and solu-
tions described could apply to a number of services.
Numbers in the chart correspond to the number assigned to each
problem in this guide. A summary listing of these problems is at the
beginning of the next section.
The suggestions and solutions presented in this guide come from a
number of sources, including operations research studiel, pHC consultants
and teachers, case studies, articles, and trial-and-error experience of pHC
managers. Numbers in superscript refer to the sources of the information,
which are listed in the References at the end of the guide.
The second section describes a general approach that managers can
use to analyse problems, identify root causes, and develop appropriate
solutions to address these causes. This section builds on'thl'probl.-
identification and analysis process embodied in the pHC MAp Modules. It
also includes some simple tools that you and your team can use, such as
brainstorming, nominal group techniques, cause-effect analysis, flowcharts,
and fishbone diagrams.
.ln presenting these problems, suggestions and practical solutions, it is
our.hope that programme managers, outreach, clinic and hospital-based
health care providers and planners will be able to use the suggestions offered
as a "springboard" for their own ideas, inspiring them to d-velop appropri-
ate solutions to their own problems.
Problem-solvin g; introduction
3
:l.iitfiii!!.!.W!i.#, -P#i1.ffi'! i tii:i!':':*it:!iiii'i
Common problems in primary health care

The following list summarises the problems discussed in this guide,
arranged according to the six management functions described in the
Introdluction. Thii list is followed by an in-depth discussion of each
problem, suggested solutions, and examples from PHC managers'
CommunitY organisation
Problem 1: Even though project interventions are acceptable to
individualcommunity members, they do not want to
join in activities that would support those interven-
iions, since they perceive that they will enjoy the
same benefits whether or not they themselves par-
ticipate.
Problem 2: Patients tend to bypass peripheral health units and
seek care directly at the hospital outpatient depart-
ment.
Problem 3: Utilisation and support of health programmes are
low.
Problem 4: Family planning activities are hindered by a.lack of
tuppotf from influential village members who hold
negative impressions of family planning based on
reports from dissatisfied clients.
Information, education and communication

Problem 5: 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 wellreceived
because of strong religious influences.
Problem 8: Heavy case loads limit the opportunities for educa-
tion in the health centre.
Problem-solving; common Problems

Problem 9: Mothers are not alert to changes in their children's
weights that may signal the initial stages of malnu-
trition.
Problem 1O: 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 rein-
force 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 allected 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 adopt-
ers, 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 effec-
tively.
Personnel and training

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

5
Problem 20: Family planning workers are not accepted by the

community.
Problem 21: There are not enough health workers to provide
elfective coverage. The programme is not having a
strong impact on family planning acceptance, or on
reductions in fertility.
Logistics
Problem22z 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 bath-
room 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: 'lbo many tasks are assigned to CHWs. Tasks do not
have a clear priority.
Problem 272 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/supple-
mental feeding projects.
Problem-solving; common Problems

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

7
Problem l: Even though project interventions are acceptable

to individualcommunity members, they do not want
to join in activities that would support those inter-
ventions, since they perceive that they will enjoy the
same benefits whether or not they themselves par-
ticipate.
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 family is best off if everyone
else builds one, while it retains old waste disposal practices. Such a family
is a "free rider" -- it gets the benefits of cleaner water without having to
bear the costs of providing it. If the latrine is seen as a source.of prestige
for the household, more households may aspire to having one."
Example: The Indonesia Rural tvVater Supply Project installed 100 gravity water
supply systems, and a few rainwater catchment systems. The implementing agency
wasCARE-USA, whose development strategy stresses community involvement and
fits well with Indonesia's national philosophy of selFhelp. CARE employed and
trained Indonesian project workers who lived in the village during the construction
phase, and participated in village life to draw political, religious, and other leaders
into the planning and implementing activities. In each village, the details of
implementation were set by a subgroup of the village community endurance
institution (VCEI), a voluntary civic body found in most Indonesian communities.
By tying water project responsibilities to the indigenous organisation, project
workers encouraged the VCEI subgroup to organise neighborhoods and involve
prestige and
.villagers in the project. In addition, the VCEI subgroups enjoyed added
power. The success of the CARE community participation approach is explained
largely by this strategy of using existing decision-making infrastructures, rather than
creating a mechanism which would compete for human resources and power.'"

Problem 2: Patients tend to bypass peripheral health units and
seek care directly at the hospital outpatient depart-
ment.
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 ZoneinZaire,the zone hospitalpractised this

policy. It had no general non-referral dispensary, for patients from the town in
which the holpital was located, a separate health centre was provided 0.5 km from
the hospital.34
Example At the village health centre in a Somali project, priority was given to
patients who had &en relerred by CHW's. This enhanced the cHws importance
in the eyes of the community, and served as a valuable teaching tool for CHW's on
their referrals.r
Problem 3: Utilisation and support of health programmes are

low.
Suggestion A: Public displays, such as community charts and black-
boards placed in a prominent location showing proj-
ect achievements, can generate interest and aware-
ness.
Suggestion B: Encourage involvement in the health programme
from active organisations from as many different
sectors as possible, including non-health or-
ganisations 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 contri-
butions to projects are most often in-kind services such as: provision of
Iabour and materials for health centres, latrines, sanitation projects, con-
structing wells, training visits; provision and selection of volunteers to serve
as CHW's; compensation of some form for CHWs; organisation and support
of health committees.z
Problem-solving; comrnunity organisation

9
ln general, projects successful in involving communities have been those:

. in which the major capital-investment costs of health improvement
were carried by either the government or the ptoject, but not ihe
communitY;
. which were small scale or locally implemented, and which tended to
involve one-time efforts requiring little involvement once completed;
. which emphasised the generation of community support and which
linked the problem of sustained community participation to supervision;
and
. in which the community perceived the health benefits to be high.z
Example In its seven years of operation, the Togo Rural water supply Project
i"riuif.?""urly 1,000 tube wells in745 villages and towns. A unique feature of this
project was its socio-health component, which integrated community organisation
and health education activities to involve villagers in installing, operating, and
maintaining their wells. The field workers initiating these activities were Togolese
tr.i"i iffiit. agents. The final evaluation attributed a large part oftraining
the project's
of the
success to its community participation approach and to its careful
social affairs agents in heaittr education and commuttity organisation, of the village
in
development Committee (VDC) members in local management, and of villagers
h;gi""; education. In iis last three years, the project broadened community
pliii"iputio" to involve more women indecisions about the operation and mainte-
"pump minder," in which
.,un"n of the water system. It established the position of
proper use of
;;;-;n living nearihe well was made t"pot tibl"pump' T!" the minders
for oveseeing
were
ihe ,ystem ani monitoring the operation of the nurnp
noi ontv appointed uy hJvoc's but also became full VDC members. During the
ii"ur v"ir,ln onr prolect was started in villages with compleEd well installations'
irr" ipc selected iiu" *orn"n, who thereby-b"catne full VDC members, asto oRT give
uoi,rnt""rr. These five women and one VDC member were then trained
demonstrations and provide individual counseling to mothers in therpreParation
iJ-inittration oi sugar-salt solutions for children with diarrhoea.^"
-xample, In Ivory Coait, a school health education prograrnme was initiated to
"nJ
improve public participation in immunization activities. A simple lesson
plan was
distributed to primary school teachers Pupils were taught the need for their lDunger
siblings and neighbourhood infants to be immunized against childhood diseases'
After completing the lesson plan, the pupiis carried rit home together with
appointment slips to have the target children immunized'^"
Example In Bangladesh, district family planning management teams consisting
of heaith and lamily planning officials, community leaderq and district heads visited
Indonesia's successful family planning board. These teams then designed and
managed community action plans themselves. In some district programmes con-
traceptive prevalence rates have increased dramatically and community participa-

#
10
tion and leadership have increased. 33

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

ing, 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 required
no new financial resources. After collaboration with local nurses, the team suggested
intensive home visiting by VHWs living in six villages. By asking the VHWs to
identify women who were not in the habit of using clinic services for curative care,
and then confirming the selection by consulting clinic records, 25 mothers from
each village were selected to participate, A one-week training reviewed the goals
and strategies, and offered a refresher course in health education techniques and
messages. The nurses were advised on techniques for supervising the VHWs and
were provided a newly formulated supervisory checklist to guide them in evaluating
performance and offering feedback. Over the course of six months, the mothers
received one home visit per month by a VHW. Each visit began with the completion
of a brief questionnaire to survey the mother's current understanding of health
related topics and to assess her recent participation in child survival services. Then,
the VHW counseled the mother on topics such as the completion of the vaccination
series, management of diarrhoea, treatment oI tever,and prevention of malnutrition.
Throughout the period, the local nurses conducted weekly supervisory visits to the
VHW making home visit rounds. Over this six-month period, mothers'knowledge
of childhood illnesses and the utilisation of child survival services improved
dramatically. Utilisation of preventive services rose from 33% in the first month of
the study to 88%. similarly, utilisation of curative services rose from 26% to72%.9

11
Suggestion D: Disperse service sites to increase outreach efforts.
Example In the health zone ol Zongo (Zairel, an alternative strategy for increasing
utilisation rates was tested. After consulting local officials, and health personnel,
the zonemedical officer decided to test the impact of dispersing the sites of growth
monitoring and vaccination sessions. At least once a month, these services were
offeredby-local nurses at a distance of five km or more from the health centre and
from all other outreach sites. A total of 202 mothers in the catchment area of two
separate health centres were surveyed both before and after the 9-month interven-
tion period. The intervention led to increased participation in the immunization
progiu*-", from 3970 to610/o. Furthermore, the outreach effort was also associated
witf, an increase lrom 44o/o to 610/o in the use of clinical services for curative care
in the event of an episode of childhood illness. Finally, the dispersion of preventive
services also provid-ed additionaloopportunity for the identification and referral ol
sick children requiring treatment''
Problem 4: 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.*
Suggestion A: Examine the quality of services and determine where
they can be improved.
Quality oI care is increasingly being recognised as an important deter-

minant of contraceptive acceptance and continuation. One framework for
quality of family planning services emphasises six basic elements:
o Choice of methods: number and variety of methods offeted
. Information given: methods available, their use, potential side effects,
service arrangements, etc.
. Technical competencq providers' competence at performing clinical
family planning services
. lnterpersonal relations: clients' perceptions of their interactions with
service providers
o Mechanisms to encourage continuity: media campaigns, home visits,
appointments, etc.
o Appropriate constellation of services: convenience and acceptability of
services to clients

t2
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 1986were followed and interviewed in 1986 and 1987. coniinuers and
discontinuers exhibited differences that have important implications for the quality
of care delivered by clinics: IUD continuers were more likeiy than discontinuers to
have received information on side effects prior to acceptance; continuers were more
likely than discontinuers to have received information on alternative methods. The
l2-month continuation rate was 63% among women with incomplete information.
compared withTlo/o among those with more complete information.zg
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.
Mllage leaders wereo"informed of the action taken. opposition to the programme
declined over time. zo

13
Management function: Information,

education, and communication
Good communication and rapport with clients can stimulate use of
services. People respond positively when they teceive privacy and respect,
are treated with empathy, and have their questions answered. Communi-
cation involves the sharing of ideas, knowledge, attitudes, and feelings. If
efforts to communicate health messages do not achieve the results intended
it may be for one of the following r€dsonS:
The message may reach only some of the target audience because few
communication channels are used. For example, some health pro-
grammes 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 incor-
rectly. For example, mothers who are taught to use ORT may use too
1nuci1 water, which makes the solution ineffective, or too little, making
the solution potentially dangerous.
The people may receive and understand the new information but be
unabie to act upon it because of their poverty, or because basic services
are not available. For example mass media campaigns can increase
community demand for packets of oRS, but if the packets are too
expensive or unavailable from the health services or private pharmacies,
the money spent on such campaigns is wasted'
-hejlth may receive and understand the information, and learn
The people a
with
new aciion correctly, but the knowledge may conflict
existing attitudes and beliefs. For example, mothers who are.taught to
continJe feeding a child with diarrhoea may not act on this information
because it conflicts with traditional belief that the stomach needs to be
rested during diarrhoea.
Problem-solving; communication
L4
. The people may receive the information but change their behaviour
only temporarily because of disappointment with the results. For
example, mothers may learn to prepare and administer ORT correctly
but lose faith in the therapy because what they want is a treatment to
stop diarrhoea quickly rather than prevent dehydration.
Communication breakdowns of this kind are not inevitable. They can
usually be avoided if communicators first try to understand the atlitudes,
beliefs and social factors that determine people's health behaviour.+r
Problem 5: 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 the need for medical
care. Once the poultry problem was diagnosed as Newcastle disease and veterinary
treatment was made available, the community became interested in its own health
problems and developed its own community health p.ogra-*e-l
Problem 6: 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 tech-
niques being used to teach mothers about prepa-
ration 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 pro-
cess of service delivery.
.15
Extensive field experience with ORT has demonstrated that programme

success depends on effective communication between the mother
and
health *ork", to ensure that behaviour changes. systems analysis data
revealed that health workers, whether in the home or in the health
centres,
key messages, and that encounters were generally
iiequently did not convey
not used to encourage motirers to put into practice those messages that
they did understand. Operations research has shown in many countries
thai while mothers know of ORT, few can prepare and administer it
correctly.
promote the
Example: An ORf programme in The Gambia used mass media to
A common container suitable for measur-
use of a home-make ialtlsugar solution.
and mothers_were told how to prepare the solution'
i"g OnS ingredients was forind,
told how to administer ORS, how to determine if their child was
Vt6tn"r, wJre also
get better..Experienced mothers
iiprt"i"g,-U""n to seek help if the child did not
runo nua
"ndtrained in OIiT techniques flew "happy baby" flags over their homes'
f"f"if,"rr were told thit they could go to the fiag holders for help with rein-
ORT'
print, instructions
b;;;;;"tary (and pre+ested) radio, and face-to-face
in which
forced one another to have maximum impact. A contest was launched,
if tn"y mixed the solution correctly' The
mothers could win small household items
*i"ning mothers were entered in a grand prize drawing for 15 radios' The
""-"r.f
;il6; i;t.i;s oit tn" -orl mothers for the contelt each week received a S0-kilo
iuf;f *s"i"".a a 100-kilo bag of rice. Unlike other programmes in which the
one it was given to mothers' After
incentive was given to n"uttn w"orkers, in this
the number of mothers reporting using
"igni
-r"tns Jf promotion andoftraining, episgles. The number of mothers
Oilf .fi-U"a from 3%o to 48o/o all diairhoea
who could recite the formula rose from Lo/o b 640/0'27
Problem 7: Family planning messages are not well received

becaule of strong religious influences'
Suggestion A: Combine family planning efforts with other helpful
information aUout healtlipromotion or other health
topics, such as nutrition, which may be perceived as
more relevant. By demonstrating a practical link
between the two topics, family planning messages
may be made more "palatable." Integration of ser-
vices has been shown to be more cost effective than
delivery of separate services.
76
Example The second Population Project, servicing zooto of theegyptian popr.rla--

tion, integ-rated family planning and MCH service delivery in order to work lowards
its goal of reduced fertility rates. It developed an implementation strategy rooted
in the Qur'an, using a combination of birth spacing and breast feeding -i"rrug".
with underJying health rationales. It relied upon eur'anic injunctions requiring a
woman to breast feed two full years. The project presented modern contraception
as a means to ensure the necessary spacing of births. A combination of *iitt"n
and broadcast media as well as outreach aCtivities were used to communicate its
message, many of which indirectly introduced the concept of family planning while
addressing directly the issues of the Islamic family in maternal and child health.
Using a non-confrontation manner, their
-"suge *us not confined to the tradi-
tional target.population as defined in terms of fertility but was also directed to
militant fundamentalists who might not otherwise Le viewed as relevant to
reproductive decision-m.aking. overall, the problem of implementation was ap-
proached at two levels: 1) the operational level, considering tire determinants of
use
with their associated functional details, such as pertotttt"i] logistics, etc., and 2) the
external environment, which conditions the kinds of programme implementation
choices implied in ttre operational level of planning.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, th
modifications to the Pre-schoolClinic (PSC) System to illow tire nurse to increase
the time allotted for the examination of malnourished children and the counselling
of the mothers. Two changes were proposed: r) begin the weighings as soon as
mothers arrive at the PSC session, to eiiminate'the-"dead time'ispent waiting for
mothers to assemble and to ensure greater participation in the health education
session, and2l institute a system of triage, whereby nurses examine only the
children
yh9l" weight had failed to.progress. A part of tlre solution, volunteer community
health workers were trained to assist wiih the weighings, aliowing nurses to speni
more time counseling the mothers of malnourished children.They flund that plicing
the health education session in the middle of the PSC session decreased long waitini
lines and imp-roved attendance at the health education lessons. The triate
of ttrl
malnourished children allowed nurses to triple the time they spent with malnour-
ished children. Furthermore, there was a su'bstantial augme-ntation in the propor-
tion of mothers who correctly understood whether their c-hild's weight had increased.
ll,{^dlj"" jo improving the quality of services, the modifications frad the ;;pii.r-s
effect of actually reducing the aveiage length of psc r"*io". bt t0 ;;t;11
17
Problem 9: Mothers are not alert to changes in their child's

weight that may signal the initihl stages of malnu-
trition.
Suggestion A: Use cultural or traditional indicators to encourage
awareness of growth. Emphasise size, using clothing
as a useful indicator. Wth poor growth, clothes
become loose around the body or are still a good fit
many month later. A survey in India found that
mothers used indicators for growth such as the child
being heavier to lift or outgrowing her clothes.
As malnutrition is not aways evident to mothers,
give her a mental checklist of four or five key signs
and symptoms to look for that serve as a cue to bring
the child to the health centre such as: poor appetite,
listlessness, not urinating enough, repeated colds or
infections, etc.
Eximplet 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
utouni the waist should have been changed or adjusted five tjmes. Other items
mentioned included metal bracelets, necklaces, and finger rings.r
Problem 1O: 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 col-
lection. There may not be enough feedback and edu-
cation 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 understand-
able recommendations. Involve the mother interac-
tively 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.
1R
. Weighing frequently, as often as every month or two,

if feasible.
. Feeding back monitoring results to the mother im-
mediately, so she can take eflective 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. These skills can be taught in
training, or by supervisory example and guidance on the job. Supervisors them-
selves often fail to discuss and explain issues and information with workers, setting
a negative example for workers regarding communication and information sharing.
Those responsible for growth monitoring can make it a point to provide each mother
with information about her child's growth and some concrete piece of advice to
follow until the next session. Several countries have successfully implemented school
programmes to teach students about nutrition and growth monitoring. Students
monitor their siblings'growth and help mothers adopt good nutritional practices.
Problem 1l: 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
9os1 glv money, was cleaner and easier than bottle feeding, and was a gift from
God. The mother was bottle feeding her child and believed snl aia not have enough
milk to breast-feed her child. At this point, another nurse came over and said to
the mother, "You know, nowadays children are growing up without close bonds with
their mothers because they were not breast-fed." The mother's attitude changed
instantly, and she began to take an interest in the benefits of breast-feedirrg her
child.
1,9
Problem 12: Supplementary feeding programmes do not rein-

force behaviour change or independence.
Suggestion A: Involve mothers by setting up a nutrition fund,
training them as peer counsellors, etc. Remove ele-
ments in your programme that encourage them to be
passive recipients.
E-.-pl", A" innovative activity in a programme in Thailand has been the

establiihment of a nutrition fund at the village level. Each project village is given a
start-up fund of about US 5150.00 in materials and foodstuffs to start producing
supplementary food. Community members are given the opportunity to buy shares
to'add to the starting capital, *hi.h th"n entitles them to the profit generated,by
the sales of the suppLmentary food (about US 50.10 per 100-gram package)' In this
scheme, third degree mainourished children receive the package free.
Exampie, A study in'Ibgo selected mothers from among the regular participants
at growth monitoiing s"sionr at a nutrition centre group to be trained as peer
corinsellors. They conducted home visits to other mothers to reinforce health
eJucation *nrrui"r. Prior to beginning their home visiting activities the mothers
participated in a*2-day training iession which covered procedures for conducting
i,o*" uirits and basic iechniquls in health education. They also learned the use of
during
fictorial guides to help record information about messages communicated
centre services
ihe visit. I-t was concluded that mothers could help extend nutrition
effectively. Futhermore, mothers reported that they were more comfortable being
visited by other mothers tuth"ll!9tt-ly.jlinffil!
Suggestion B: Recommend appropriate local foods which are al-

ready in populai use for other nutritionally susceptible
groups, such as the elderlY.
@amPithoWeaningFoodsProjectinNepalbeganasa
*pple-entury feeding programme for mothers and pre-school children. The
programme *u, .or,l-y, exferienced several distribution problems, and created
lnd-esirable dependencies. A nutrition survey was conducted to identi{y appropriate
local foods and current infant feeding practices. The survey of weaning age children
showed that all were breast feeding Uu1 tnut many were malnourished because
they
did not receiveenough well-balanced supplemenial foods. The investigators noticed
that almost all mothLrs knew how to piepare a nutritious and popular traditional
snack of beans and cereal grains, which were sometimes ground and mixed with
milk or water to prepare a gruel for elderly pople. Staff believed that a low-cost
weaning food couid be made in the same way A nutritious mixture was developed,
and edulation on its preparation and use was included in an integrated campaign
to reduce malnutrition via promotion of weaning foods, ORT, and growth monitor-
20
in9. Evaluations suggest there have been positive changes associated with this
intervention.c
suggestion c: separate food distribution activities from growth

monitoring
Experience has shown that if food distribution is combined with
monitoring, it will tend to take "centre stage," diverting attention from
preventive/promotive aspects of the intervention.
Example The Tamil Nadu project (TNINP) in India experi-

-lntegrated Nutrition
mented with innovative methodsJor providing food supplements, when
but with a preventive emphasis. It focused on early detlction of'growth""""r!iry,
falterini.
Monitoring was followed by various promotive activities, as well as fJod supplemenis
when appropriate. Rather than focusing on older children *no ur" easier to find
but among whom malnutrition is often far advanced, TNINP concentrated
on
children from birth to 36 months in order to prevent poor growth. Feeding
was
considered^lo be primarily parent's,.rerpor,ribitity. particifiation in feedini wis
Iimited to-90 days for each lfre.
"admission." The food s6rved ur'i ,uppt"-ent tJhelp
young chlldren with faltering growth, and also provided an educa'tilnal
experienc'e
parents. The project was able to economise significanilv o. roJ l;il
f.or.!fe 4;
limiting the-frequency of participation and by more seleftive t"rdti";. A mid
-term
impact ernluation showed that during the first 3.5 years of oieraiion, third and
fourth degree malnutrition in the project block_frai decliii-Aoi, *i,it" i. th"
control block the percentage had increasedLgVo.n
21,
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 delivery and support activities. It is a
systematic way of collecting, reporting, and using data at all programme
levels, and is organised around key indicators that measure a programme's
progress toward its goals.
Better record keeping promotes eflective supervision and monitoring,
can aid in the evaluation of worker's performance, and can help monitor
progress and identify problem areas.
Problem 13: 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 accu-
mulated forms, which have been kept separately for
each clinic and distri-b.utes 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: Preparc "rainbow" family cards with coloured tabs
across the top, each in a distinct colour.
Example Each coloured tab corresponds to a different condition, such as preg-

nancy, need for vaccination, malnutrition, etc. If a given condition is present, the
corresponding tab is folded up. Otherwise, it is folded down. The cards are stored
in a file box. Each month. the tabs are counted. The count indicates the relative
magnitude of the problem and trends from previous months. In addition, the
families with unfolded tabs can be identified for visitation by the health worker each
month. This system was developed by Fondacion CIMDER, Universidad del Valle,
Cali, Colombia.
Problem-solving; information
22
Suggestion B: Make charts easier for CHW's and mothers to use

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 programme developed coloured stickers that
CHWs could stick onto family folders to identify a pregnant woman, an underweight
child, a child with diarrhoea, etc,
Example: Kenyan students were assigned to help cHw's with their recording and
reporting. They also helped in case-finding and follow-up. This study fbund
collaboration between schools and CHW's to be the most cost-effective team
arrangement for basic preventive services. School children, in addition to learning
about health, llglped monitor siblings and mothers needing growth monitoring anl
immunization.2S'
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 t1o/o 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 49o/o of their time on record keeping and reporting.
The programme simplified the MIS by reducing the number of indicatois to be
reported oq the frequency of data collection, and the frequency of tabulation and
reporting' This made information collected more useful and has significantly
reduced thê amount of time health staff spend on management iriformation
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,
o individual family cards, listing family members by age, occupation, education
and immunization status,
. pregnancy chart for each woman.recieving antenatal care,
. weight charts for all children under five.
23
Health workers have service delivery targets, and work with their supervisor
each month to prepare a report comparing actual service with targeted service.
Managers are trained to look for unquantified events affecting health, such as:
. local employment patterns,
o local food prices and availability,
. localised disease outbreaks,
o changes in the physical and/or natural infrasturcture, or
o the existence of other governmental of private programmes affecting
nutrition.
They also use monthly and quarterly reports to identify villages that:
. deviate from norms established by other villages,
o deviate substantially from their own established trends, or
o fail to exhibit positive improvements over a substantial period of time.
Managers then visit exceptional villages to better understand successes and
failures. In addition, every village conducts an annual review to assess programmes,
review progra-mme operations, and set goals and operating procedures for the
coming yeai.24
indicators.
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 cumbeisoine and expensive system of paperwork placed the greatest
ieporting burden on peripheral failities. More importantly, the information flow
tended to go in one direction only, from the periphery to the central level. Finally,
there was little analysis of the information and therefore limited use of the data for
planning or policy making and almost no feedback to the periphery. After several
workshJps with division managers and provincial-level staff, a provincial-level
analysis of project information flow and needs was completed and several changes
were madei l,) ihe use of coverage rates (versus counts) was endorsed as the most
approproate PHC indicators,2l reporting frequency was reduced to no more than
iour months, 3)the list of essential coverage indicators for PHClchild survival
"u"ty
elements was reduced to seven, 4) a format for feedback reports was agreed upon,
which would provide national, regional, and provincial coverage rates for all of the
indicators in the system thus allowing for comparisons among provinces and within
geographic regions, a4{ allowing overall progress toward national service coverage
goals to be estimated.ru
24
Problem 16: Poor record keeping by field workers.

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

elsewhere:
. The card must be able to stand on its own. Even if health staff have
time to do a good job of explaining it at the time of vaccination, the
mother must be able to comprehend it once she has returned home and
time has passed.
. The card should show clearly four types of information: 1) which
vaccines are needed,2)the necessary number of doses for.each vaccine,
3)how many of these doses have been received, and 4)when to return
for the next immunization.
. The card should be attractive. Illustrations make the card both more
attractive and help it communicate the information.
. The card should be culture-specific. It should be in the local language
and illustrations, if used, should look like local people and adhere to
cultural standards.
. The size should be neither too small nor too large, large enough to
comprehend easily but small enough to carry easily.
Problem 17: Performance records show wide variations among

field workers. For example, in the same period of time,
some recruit over 100 family planning adopters, while
others recruit iewer than 20.
suggestion A: Examine the factors that could account for the

variations in performance, and develop and imple-
ment changes that would raise overall project effec-
tiveness.
E-"-pt"t F' f"-ily pl*t*ng project in rural Bangladesh, SOPIRET' conducted an

OR propct which identified-some differences in practices between high-and
low-performing field workers: high performers tended to carry more supplies with
them, spent more time with non-ubrs, w€re more likely to check client supplies
and visited clients more often; the low performers reported encountering consider-
ably more religious opposition in their areas, did not cover their prescribed
catchment areai, only visited current users, did not contact younger womel -and
did not discuss side effects. In light of these findings, SOPIRET decided to
implement the foltowing changes: provide field workers with messages and materials
to respond to religious concerns, emphasise discussions of side effects, implement
a uniform weekly work plan, and ask low performers to set targets for new adopters.
Despite externai disruptions to the programme, modest results were obtained: the
CPR rose, use continuition improved, reported pregnanicies dropped, and the low
26
performing field workers halved the-{ifference between themselves and the high
performerJ 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 effec-
tively.
Suggestion A: Conduct a skills assessment of CHWs. Develop a
list of skills needed. Design training to emphasise
skill development (as opposed to teaching informa-
tion). 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 repated practice of the actual skills needed.
It was reported that after three or four weighing sessions, community health workers
with minimal education levels could accurately weigh a child in very little time. The
use of the local market scale helped make this po-ssible, as it wai a familiar and
appropriate technology for the workers concerned.o
Suggestion B: Develop simple job aids that will help CHW's recall
points which must be discussed during counselling
sessions.
Example After research and testing, the Northwest Frontier Provincial Health
Service in Pakistan developed two memory aids to guide service delivery in key
interventions. These aids would.assist health workers to remember the relatively
large number of procedures to be followed in delivering a given intervention. One
of these aids consisted of a series oI relerence guides for each of the interventions,
which were placed beneath the Plexiglas covers of examination tables. A modified
outpatient dispensary slip served as a second memory aid. On this slip, health
workers were to fill in or check such key tasks as taking a history, conducting a
physical exam, providing treatment, and cotrnselling patients. A follow-up study
showed that health workers carried out diagnostic procedures with greater
frequency. Counselling also seemed to improve in both content and technique.
Clearly, memory aids such as these should not be constructed as a panacea for
27
resolving service delivery problems. While improvements can be made, other

problems willremain. Detailed information about the types of problems that impede
elfeclive service delivery enables,decision makers to implement simple corrective
measures that make a difference.'"
28
lllillliiliri$ilii;lri::I
Management function: Personnel and

training
Personnel management ensures that the organisation attracts and
retains competent people, that staff can be productive and efficient in their
jobs, and that they are recognised appropriately by the organisation for
their service.
Tiaining serves to continually improve upon the knowledge, skills, and
competencies of health workers so that service delivery or management
activities can be carried out correctlu.
Problem 19: 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 con-
ference, public recognition for their accomplish-
ments, 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 CHWs: make sure they understand what
the CHW's role willbe, and the CHW understands what the community
expects.
29
a Few opportunities for training, upgrading of skills.

a Lack of support from the project, i.e., travel, regular visits from central
staff, regular feedback, etc.
Inadequate frequency and/or effectiveness of supervisory visits.
some countries have found that having the community discuss and
implement financing mechanisms before the CHW is selected helps address
the problem of CHW sustainability and attrition. A project in Mauritania,
for example, requires villages to work out a viable financial plan before a
selected CHW can receive training''
Non-material incentives are also effective:
. 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.
o 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'
o Possession of charts, pictures, and simple equipment can help CHW's
communicate better as well as enhance their status.
o Another possibility is to routinely collect contributions to pay the CHW
from the community. This can take the form of produce or in-kind
services. In Swaziland, for example, the community plowed the cHws
field.
At monthly meetings, teach cHW's a new concept or skill, conduct
refresher courses to review knowledge and improve skills. In one case'
interviewing of CHW'S, community members, and supervisors led to
identificatio-n of factors leading to attrition. Among them was a desire
to learn more about curative services, which was incorporated in
training.
Career ladders are important for job satisfaction and retention. Some
cHW's in Northern Pakistan have gone into training as Lady Health
Visitors, while in other countries, some have become "senior cHw's"
and trainers after two or three years service. When they reach this level,
communities may be more willing to pay them a stipend, since this
requires more work, but also because it provides them with more
prestige.
a Provide free medical care to the CHW and his/her family'
28
a Exemption from military service'
Problem-solving; personnel
30
Many countries also finance CHW's (partially) through:

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

North-western Somalia offer some low-cost alternatives:
o Water tax on the village pump; a certain amount per household pays for a CHW,
pump maintenance.
o Shop and tea shop cash collection; travellers from outside the village indirectly
support community health.
r Insurance type collection; payment of a small fee
. Payment-in.kind; once-a-year livestock or grain collection.
r Waived village fees, e.g., for water.3
Example: A Kenyan study provided different sets of incentives to three groups.
One received token payments and a newsletter, the second received community
recognition and lapel pins, and the third group received all of the above as well as
diplomas for "healthy households." A healthy household was defined as one in which
all children under five years were fully immunized, which had a clean water supply,
which maintained adequate nutritional status for children under five, and which
practised family planning. The study found no difference in the performance of the
different incentive groups, but all group areas showed improvement in health
status.zc
Suggestion B: Keep in touch with field workers not only at regular

meetings/visits but by commenting on their reports,
offering praise where it is due. At monthly meetings
encourage a two-way flow of information. Give
feedback on the results of their work to encourage
commitment to the organisation and job. Discuss
31
performance and problems and, where possible, de-

velop new strategies together.
Feedback to workers is critical, not only to improve their morale and

effectiveness, but also to give them an incentive for reporting correctly.
Feedback can include:
. suggestions for improving record-keeping
. information that might be helpful in preventing or solving problems
. results of home visits to patients (or referrals)
. congratulations on doing a good job in delivering a service36
Feedback should be task-related, prompt, action-oriented, motivating,
and constru ctive.42
Example Profamilia, a successful family planning project in Colombia, addressed

tnir i.r'u" by rotating field workers into the health centre for a day so they could
experience in" n"dtn project from the manager's perspective and gain an under-
standing of the system and organisation.
Problem 2O: 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 re-
cruiting family planning workers.
Recruitment should be done using a job description outlining what the
responsibilities willbe and the skills and qualifications necessary to accom-
pliih them. Include attitudes and personal qualities you think the person
should have. This willensure tllqt you hire someone who can do the work
and with whom you can work.*"
A PHC project in two Bangladeshi upazilas found the following selection
criteria of CHW's useful:
. CHW'S should be permanent residents of the village. Avoid temporary
residents and job seekers.
. CHW'S should have good reputation in their area and be acceptable to
the people in their locality. Preterenceshould be given to traditionalbirth
attendants, traditional healers, women, retired officers, and those who are
already doing social work.
Problem-solving; Personnel
32
. Some basic education preferable. However, enthusiastic individuals active

in community service can be selected even if they are illiterate.Preference
is given to married women above 20 years oI ige.ao
Example: In Bangladesh, field workers whose characteristics are closer to those of

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

use. They can be especially effective as
family plan-
ning promoters and contraceptive distributors.
Project experience has shown that women counseled by satisfied
acceptors are less likely to discontinue use than those counseled by a
midwife^.alone; satisfied users are better able to reduce the fears of side
effects. tt Often, the adoption of a method by a charismatic and respected
local person can lead to rapid dissemination of the same method in a village.
Example: In Sri Lanka, satisfied acceptors with high community standing were
encouraged to motivate other mothers. This approach was found to be successful
and cost-effective. Satisfied acceptors were dffective in counseling womgn who
believed temporary modern methods have too many negative side Jffects. 37
Problem 21: There are not enough health workers to provide

elfective coverage. The programme is not having a
strong impact on family planning acceptance, or on
reductions in fertility.
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 couplel could be
marked in red on target couple registers for easy visual identification. This plan
was implemented in aproject in India and made a considerable contribution to the
success of the project.z
33
Suggestion B: Reduce client-worker ratios to increase frequency of

contact. Field workers should spend more time
with new acceptors.
Example: In a project in rural Bangladesh, reducing the client-worker ratios

enabled field workers to complete their visits on time and allowed more time to be
spent with each couple. Iqcreased home visits have been associated with increased
ctntraceptive pr.u ui.n
".2l
Suggestion C: One very eflective way to increase coverage is to
authorise paramedic personnel to distribute contra-
ceptives.
The use of paramedics to distribute contraceptives is beneficial for

several reasons. In developing countries, they already offer fairly wide
coverage of the population. Thus, once they are trained, they provide an
extensive base for contraceptive service delivery. Physicians generally leave
their villages to work in the cities, where the pay is usually higher, but
paramedics tend to live and work in the vicinity in which they were raised.
Also, because they work in the same area in which they live, paramedics
often have long-standing relationships with their clients, which contributes
to improved contraceptive use and longer continuation rates. Paramedics
can db much to extend contraceptive use and thereby reduce the incidence
of unwanted pregnancies. This, in turn, reduces medical complications,
unsafe abortions,lnd maternaldeqihs. Such benefits greatly outweigh the
risks attendant upon contraceptive use.
Example A pilot study in Thailand demonstrated the safety and effectiveness of

allowing paramedics to dispense oral contraceptives, usin-g a simple checklist for
contraiidications. Following the success of this trial, the Ministry of Public Health
ruled that all auxiliary nurse midwives who had received basic fhmily planning
training were authorir"d to dirttibute the pill. This immediately increased the total
numbei of providers offering the pill from approximatbly 350 to 3,500. The number
of acceptois rose from only 25,000 in the three months prior to,the ruling to over
35,000 in the three montirs afterward. One and a half"years later, over 80,000
women accepted the pill in a single three-month period. ""
34
tP;#$$i$$i:s$i;1\tE\\-a$,qsnr:i* $(.qi'Hrl[-!iFii;ii.il;lii.i.iiii:: ii;lllliflIl{llllll$til-q-\iiiij.{t#i"
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 bath-
room 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 mainte-

nance procedures were developed for scales and a manual prepared for staff at
health units. In-service training was conducted to improve workers' weighing
technique as well as refresher training to improve weighing skills and ability to
calculate age correctly.
Problem-solving; logistics
35
Mangement function: SuPervision

The supervision of personnel serves many critical purposes. It ensures
that staff perform thlir duties effectivelg through support, guidance,
on-the-job iraining, and assistance in identifying and solving problems. It
is a means to motivate and boost the morale of staff; to provide continuing
education and advice; to enhance field worker's credibility in the eyes of
community members; to assess quality and quantity of staff efforts; and to
gather othier information which can be fed back to programme staff and
community members.
Fieldworker performance has improved when supervisors make home
visits with workers and question clients about the worker's activities in the
p."r".,." of the field worker, when supervisors discuss the client's Prgrblem
with the field worker, and when the supervisor visits clients'homes.'^
some general strategies to consider to improve supervision:
. A regular village visitation programme where staff spend one full week
t*o months - nearly six weeks per year - in.each community can
be ai essential part of efforts to reinvigorate health workers and restart
"unry
health-related ictivities in the villages, if they have slackened.
. Regular meetings with CHW's ensure that potential problems can be
handled early on'
o Use two-way oradios, especially in isolated areas' to supervise, inform,
and motivate.'
Problem 24: Ineffective and infrequent supervision of CHW'S.
Suggestion A: Supervisors should use guidelines andchecklists for
actual tasks performed by staff and field workers'
Have supervisors emphasise feedback on technical
skills raiher than on administrative ones' Staff
should have a job description and performance ob-
jectives to know what is expected of them and how
iheir performance will be appraised' Cqnduct peri-
odic performance appraisals to make sure objectives
are met and to discuss any problems CHW's are
having.42
"CHW'S have been found to benefit from high quality and frequent
supeivision and from unusually motivated community organisations; where
these have been lacking, CAW'S have poor morale and high dropout
Problem-solving; suPervision
36
rates."28"when supervision is ineffectual or focused o11 clerical matters,

an
increase in frequency had no effect on performance."3l
99-" simple tasks that -can improve supervision include revising
guidelines for content and frequency of supervisory visits; identifyini
appropriate personnel for supervision; using standardized checktists foi
monitoring and forms for inventory control.
Example: An operations research project in Bangladesh found that high perform-

ing supervisors: visited more homes with the field workers; asked clieits whether
they were screened for contraindications and had side effects explained to them;
had more extensive and frequent contact with field workers; and ch?cked
on client's
contraceptive supplies. Field workers in high performing programmes followed
a
regular visting plan, visited homes more oftJn, visited non-u."r-r more often,
varied
messages to suit the listener, promoted the advantages of contraception
more
forcefuLly, an"d provided more thorough information on method
use and on possible
side effects.r/
Example: In Guatemala, the major factors for high turnover rate among cHw's
and- ensuing loss of community confidence were irrlgular and insufficient
of drugs and lack of supe_rv-ision. The dropout rate was two to three timlsirovision
higher
among- unsupervised cHW's than among those with regular supervision.
-cHw In the
eyes of the community, the supervised seemed io e"py i"creased status
because of the evident-link to_outside projects in Mali and Niger have
also noted that for illiterate cHw's, "*[rtir".
-orl p"rronal contact is indicated and that
literate CHW's can be effectively supervised with a mixture p"ironut contact and
correspondence.- "t
Problem 25: Staff have a limited amount of time to perform
duties. Coverage and hence prevalence of family plan-
ning 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 activitiel, the CHW
-"Lt *ith
specific groups of mothers to provide education on a
common problem to save time. This willalso provide
an opportunity to learn different teaching skills.
Problem-solving supervision
37
Example: In Bangladesh, a community-based service project active in 24 urban

areas identified problems in client coverage, record keeping, planning and supervi-
sion. Three -uttug"*"ttt interventions (work plans for field workers, a reduced
client-worker ratio, and a simplified record-keeping system) helped improve cover-
age, supervision, and services, The most ellective 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'l they ensured regular visits to MWRA's;
and 3) they facilitated supervision. The main disadvantage was "serial
visiting." All women had to be visited in turn, which precluded revisits
to those women who needed to be seen sooner.
Better record keeping and improved monitoring. The new
system was simpler and less time-consuming. The main advantages:1)
ii systematised record keepin g; 2\ helped promote eflectiv e supervision
and monitoring;and 3)helped in evaluating field worker performance.
The main drawback, it didnt produce all the data needed for reports to
donors. Thus, both the new and the new and the old system operated
side by side, which increased the workload.
Reduced client-worker ratios improved coverage. Two of the
three projects that implemented this intervention hired additional field
workers and adjust"d some of the catchment areas to reduce the
client-worker ratios. The third project increased the number of assigned
couples per field worker, thus increasing the ratio. where the ratios
*"te r"du."d, staff reported that the main advantages were that:1) field
workers completed their visit cycles on time; 2) more time could be
spent with each couple; 3) more low-parity women coqld be recruited;
and 4) new acceptor targets could be more easily met'"'
Problem 26: lbo many tasks are assigned to cHws. Tasks do not
have a clear priority.
Suggestion A: Institute work plans for field workers to help sys-
tematise activities and establish priorities.
An effective work plan minimises travel time, maximises client con-
tact, and systematicaliy covers all eligible clients in the assigned catch-
ment area.
Problem-solving; supervision
38
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
Ptoblem2T: Opportunities for immunization are often missed,

even when a child does make contact with a health
facility that is prepared to vaccinate.
Suggestion A: liy to identify reasons for missed opportunities. Ask
yourself some questions: Is the health centre too
busy? Do health personnel have to review each
patient file to examine the immunization record? Do
waiting times and case loads preclude attention to
immunization? Can patient intake procedures be
better structured to help minimise the chances of a
missed opportunity? What is the best time in the
visit for a child to receive immunization? Use an-
swers to these kinds of questions to reorganise your
clinic's system for immunization and patient atten-
tion. More sophisticated studies might include in-
depth interviews at a clinic, health workers'interpre-
tations of national EPI policies, observations about
how health workers calculated ages and dose sched-
ules, and observations of clinic organisation and
supply systems.
Example: In Lagos, Nigeria a paediatric clinic reorganised itself to reduce waiting

ti.me_sby setting up a separate vaccination station and then vaccinating all sicl
children after they had received treatment for illness. Coverage rates acielerated
with no increase in cost, and staff work load decreased because staff no longer had
to do a full medical history and examination to prepare for vaccinations. Waiting
time for siqh -patients fell as the ones coming for vaccinations only *"r" seru"d
19
separately.
Example: The EPI in Mozambique reclassified its immunization schedules and reorganised
its clinics sothat yaccinations are no'.r,r given at the time a child registerq seriouly sic[ Ehildren
are',raccinated before leaving the clinic or soon after a required hospitalisation. 19
Problem-solvin g; supervision
39
Example: The village health centre personnel in some rural health centres in
Honduras wilt not provide consultations unless the mother presents the child's
vaccination card for verification. Children who are missing vaccinations are easily
identified, and the importance of immunization is emphasised at each visit.
Example At a health centre in Manila, a campaign was started that introduced
changes designed to reduce missed opportunities;l) measles vaccination was made
available for use at least once a week in every health facility, and the health facility
remained open until 8 p.m.to allow working mothers to bring their children, 2)
there was a relaxation of wastage allowances so that the health workers could open
a new vial for only one child, and 3) a communications programme was initiated
among health centre staff about the importance of measles immunization. A survey
performed after the introduction of these interventions showed that missed oppor-
tunities for measles decreased by 20 prcentage points'lg
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, irrl-
plementation, and evaluation process. Supervision
iystems that use this system and provide direct and
concrete feedback to workers on how they can
improve have been found to be quite eflectlve.
Many project reviewers have emphasised the importance of developing
and using performance guidelines that divide the growth monitoring
process into at least five discrete tasks (motivating, weighing, recording,
interpreting, and taking action) and then clearly describe the specific
behaviours or actions that need to be completed at each step. They may
be developed initially for a variety of purposes, such as training, to serve as
checklists for supervisors or workers or to^serve as tools for systems
analysis, project monitoring, and assessment27
When developing a supervision strategy also consider including the
following elements:
. targeted supervision schedules
. supervision forms
o task performance norms
o training of supervisors
. improved supervision "style"
40
r time available calculations

. number of supervisors available3S
Example: A study in Togo had supervisors spend more time at health centres. A
day's activities were observed rather than just the growth moriitoring session.
Feedback was provided to staff at the end of sessions. Supervisors focused on skills
such as balancing the scale, reading and plotting weight, communicating results to
the mother. Findings were used to train personnel in calculating a child's age,
interpreting the growth curve, tailoring individual recommendations.
Supervisors also took note of counseling, observing whether mothers received.
specific messages, whether the chart faced the mother when she was receiving
feedback, and whether mothers were able to interpret the chart.
Supervisors identified and corrected mistakes and interacted directly with the
staff and mothers. Staff showed increased motivation and made fewer errors.
Mothers became more active in interacting_wlth staff in identifying and resolving
problems related to their children's growth.d
Problem 29: Lack of organisation in growth monitoring,/ supple-

mental feeding projects.
Suggestion A: Implement new selection criteria to focus the pro-
gramme. Select those children who are most mal-
nourished and those whose growth is faltering.
Weigh these children each month and provide spe-
cific steps and strategies for the mothers to under-
stand and resolve the problem.
Organisational problems can be related to the size of the session and
the amount of time available for weighing and examining, interpreting
growth charts, receiving information from the mother, and providing results
and advice. Programmes in Togo and other countries have reorganised
clinics so that mothers distribute food, increasing counseling time and
reducing overall session length.
Problem-solvin g; supervision
4L
Example The Kasa Project in India makes sure that those children who are
nutritionally at risk - those who have low nutritional status fail to gain weight e','cry
three months, lose weight over two months, or are sick - are weighed every month.
Other children are weighed every three months'
Example In the Dominican Republic, participation criteria include both age and
nutritional status. All children under five are weighed once ever six months in order
to compile a community profile; then high-risk children are selected and weighed
monthly. These children include all those under one and children three tg-five who
at"'cias'sifi"Jas -ufnourirnJ oi*no f'taue gainea sufficient weigl'tt.$
"ot
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.
bxampler A health centre in Honduras divides groups by degree of malnutrition,
thus allowing specific and targeted communication with mothers.
l
42
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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. Dont overlook them. Problems and opportunities can be
thought of as the "gab" between what is happening and what is desired. By
correcting problems and making improvements you willclose that gap.
Step t ldentify, select, and define the problem
Begin seeking out potentialproblems or areas for improvement through
existing information or data. Many teams have begun this process by
brainstorming to list khown areas of problems and frustrations. If the team
members do not have ideas on potential problems, then you need to gather
more information from other staff.
As you develop your list of problems, there are some dangers. You should
be aware of them so-you can avoid them or take corrective action when
they are discovered:
. You can become overburdened with problems; identifying more than
you can handle.
. You can raise y6ur people's expectations so that they believe that you
or someone else will fix their problems immediately.
. You can get side-tracked and identify others' problems but not your
own.
' Adapted frun; Peace Corps training, 'Continuous quality improvement and the problem-solving
process; continuous medical edrrcation.'Peace Crops Office of Medical Services; URC/CHS,1992.
Problem-solving; process
43
problem-solving process
A gap between what is happening and what you want
Identify, select, and define the problem and clarify the
desired results
Seek out potential problems or areas for improvement. Define
criteria for selecting the most important problems' Define the
selected problem operationally: how do we know it is a problem?
Determine how we know when the problem is solved by Bninrlsb
criteria for success. This is NOT the same thing as defrning the
solution. Choose a team to work on the problem.
Learn everything about the existing process
Determine where and when the problem is occurring. Understand
the process in which the problem occurs.
Determine the basic causes of the problem or where the
process is flawed
Determine the factors that contribute to the problem. Use tools to
generate and test hypotheses about possible causes of the problem.
bollect data to test hypotheses and determine which causes are the
"critical few."
Identify all possible solutions .
Think creatively about how the critical causes might be addressed.
Choose a solution to imPlement
Analyse the possible solutions against their ability to meet your
criteria for success, the costs involved, the feasibility of
implementation, or other criteria.
Pilot test the solution and evaluate its effectiveness
This is the Plan-Do-Check-Act cycle. It involves planning out the
steps of implementation (including addressing resisfon ce to changeJ,
doing it (implementing the solution), checking out whether it had the
desirld effect (monitoring the results), and acting on what you found
(modifying the solution, changing to another solution, extending
implementation).
44
Selecting a problem
You cannot work on all problems at the same time. The list is usually
long and needs to be narrowed to the most important areas. For initial
problem-solving activities, it is best that the problem is a small or a
well-focused issue, emotionally appealing, one that others can readily see
the value of solving, and one where data are relatively easy to obtain.
Other criteria are needed to narrow down the list. The problem should
be considered to be important to the people working on it. It should be
feasible (size and complexity are manageable), the benefit of solving the
problem should be worth the cost and effort required, and there should be
support for changes and improvements in the current process.
Define the problem operationally
Many problem-solving efforts go astray because the group does not have
a clear and common understanding of what it is supposed to solve. It is
best to develop a statement of the problem in specific and observable terms.
The answers to the following questions willassist in defining the problem:
o What do you think is the problem?
o How do you know it is a problem?
o What are the effects of this problem?
. How long has this been a.problem? How frequently does it occur?
o How will you know the problem is solved?
o Where do you want to begin looking at the problem? And where do
you want to end looking (boundaries of the problem)?
The problem statement should answer these questions, be measurable,
and be process-oriented. It should never give or imply any preconceived
indication of what the cause might be, state or imply a particular solution,
or affix or imply blame for the problem.
Choosing a team
Problem solving is most eflective when those involved in the problem
participate in analysing it and developing solutions. Once the problem
statement is written, the next step is to answer the question, "Who knows
about the process where this problem is found?"'lb answer this question
you may need to do a flow chart that identifies the major steps in the process
and helps you to focus on the key problem area. Once you know the key
problem area(s), ask yourself the following questions:
45
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.
a Who might help solve this problem?
a Who can help you understand this problem?
These people will provide special knowledge, insights, and services
during your problem-solving journey. some you will work with closely,
otheri you may just call on when you have a specific need.
Step 2z Learn everything about the existing problem
start with what you know about the problem: clarify your understand-
ing of what is presently happening. Analyse the data that you already have
to-see if you.in uttr*"t the "who, what, when and where" of the problem.
Very often people do not have a clear picture of the process, especially
the links between what they do as individuals and the work of others in
the process. A flow chart is a useful tool to help you understand how the
proi"tt operates. If you use a flow chart, be sure that it reflects the process
is it actually functions so that everyone is working within the same context.
Step 3: Determine the basic causes of the problem
Effective problem-solving involves identifying and understanding the
root causes oi th" problem so that an appropriate solution can be chosen.
There are three steps to identifying root causes; 1) identify all potential
causes, 2l develop t6eories of cause, and 3) collect data to test theories of
cause.
Identify possible causes
In order to identify the root cause, you should generate a list of as many
potential causes of the problem as possible. An excellent tool for helping
io organise and sort your ideas and to begin creating theories is the
causeland-effect analysis. A cause-and-effect analysis helps you to look
beyond the symptoms of the problem, which reflect the manifestation of
the cause buf do not necessarily indicate the specific cause. A cause-and-
effect analysis pushes you to ask, "What causes that and what is behind it?"
It is also designed to bioaden your thinking about causes and explore other
areas that might be contributing to the problem.
46
Develop hypotheses of cause

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

It is important to remember that all the causes you have generated are
only theories. Now it is time to collect data to prove or disprove these
theories: specifically, the goal of data collection is to test theories of cause.
Data collection is the key component to making improvements. Your
picture of what is going on must be based on facts, not opinions or
assumptions. Data collection can also be used to reveal areas for process
improvement, verify the existence of a problem, assess the effectiveness of
a solution, and prevent problems.
Step 4: Identify all possible solutions
Once the root causes of the problem have been identified, it is time for
the group to think creatively about how they can be addressed. Selecting
a good solution involves having a range of good options from which to
choose. The following are suggestions concerning how to ensure that as
many solutions as possible are considered:
o Review steps 1-3 (defining the problem, learning about the existing
process, determining the basic causes). Once again look at the precise
problem, the unfulfilled need, and the people involved.
o Brainstorm to get ideas. Be sure to consider conventional, minor, and
unconventional solutions. Don't forget your past experiences!
. Clarify each suggested solution.
. Involve people outside the group. Look for those who may be doing
similar tasks, even if they are not in the same business. This is referred
to as bench marking. You can find out what others are doing through
interviews or surveys.
The irnportant thing to remember when you are developing solutions is "to
think outside the box," to get ideas from other rour.es, io Jvoid evaluation,
and to ensure that everyone has a common understanding of the suggested
solutions.
47
Step 5: Choose and implement a solution

Once you have identified as many solutions as possible, it is time to
ut utyr" thLm to determine which is the best one to implement. As in Step
1 (siecting the problem), you must determine the choice by examining
criteria and constraints'
Criteria
Typical criteria for solutions include:
. Costs of the solution
. Technical difficulties of implementation
e Potential side effects
. Resistance to change
. Time required to implement the solution
It is also important to distinguish between which criteria are a "must"
in order to be cbnsidered and which are only "wants"'
Constraints you
constraints are unchangeable factors that will limit the options
can realistically consider. 11 is important to note that these constraints
should be chailenged and tested prior to acceptance, for
many times
things that are considered "unchingeable" are, in fact, flexible'
Decision maklng
each po-
Once you haveldentified the criteria and constraints, discuss
teniial soiution in lighi of them . During this discussion
phase, identify
positive and negati,ie .ont"qu"nces of the atternatives. Essential to ef-
in active discussion
id;; d;;;ioninaking is th'e amount of time spent point of view'
;;;;il;;; must feet ireetopresent his or her individualfeel that they have
once the team reaches a point where the members
tools for
sufficient information to make a decision, it can-employ
various
or by using
a".irio"-.aking. These decisions can be made by an expert
rank ordering, multivoting , and/or matrices'
Step 6: Implementing quality improvement solu-
tions
There are four steps to effective implementation of solutions:
. plan the imPlementation
. do the implementation
. check the results of implementation
Problem-solving; Process
48
. act on what you find, by either continuing implementation, modifying

the solution, or returning to look for a better solution
Plan: Before you start implementing the solution, you need to deter-
mine the objectives and criteria for success. You must also decide who,
what, where, when, and how the solution willbe implemented. It is im-
portant to clarify your assumptions at this stage and to think about pos-
sible resistance you might encounter. Finally, you need to decide whit
data to collect to monitor implementation.
Do: Implementing the solution often involves providing training and
always involves collecting information to monitorongoing changei and
ease of implementation. observe how implementation isleing iarried
out. Document anything that goes wrong: Every problem or error is an
opportunity for improvement.
check: observe the effects of implementation and draw conclusions
about "lessons learned."
Act: Thke action on what was learned: Adopt the solution, abandon
it, or go through the cycle again to test modifications.
I
51
iliilitriiilli#if,siiriitc*#pr.s$l#iafrffi iEgffiltFiH+ti$i;Jilitiljiiiliiii,:;i'j1l
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-- Center
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;;;i;"i solutionr improving heJlth worker performance." -.!g-uqlgp
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b;ids;'il;lR;;;;i.s"[n"'aalMarvland,June,lee0'
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Suruiual Report
13. Chowdhurv, M. "Evaluating community oRT programmes: Indicators
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project Olqq2ing. International Development Institute, BloomingtOn,
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Mrginia, 1989.
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Community organisation. PRICOR, May, 1985.
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UNICtr, Septembea7985.
19. Grabows_k_y, M. _lu!iss9d, ôpportunities for immunization. REACH,
Rossyln, Vrginia, March, 1991.
20. Hendratta, L. Consultant report t'or Thailand. International Nutrition
Communication Service, January, 1.983.
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No. 4, July,/August, 1989.
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ington, D.C., n.d.
54
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, pertussisand tetanus vaccines
EPI Expanded Programme on 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
TB,{ Traditional birth attendant
TT Tetanus toxoid
URC University Research Corporation
VCEI Village community endurance institution
VDC Village development committee
VHW Village health worker
WHO World Health Organization
Problem-solving; acronymr
PHC MAP MANAGEMENT COMMITTEE
'. i!$'\ 1 i', i rI;ii
Dr. Ronald Wilson o Aga Khan Foundation, Switzerland (Co-Chair)

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

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THE PHC MAP SERIES OF MODULES.

Each module includes:

Production Managers: Ronald Wilson, Aga Khan Foundation, Geneva, and

An overvi€w of PHC MAP

Health and management services

Several Manager's guides supplement these modules. These are: Better

MANAGEMENT FUNCTIONS: Community organisation """ 6

General Immunisatlon ORT Famtly Growth Breast

:l.iitfiii!!.!.W!i.#, -P#i1.ffi'! i tii:i!':':*it:!iiii'i

Common problems in primary health care

Information, education and communication

Problem-solving; common Problems

Information systems and record-keeping

Personnel and training

Problem-solving; common problems

Problem 20: Family planning workers are not accepted by the

Problem-solving; common Problems

Problem-solving; community organisation

Problem l: Even though project interventions are acceptable

Problem-solving; community organisation

Example In the Bwamanda Health ZoneinZaire,the zone hospitalpractised this

Problem 3: Utilisation and support of health programmes are

Problem-solving; comrnunity organisation

ln general, projects successful in involving communities have been those:

Problem-solving; community organisation

tion and leadership have increased. 33

Suggestion C: Reorganise the programme to intensify home visit-

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

Problem-solving; community organisation

Suggestion D: Disperse service sites to increase outreach efforts.

Problem 4: Family planning activities are hindered by a lack of

Quality oI care is increasingly being recognised as an important deter-

Problem-solving; community organisation

Example A study was conducted on the impact of information given to clients on

Suggestion B: Identify dissatisfied clients and visit with them to

Example: In a district of the Indian state of Andhra Pradesh. dissatisfied clients

Problem-solving; community organisation

Management function: Information,

Problem 6: Despite high recognition of ORT among mothers,

Extensive field experience with ORT has demonstrated that programme

Problem 7: Family planning messages are not well received

Example The second Population Project, servicing zooto of theegyptian popr.rla--

Problem 9: Mothers are not alert to changes in their child's

Eximplet It is customary in central Ghana, as in many cultures, to make a string

Problem 1O: Mothers do not recognise the importance or utility

. Weighing frequently, as often as every month or two,

Problem 1l: Health workers have difficulty convincing mothers

Problem 12: Supplementary feeding programmes do not rein-

E-.-pl", A" innovative activity in a programme in Thailand has been the

Suggestion B: Recommend appropriate local foods which are al-

suggestion c: separate food distribution activities from growth

Example The Tamil Nadu project (TNINP) in India experi-

Management function: Information systems

Problem 13: Referring providers do not learn from their referrals.

Example Each coloured tab corresponds to a different condition, such as preg-

Suggestion B: Make charts easier for CHW's and mothers to use

Problem 15: Record-keeping and reporting requirements are time

Example: An evaluation of a programme in Karachi, pakistan, found that health

Example An analysis of Thailand's PHC management system revealed that most

Problem 16: Poor record keeping by field workers.

This experience suggests the following guidelines for vaccination cards

Problem 17: Performance records show wide variations among

suggestion A: Examine the factors that could account for the

E-"-pt"t F' f"-ily pltng project in rural Bangladesh, SOPIRET' conducted an

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