LHW Management Review - Oxford Policy Management

LHWP – Management Review
communication channels backed up by supervision to provide the message that poor
families need greater support.
• Increased collaboration with other organisations that provide basic safety nets would
enable the LHW to provide services to the very poor.
6. What have been the benefits and tensions of expansion from 37,000 LHW to 90,000
LHWs?
• Given concerns about financing and management capacity being insufficient for
Programme expansion, the Strategic Plan proposed a review that would include the
options of reducing the target number of LHWs or allocating more resources, or
modifying the level and package of services being provided by LHWs. It is not clear
that these options were in fact reviewed. Rather it appears that the target of 100,000
LHWs was just retained and more resources were allocated.
• Proposals for expansion of the Programme by Government need to consider the
implications re: funding, sustainability, the opportunities for increasing coverage into
remote areas; the functioning of health facilities and the organizational capability of
the Programme.
• The greatest period of expansion was between 2001 and 2003. The rate of
expansion since then has slowed considerably.
• While provincial allocations remain fairly constant there is an uneven pattern of
expansion between districts. In comparison with 2003, 13 percent of districts had
fewer LHWs in 2008. A further 20 percent had only increased by within 10 percent. In
15 percent of districts, expansion was over 50 percent.
• Expansion has resulted in LHWs now having to cover fewer health facilities, due to
health facilities increasing the number of LHWs per facility and in addition, the ratio of
LHWs to LHWs has reduced.
• Expansion has resulted in greater coverage, although there are still poorer areas
where there is no or very limited coverage.
• The Programme has also managed to upscale using the same mode of operation. It
is a credit to the original designers of the Programme that this has been possible.
• However, there are tensions associated with expansion, in particular for larger
districts. These are resolvable. Essentially there needs to be an increase in
managers responsible for the LHWs. There also needs to be an increase in
resources at the district level that support good human resource management and
organizational development.
7. Has the Programme managed to deal effectively with non-performing LHWs?
• While the Programme has made a big effort with strengthening positive incentives for
LHW performance there are still a significant number of non-performing LHWs. The
benchmark used for service provision in the survey shows that the bottom 25 percent
of LHWs are only delivering one third of the level of service provided by the top 25
percent, the High Performers.
• These High Performers are making a significantly higher impact on health in their
communities. Communities with non-performing LHWs are not getting the services
that they deserve and that the Programme is paying for. The Programme needs to
strengthen its ability to manage non-performance by terminating those LHW who do
not wish to provide a service.
• To do this the Programme could provide more accountability and support to the
district. This might include additional managers for the teams of LHSs – and, in
particular, increasing the number of Assistant District Coordinators (ADCs) to ensure
one-on-one support and supervision is available. A maximum span of control needs
to be established of one manager (in particular the ADC role) to around 15–20
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