LHW Management Review - Oxford Policy Management

LHWP – Management Review
• The building of partnerships with non-governmental organisations (NGOs) has been
limited. There was limited partnership building with NGOs at the national level.
Individual units of the Programme are not authorised to initiate projects and
partnerships. However, we can use training programmes as an indicator of other
activity. From the results of the survey of LHWs it is clear that a reasonable number
of them have attended training courses that have not been authorised by the
Programme. This presents risks, both in a lack of control of the quality of the training
and of the LHW becoming confused as to her priorities in service delivery;
• The EPI policy of the national administration of various childhood vaccines by LHWs
was not fully implemented 5 ;
• The planned reviews in areas of high expenditure (salary policy; development of a
fleet management system; improvement of the logistics management system.) did
not occur;
• In addition, the Programme failed to address some difficult problems. These include:
the significant number of LHWs in Sindh being non-resident in the area served; the
lack of sanction on non-performing LHWs; the write-off, disposal and replacement of
outdated vehicles; and on-time procurement of drugs.
Any organisation has limits on the amount of management attention available. In a
bureaucracy working in a challenging environment, such as rural Pakistan, this attention is
quickly absorbed by day-to-day operations. And so it is with the Programme. The
governance arrangements of the Programme are there to allow management (both internal
and within the ministry and departments of health) to provide leadership and to make and
implement the necessary strategic decisions. That they have generally failed to do so
became evident as we addressed the seven questions of the management review. Some of
the issues that were not addressed are as follows: options for decentralisation, noncompliance
with residency criteria in Sindh, issues of integration with Basic Health Units that
have been contracted out to non-governmental organisations and further expansion in urban
areas at the expense of development of the Programme into poorer rural areas. These are
issues that needed to be exposed by the National Coordinator of the Programme, addressed
through the governance committees, and on which decisions needed to be taken to resolve
the issues by the Secretary of Health and the central agencies.
The Programme managers must now plan for the future. There are emerging risks that must
be managed by the Programme. These include:
• Tolerating non-compliance; for example, by the 25 percent of LHWs providing a low
level of service, LHWs not maintaining the residency criteria in Sindh, LHWs working
outside their catchment area and/or for other organisations, and LHWs charging for
services. The Programme needs support from government to apply sanctions for
non-compliance.
• The lack of accountability of the Programme to the government for full
implementation of the Strategic Plan and the PC-1 between June 2003 and June
2008. There needs to be a more formal system of reporting against key performance
indicators. The Programme also needs support by government to implement
initiatives that will ensure development and risk management.
• Rapid turnover in management positions at all levels in the Programme presenting a
risk that managers are not in position for sufficiently long periods to provide
leadership. In addition there is a shortage of expertise in the management of the
fleet, procurement, and logistics management at senior levels.
5
This is a separate policy from that of using LHWs a mobilisers on National Immunisation Days.
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