LHW Management Review - Oxford Policy Management

LHWP – Management Review
• tolerating non-compliance; for example, by the 25 percent of LHWs providing a low
level of service; not maintaining the residency criteria in Sindh, and LHWs working
outside their catchment area; LHWs charging for services; not enforcing the minimum
levels for registration of household and client per LHW;
• 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; and
• 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 become effective.
3.3 Expansion and consolidation
Between 2001 and 2003, the Programme underwent a period of rapid expansion, from
38,000 LHWs to around 70,000. Between 2003 and 2008, the period covered by this
evaluation, expansion was at around 25 percent. The Programme is now only 10,000 short
of the target of 100,000. Programme expansion occurred both through the LHWP extending
coverage to previously uncovered health facilities in more disadvantaged areas and through
the recruitment of further LHWs to health facilities that were already a part of the
Programme.
The LHW is now established as a community service provider that is recognised by the
community for the services that she is able to deliver. The LHWP is able to provide services
to the community, and in all provinces and regions of the country.
3.4 Service delivery
The LHW is delivering a higher level of service to her eligible clients (although she has fewer
of them than she had eight years ago) in all provinces/regions. However, the average
number of clients registered per LHW has dropped from 980 to 929, and the number of
households registered has fallen from 145 to 133.
There also remains a substantial group of under-performing LHWs, however, that are
providing a very low level of service to their community and are failing to have an impact.
LHWs play an important role in the provision of preventive and promotive health care
services. The level of provision varies with the type of service. Many services reach around
half of the eligible clients, but some have higher coverage: vaccination promotion reaches
three quarters of children under three years of age. There have been substantial
improvements in the coverage of family planning services. High-performing LHWs are likely
to deliver relatively high levels of all services.
The 4th Evaluation has identified some factors under the control of the Programme that
contribute to an increase in LHW performance and knowledge:
• LHSs who provide monthly supervision (where they visit the LHWs and their
households – with and without the LHWs – and use their checklist) have higherperforming
LHWs. The ratio of LHSs to LHWs, whether it is 1:10 or 1:30, does not
affect performance. What is important is that the LHS monitors, on a monthly basis,
according to procedure;
• the more knowledgeable the LHS, the more knowledgeable the LHW;
• functioning health facilities where an individual person has responsibility for the
Programme;
• district management support where the EDO-H fulfils a leadership role, and there is
managing and monitoring by the DPIU;
10