LHW Systems Review - Oxford Policy Management

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LHWP – Systems Review• Contributing factors Duration of service and level of education contribute to thelevel of LHW knowledge. Knowledge is also at a higher level amongst those LHWswho received training at their last monthly meeting at the health facility, and for thosewho attended the food and nutrition training in the past year. However, a significantimprovement is gained through attending Counselling Card refresher training.Knowledge scores of LHWs who have the counselling card manuals haveconsiderably higher knowledge scores;• Refresher training This can make a significant difference to knowledge andperformance, depending on the topics and the training materials. Counselling Cardrefresher training is improving knowledge and the Revised MIS tools refreshertraining significantly improves performance;• Trainer training Essentially, the system has remained unchanged during this PC-1.It continued to deliver core training of LHWs and LHSs using the trainer trainingmodel;• Training system The training provided for the expansion of the Programme between2003 and 2008 was managed in a similar manner to previous expansions. Thesystem increased its throughput with a substantial programme of refresher training;• Quality of training The quality of training will become more important as theProgramme expands into difficult areas. It has to improve in order to substitute for theyears’ of experience and education of LHWs. The Programme needs motivatedtrainers who are prepared to improve the quality of their training. The solution willneed to have both incentives and sanctions;• Cost of training Training expenditure is low, at just 3.76 percent of the totalexpenditure. Additional budget to increase the quality of training might well bejustified;• Curriculum development While the core system of delivery through trainer trainingremains, there has been conservative curriculum development reflected in the corecurriculum and the refresher training modules;• Keeping the Programme focus on the role of the LHW and scope of servicesThe Programme mitigates the risk of enthusiastic stakeholders driving change byemploying an incremental approach where the change is clearly tied to the role of theLHW and the services she provides (refer to Management Review);• Unapproved training programmes LHWs have attended unapproved trainingprogrammes, causing a risk to quality control and to the perception of the role of theLHW, both by the community and herself;• Contracting out the management of the Basic Health Units This has to lead tocases of trainers not being made available by the contractor for the trainer training forthe facility staff. There have also been examples of where facility staff members wereno longer permitted to train LHWs. Some of these issues have been resolved insome districts but the experience does show up the risks of disintegrating the LHWPfrom the core health service provision;• Contributing role of development partners Amongst development partners, theProgramme’s training system appears to have the strongest relationship withUNICEF and UNFPA, both working in areas of maternal, child health, and familyplanning. In addition to supporting pilots and refresher trainings, these partners alsosponsor two long-term consultants to the Programme, who have been influential inthe development and maintenance of the integrity of the training system; and• Risk to the training system There is some anxiety that the training and theinspection system are very reliant on the dedication of these two long-termconsultants, and that the Programme has not succeeded (and with frequent transfersof staff, is unlikely to succeed) in developing their successors. The view of theevaluation team is that the main risk is not to the training system, per se, as thesystem is not complex. Rather, the risk is in losing the long-term advisors, who act toprotect the integrity of the system. This risk could be mitigated by strongervi
Programme leadership; the functioning of the oversight and managementcommittees, who would support the Programme’s values and strategic directions;and by retaining senior managers on the merit of their performance. 6Logistics management system• The supply system for medicines is performing poorly The Programme did notsucceed in achieving its performance targets. There is a significant number of LHWswho have been without various medicines for over two months. In addition, there is ashortage of non-drug items. The regular supply of drugs and contraceptives isimportant for the performance of the LHW. The main cause of lack of supply ismanagement of procurement and the level of funding;• Logistics expertise The management of logistics requires expertise andmanagement attention. Core elements of the system are the responsibility of theMinistry of Health (procurement and quality control, and budget approval). TheProgramme is primarily responsible for estimating demand and for distribution. Whilethere are some dedicated logistics officers, expertise in logistics is reportedly low inall functions. The planned review and re-engineering of the logistics system did nottake place;• Delays caused by the procurement process This places stress on the logisticssystem. Higher priority and attention need to be given to the timetable forprocurement, or for holding a higher level of supplies in the system to prevent stockouts;• Insufficient procurement There were insufficient funds spent for each LHW to haveher full supply. This is true, even though there were fewer LHWs working thanplanned. Drugs and contraceptives were planned to be 24 percent of the budget.Actual expenditure resulted in their being only 18 percent. The PC-1 specifies themonthly requirement of the LHW for drugs and medicines. No item was procured tothe quantity forecast per LHW in the PC-1;• Distribution The Programme does expend a great deal of effort in managing thetransportation of logistics, both from the PPIUs to the DPIUs and from the DPIUs tothe facilities;• Training The logistics manual and the accompanying training are positive initiatives.However, training probably only has a shelf life of one year due to turnover ofmanagement and logistics staff;• Warehousing Around 15 percent of districts reported not having their owndesignated storage space. These districts place their stores wherever they can find aspace, including in corridors and offices, hostels and wards. Of districts that did havestorage facilities, only one fifth met the criterion of a minimum storage space of fivesquare metres per LHW. Access to suitable storage space has become an increasingproblem with the need to store larger quantities of medicines as a result of anincreased number of working LHWs in the district; and• Logistics monitoring Four out of five districts reported having their logistics systemmonitored in the past year. This is commendable, but monitoring has to lead to actionby Programme management.Stipends/salaries and payments system• Delays in payments The payment of salaries is the main Programme expense. Theefficiency of the system was monitored in the Flow of Funds study. However, whilethe Programme reports that there have been increases in efficiency in recent years,at the time of the evaluation, there was a shortage of funds being released and, onceagain, there were delays in payments;6This is explored further in the Management Review, August 2009.vii
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Transportation9 Transportation‘We
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Conclusion11 ConclusionThe performa
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Annexes77
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AnnexesAnnex B Personnel positions
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AnnexesAnnex C MIS and the measurem
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AnnexesTable C.4Strategic Plan KPIs
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AnnexesTable C.6Specific objectives
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LHW Systems Review - Oxford Policy Management

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