ASSESSING THE QUALITY OF MANAGEMENT
Item
- Title
- ASSESSING THE QUALITY OF MANAGEMENT
- extracted text
-
Primary Health Care Management Advancement Programme
ii
—X~
ASSESSING
THE QUALITY
OF MANAGEMENT
AGA KHAN FOUNDATION
THE AGA KHAN UNIVERSITY
Primary Health Care Management Advancement Programme
ASSESSING
THE QUALITY
OF MANAGEMENT
Lori DiPrete Brown
University Research Corporation
MODULE 7
USER S GUIDE
Aga Khan Health Services
University Research Corporation
Center for Human Services
Dedicated to
Dr. Duane L. Smith (1939-1992),
Dr. William B. Steeler (1948-1992)
and all other health leaders, managers and workers
who follow their example in the effort to bring quality health
care to all in need.
Near Kakamega, Kenya, a nurse is teaching a mother
how to prepare maize-salt oral rehydration solution on
a cooking fire outside her house
Photo by Jean-Luc Ray for AKF
An overview of PHC MAP
The main purpose of the Primary 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 Foundation, PHC MAP is a collaborative programme
of the Aga Khan Health Network1 and PRICOR 1
2 An experienced design team and
equally experienced PHC practitioner teams in several countries, including
Bangladesh, Chile, Colombia, the Dominican Republic, Guatemala, Haiti, India,
Indonesia, Kenya, Pakistan, Senegal, Thailand and Zaire, have worked together to
develop, test and refine the PHC MAP materials to ensure that they are under
standable, easy to use and helpful.
PHC MAP includes nine units called modules. These modules focus on essential
information that is needed in the traditional management cycle of planning-doing
evaluating. The relationship between the modules and this cycle is illustrated below.
PHC MAP modules and the
planning-evaluation cycle .
PHC MAP
MODULES
1.
Information needs
2.
Community needs
3.
Wort planning
4.
Surveillance
5.
Monitoring indicators
6.
Service quality
7.
Management quality
8.
Cost analysis
9.
Sustainability
1 The Aga Khan Health Network includes the Aga Khan Foundation, the Aga Khan Health
Services, and the Aga Khan University, all of which are involved in the strengthening of
primary health care.
2 Primary Health Care Operations Research is a worldwide project of the Center for Human
Services, funded by the United States Agency for International Development.
Managers can easily adapt these tools to fit local conditions. Both new and
experienced programmers can use them. Government and NGO managers, man
agement teams, and communities can all use the modules to gather information
that fits their needs. Each module explains how to collect, process and interpret
information that managers can use to improve planning and monitoring. The
modules include User’s Guides, sample data collecting and data processing instru
ments, optional computer programs, and Facilitators 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
HEALTH SERVICES
GENERAL
OTHER HEALTH CARE
PHC household visits
Health education
Water supply, hygiene and
sanitation
School health
Childhood disabilities
Accidents and injuries
Sexually transmitted diseases
HIV/AIDS
Malaria
Tuberculosis
Treatment of minor ailments
Chronic, non-communicable
diseases
MATERNAL CARE
Antenatal care
Safe delivery
Postnatal care
Family planning
CHILD CARE
Breast feeding
Growth monitoring
Nutrition education
Immunization
Acute respiratory infection
Diarrhoeal disease control
Oral rehydration therapy
MANAGEMENT
SERVICES
Planning
Personnel management
Training
Supervision
Financial management
Logistics management
Information management
Community organisation
Several Managers Guides supplement these modules. These are: Better Manage
ment: 100 Tips, a helpful hints book that describes effective ways to help managers
improve what they do; Prob/em-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
thesaurus, a compendium of PHC indicators.
In rural Egypt where primary health care extends to
some remote areas: women grinding corn under a wall
decoration welcoming husbands back from Mecca
Photo by P Boucas for WHO
The Primary Health Care Management Advancement
Programme has been funded by the Aga Khan Foundation
Canada, the Commision 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-0158A-00-8161-00, 1988-1991); and the second was, "Strength
ening the Effectiveness, Management and Sustainability of
PHC/Mother and Child Survival Programs in Asia and
Africa" (cooperative agreement no. PCD-0158-A-00-110200, 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.
Module 7: Management quality
-3
•3
■'3
-3
3
1
—
3
Contents
•3
QUICK START
-3
3
#3
3
_Jj
13
3
U
78
1
INTRODUCTION
What is management assessment?......................................................... 3
How you can use this module................................................................. 3
Management checklists............................................................................ 5
Management discussion guidelines......................................................... 9
An overview of management services and checklists ..................... 10
Using service quality checklists for management assessment.......... 14
Strengths and limitations of the module.............................................. 17
THE MANAGEMENT ASSESSMENT PROCEDURES
Step 1: Specify the objectives of the management assessment ... 19
Step 2: Determine assessment methods .......................................... 21
Step 3: Select and adapt appropriate checklists or guidelines .... 23
Step 4: Carry out the assessment ...................................................... 24
Step 5: Tabulate and analyse the data .............................................. 26
Step 6: Present and review preliminary results ............................... 29
Step 7: Analyse the management process in more detail ............. 30
Step 8: Take action to improve management.................................. 31
APPENDICES
A. Management assessment discussion guidelines ........................... 35
B. Management assessment checklists .............................................. 51
C. Worksheet............................................................................................ 83
REFERENCES AND BIBLIOGRAPHY.................................................... 84
ACRONYMS AND ABBREVIATIONS .................................................... 85
Module 7: Management quality
Acknowledgements
The first draft of this module was reviewed and field tested in 1991 by a number of
PHC specialists and field managers. The module was also reviewed and critiqued
by the PHC MAP Technical Advisory Committee at a meeting in Bangkok in
September, 1991. Special thanks to the staff of URC’s International Division for
their critiques and suggestions, especially to Paul Richardson and Neeraj Kak for
their help in conducting field tests and in compiling and analyzing all of the field
test feedback. Thanks also to Jack Reynolds who conceptualized the module and
provided guidance throughout its development and revisions. Dr. Reynolds also
prepared the Quick start for this module. The contributions of the individuals below
were invaluable and greatly appreciated.
External reviewers and contibutors:
Donald Belcher • Veterans Administration, Seattle, WA, USA
Paul Zeitz ® Johns Hopkins School of Hygiene and Public Health, Baltimore,
MD, USA
William Reinke • Johns Hopkins School of Hygiene and Public Health, ■
Baltimore, MD, USA
Bobby Zachariah • Price Waterhouse Associates, Kingston, Jamaica
Michael Bernhardt • University of Puget Sound, WA, USA
Internal reviewers:
Thailand
Jumroon Mikhanorn • Somboon Vacharotai Foundation (SVF)
Thongchai Sapanuchart • SVF
Donna Robinson • SVF
Yawarat Porapakkham » Asian Institute for Health Development (AIHD)
Chaweewon Boonshuyar « AIHD
Som-Arch Wongkhomthong • AIHD
Orapin Singhadej • AIHD
Peerasit Kamnuansilpa ° Health and Population Research Company (HPRC)
Butsabar Subongkot » HPCR
Field tests:
Countries
Bangladesh
Pakistan
Participating organisations, field test facilitators
Test 1: 4 The Asia Foundation (TAF) sub-grantees:
Progoti Samaj Kallyan Protishthan (PSKP); Unity
through Population Service (UTPS); Polli Shishu Foun
dation of Bangladesh (PSF); Facilitator: Barkat-eKhuda, URC/Bangladesh. Test 2: 3 TAF subgrantees:
UTPS; PSKP; CWFP; PSF.
Aga Khan University, Facilitator: Khatidja Husein, Aga
Khan University, Karachi, Pakistan
Module 7: Management quality
Ministry of Public Health, Srisaket; Somboon
Vacharotai Foundation (SVF), ASEAN Institute for
Health Development (AIHD); Health and Population
Research Company (HPRC); Facilitator: Chaweewon
Boonshuyar, AIHD
India
Junagadh PHC Project; Sidhpur Sustainable Health
System Project, Gujarat; Aga Khan Health Service
India (AKHSI); Facilitators: Neeraj Kak, University Re
search Corporation (URC), Bethesda, MD, USA; Vijay
Moses, AKHSI’S
Kenya:
Mombasa PHC Project; Kisumu PHC Project; Facilita
tors: Paul Richardson, URC;- Esther Sempebwa,
Mombasa PHC Project; Matthew Onduru, Kisumu PHC
Project
Colombia:
Fundacion Santa Fe de Bogota; Facilitator: Jorge E.
Medina
Dominican Republic CARE, MUDE, Adoplafan, Aguas Vivientes, Caritas;
Facilitators: Jorge E. Medina; Linda Ashburn, URC
Indonesia
Department of Health, Jakarta; Facilitator: Sandi
Iljanto, University of Indonesia
Thailand
Module 7: Management quality
T
H T
e m W W fl fl fl f| fl fl fl W fl W f|. f|. f} fl
.
Photo by Jean-Luc Ray for AKF
m e
Children in the U.K. take plentiful clean water for granted
1
Module 7: Management quality; Quick start
Quick start
Basic management assessment
If you would like to conduct an assessment quickly, follow these guidelines. If you are
using a computer, load this file (MOD7_QS.WQ1) into Lotus 1-2-3 or Quattro Pro 4 after you
have collected your data. It will help you analyse it quickly. The Quick start option assumes
that you want to examine one of the PHC management services listed below, and that you will
use the checklists in Appendix B.
Instructions
1. Select a PHC management service to assess:
Planning
Personnel mgmt.
X
Supervision
Financial mgmt.
Training
Information mgmt,
Community organ.
Logistics mgmt.
2 Go to Appendix B and select the checklist for that service. Revise it as you wish. Select
a maximum of 15 variables.
3. Determine (and list) the number of health centres, facilities, or individuals that will be
observed
4. Determine the number of observations that you will make of each centre, facility, individual:
Select your observers and let them test the checklists with 2-3 similar centres/facilities/individuals.
6. Schedule the observations.
7. Photocopy or duplicate the number of checklists needed.
8. Conduct the observations.
9. Tabulate the resulting data on a blank checklist (enter the total number of Yes and No
observations).
10. Enter those data in the following table. If you use the computer program, it will
automatically compute percentage distributions and make a graph.
11. Identify problem areas and discuss with your staff and others to see if you can identify
causes of the problems as well as possible solutions.
12. Develop a plan of action to deal with the most important problems.
5.
Question/Variable No.
Q/V
Yes
%
1
6
50
2
5
42
3
7
58
4
8
67
5
9
75
6
12
100
Variables
7
3
25
8
4
33
9
5
42
Number of Observations «12
10
11 12 13 14
10
4
8
9
3
25 33 67 75 83
15
11
92
T
An animated conversation between an auxiliary
health worker and a villager in West Azerbaijan, Iran
Photo WHO/Ministry of Health of Iran
Module 7: Management quality; Quick start
M m R m
W TO ipi W 'B
l p|
fl Pl PI ft ft ft ft
2
3
Introduction
What is management assessment?
Management assessment is the process of evaluating the
strengths and weaknesses of such activities as planning,
supervision, training and logistics. This module presents a
series of management checklists, discussion guidelines, and
analytical techniques for management assessment. With
adaptation, managers can apply the checklists to determine
whether management systems are functioning according to
the norms and standards set by the programme. The PHC
MAP discussion guidelines and analytical techniques com
plement the checklist approach by helping the PHC team
to explore the causes at the root of the problem and to
develop creative and appropriate solutions.
The aim of management assessment is to identify specific
ways in which the management system could function
better, rather than to point out mistakes or blame those
responsible. The approach presented here is intended to help
teams work together to improve management which will, in
turn, improve the effectiveness, efficiency, and quality of
PHC services. While this module concentrates on the qual
ity of PHC management services, Module 6: Assessing the
quality of services, outlines a similar process to examine and
improve directly the quality of service delivery.
How you can use this module
This module enables managers and supervisors to carry
out management assessment with the aid of management
checklists, discussion guidelines, and analytical techniques.
The management assessment checklists presented here
Module 7: Management quality; introduction
Identify
strengths,
weaknesses
are based on explicit criteria about the various management
processes. These checklists operationalise management as
sessment activities into discrete tasks, enabling managers
and service delivery teams to conduct objective, thorough,
and systematic assessments. In-depth discussion with the
staff involved in the processes is another way to assess and
analyse management performance. The PHC MAP discus
sion guidelines can be used to structure an open-ended
discussion and analysis of management services. This man
agement assessment approach can be used in a variety of
ways. Examples include:
• Management evaluation: These tools can form the
basis of an evaluation of PHC management. Such an
assessment would include observation of activities, a re
view of records, and a review of the health facility itself. It
could also include interviews with members of the health
team and community members who are or should be
served by the programme. Structured interviews and openended informal discussions could be used. A multi-facility
review could also be carried out based on the materials
presented here.
• Guidelines for team self-assessment: PHC MAP
tools can also be used for team self-assessment. Group
discussion, based on the PHC MAP discussion guidelines,
can serve as a starting point for sharing information and
opinions and identifying areas that need attention.
• Guidelines for planning new management proce
dures: Some teams may find that important management
services are not in place in their health programmes.
Rather than beginning with assessment in such cases, the
checklists can be used by a manager or team as a planning
tool for a needed management procedure.
• Tools for monitoring management improvement
efforts: Managers can also use the tools to monitor the
impact of attempts to improve management. This could
be especially valuable after an initial assessment has taken
place, or as an interim activity between assessments.
• Management job aids: Managers or PHC teams can
also use these guidelines as job aids in the various manage
ment areas addressed. In each management area, specific
Module 7: Management quality; introduction
5
tasks that contribute to better management are listed. This
list of tasks could be used as a checklist that managers can
refer to as they plan and carry out management activities.
• Management training: These materials are also useful
in the development of a management training programme.
Management assessment activities are intended to comple
ment the other elements of the PHC Management Ad
vancement Programme. Areas for programme improve
ment will be identified through a management information
audit (Module 1), service quality assessment (Module 6), or
routine programme monitoring (Module 5). Problems en
countered in these areas are sometimes caused by short
comings in programme management. With the help of
these management guidelines, problem areas can be ex
plored in more detail so that appropriate action may be
taken. Further, since service delivery problems are often
solved through management interventions, these guide
lines can be used to develop and monitor efforts to improve
the programme.
Management assessments can be carried out by manag
ers, service delivery teams, community groups, or outside
evaluators. They are most effective when they are used for
internal assessment by the PHC team to identify areas for
improvement and to develop plans for action.
Complements
other modules
Management checklists
PHC management checklists have been developed for 8
management services. Each checklist consists of an or
ganised list of specific recommended tasks, along with brief
instructions about how the information gathered can be
used. These checklists can be easily adapted to specific
public and private programmes by adding, modifying, or
omitting items. They can be used to assess overall PHC
management, specific management services or sub-func
tions, or vertical service delivery programmes. Information
can be gathered through interviews, group discussions, doc
ument review, observation of management activities, or a
review of the health facility. The management services
listed on the following page are included.
Module 7: Management quality; introduction
Easily
adaptable
6
Planning
Personnel management
Training
Supervision
Financial management
Logistics management
Information management
Community organisation
■ Each checklist divides the management service into ac
tivities, which are further divided into distinct tasks. For
example, the planning checklist has a section on the mission
statement, programme objectives, information needed for
planning, financial planning, programme planning, and in
dividual work planning. This structure will help the user to
identify major sub-functions that are problematic so that
appropriate action may be taken.
The PHC MAP checklist for planning is presented in
Exhibit 1 on the following page. Detailed checklists for all
eight management services functions are included in Ap
pendix B. In the form presented here, most questions are
phrased for a yes/no response. The questions are formulated
so that a "no" response indicates a potential problem area
that may require further attention. The yes/no format was
chosen so that analysis of the data would be straightforward.
However, the checklist can be used in other ways if more
flexibility is needed.
For example, if a manager feels that the yes/no format
is too rigid for some questions, those questions could be
re-worded slightly and a scale of 1-5 could be used. For
example, the question, "Do staff members understand the
programme mission?", could be changed to, "How well do
staff members understand the programme mission?" The 5
point scale could be defined as, 1 = very poorly, 2 = poorly,
3 = adequately, 4 = well, and 5 = very well. Alternatively,
the question could be phrased as a declarative sentence,
"Staff members understand the programme 'mission well”,
and the scale could be defined as 1 = disagree strongly, 2 =
disagree, 3 = neutral, 4 = agree, and 5 = agree strongly. Other
modifications on the scale are also possible.
Some questions ask for opinions about the quality or
adequacy of specific tasks. In such cases the perspectives of
managers, health service providers, and community
members should be taken'into account.
Module 7: Management quality; introduction
7
Some questions, such as, "Does the facility have a refrig
erator?”, are straightforward and can be answered reliably
by one respondent, although a check on such information is
sometimes useful. Others should be explored from more
than one point of view. For example, the question, "Do
health workers receive adequate technical support and su
pervision?", should be explored through consultation with
supervisors and health workers themselves. Sources of
information can include managers, health service providers,
community health workers, clients, and other community
members. Records of reviews, observation of activities, and
site visits are also important sources of information.
EXHIBIT 1: MANAGEMENT ASSESSMENT
Checklist for planning
"Health planning is the process of defining community health problems,
identifying needs and resources, establishing priority goals, and setting
out the administrative action needed to reach those goals".
This checklist is intended for use in the assessment of planning activities. Its objective is to
help managers to enhance the quality of their programmes by identifying and resolving
problems in the planning area. They can be adapted for use in both vertical programmes and
integrated PHC efforts. The questions below can be answered through interviews, document
review, observation of management activities, or a review of the health facility. Some
questions ask for the respondents opinion about the quality or adequacy of specific tasks. In
such cases the perspectives of managers, health service providers, and community members
should be taken into account. Areas that are deemed inadequate can be further explored
through focused discussions with key informants. With modification, the checklists can be
used as a basis for an open-ended interview or group assessment.
Health facility
Service provider
Observer/Supervisor
Date
1.
2.
3.
4.
Mission statement
A mission statement describes the purposes and overall goals of an organisation.
These questions will help you to determine whether the mission is clearly defined
and understood by programme staff, the community, and donors:
5.
6.
YES
YES
NO
NO
Is there a written mission statement?
Does the mission statement include a clear primary health
care strategy?
(continued)
Module 7: Management quality; introduction
8
(continued)
YES____ NO____ Is the mission statement understood by the health centre
staff?
8. YES____ NO____ Is the mission statement understood by the community?
9. YES__ _NO____ Is the mission statement understood by health centre
management?
10. YES____ NO____ Is the mission statement understood by the board?
NO
Is the mission statement understood by the donors?
11. YES
12. YES____ NO____ Does the programme plan directly address the overall
programme mission?
7.
Programme objectives
Objectives are the specific results that are expected from a programme or activity.
These questions will help you determine whether the objectives are defined
adequately for the purpose of planning:
13.
14.
15.
16.
17.
18.
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
19.
20.
YES
YES
NO
NO
21.
YES
NO
22.
23.
24.
25.
YES
YES
YES
YES
NO
NO
NO
NO
26.
YES
NO
27.
YES
NO
28.
29.
YES
YES
NO
NO
30.
YES
NO
Is the geographic area to be served clearly defined?
Are the age groups to be served clearly defined?
Are high-risk groups to be served specified?
Are the services offered specified?
Are there explicit programme objectives?
Did the community play a role in setting goals and
objectives?
Are the objectives reviewed and revised on a regular basis?
Do government programmes and/or donors understand
and agree with the goals and objectives?
Are coverage objectives for each service stated and
quantified?
Are coverage objectives understood by staff?
Are objectives for service quality stated and quantified?
Are service quality objectives understood by staff?
Are objectives for improvements in knowledge in specific
PHC areas stated and quantified?
Are objectives for improvements in knowledge understood
by staff?
Are objectives for behaviour change in specific PHC
areas stated and quantified?
Are behaviour change objectives understood by staff?
Are objectives for health status improvement stated and
quantified?
Are health status objectives understood by staff?
This checklist continues with 37 more questions on information needed, planning and staff
work. See Appendix B.
Module 7: Management quality; introduction
9
Management discussion guidelines
PHC MAP management checklists attempt to measure
or quantify management performance. However, many
management areas are difficult to quantify or isolate into a
yes/no question. Because management is complex and
multi-faceted, a more qualitative type of assessment tool is
needed. The PHC MAP discussion guidelines complement
the checklists by helping managers to capture the complex
ity of their management systems and to study them in depth.
Discussion guidelines for all 8 PHC MAP management
services have been developed (see Appendix A). Exhibit 2
presents an example of the discussion guidelines for training.
The discussion guidelines can be used as a basis for an
open-ended group discussion. The participatory nature of
this method is especially important because the interaction
among group members will make for a richer response and
groups are better than individuals at identifying problems
and their multiple causes.
EXHIBIT 2: MANAGEMENT ASSESSMENT
Discussion guidelines for training
Training is the process of continually improving the knowledge, skills and compe
tencies of health workers.
Introduction: Welcome the group and briefly give the purpose of the discussion.
Ground rules: Explain the following ground rules to the group:
Ground rules for group discussion
Everyone’s ideas and opinions are important.
There are no right or wrong answers.
Both positive and negative comments are welcome.
Participants should feel free to disagree with one another so that all points of view
are heard.
Don't wait to be called on; it’s a group discussion.
Please speak one at a time.
These discussion guidelines are provided to help you to lead a group discussion
about your training system. You may also refer to the detailed version of the
management checklists (Appendix B) as a resource for the discussion.
Module 7: Management quality; introduction
1.
PLANNING
Health planning is the process of defining
community health problems, identifying needs and re
sources, establishing priority goals, and setting out the
administrative action needed to reach those goals.
Definition:
Module 7: Management quality; introduction
T
O T
O T
O T
O T
O
? T
O T
O T
O T
O T
O T
O T
O T
O
T
This section defines the eight management services in
cluded in the PHC MAP programme and describes the key
components of the management checklists. Clear under
standing of these basic management concepts is essential
for project managers and health centre teams who want to
assess and improve their programmes.
$ to
An overview of management services and
checklists
® w
Discussion
• What works well in the way we do training?
Guidelines
• What aspects of the way we do training do not work well?
• What kind of information do you use to plan or focus training? Do you use
information about health worker knowledge, attitudes, and practices? Do you
use information about community needs? Is this information available to you?
• What training methods are used? Are they used correctly? Are they effective?
Is the content of the training appropriate for local norms?
• What resources are available to support training? What resources are needed?
Key questions
• Is programme specific information (from MIS or supervisor) about service quality
used to plan or focus the training?
• Did the training include a pre-test of health worker knowledge and skills?
• Does training include a post-test of health worker knowledge and skills?
• Is there a follow-up assessment of training (about six months later) to assess the
impact of the training?
• Are training topics explained clearly?
• Are training topics demonstrated9
• Do trainees receive written materials?
• Are health workers satisfied with the training they receive?
• Will training be followed up through the regular supervision system?
• Will trainee performance in new skill areas be monitored through MIS?
’ Is the training content complete and accurate according to local norms?
• Are resources adequate?
<»
10
>
11
Description and explanation of guidelines: The guide
lines are divided into five sections which address differ
ent aspects of the planning process. The first section
assesses whether there is a mission statement and
whether it is understood by programme staff, the com
munity, and donors. The second section assesses
whether programme objectives (specific results that are
expected from a programme or activity) have been
adequately defined for the purpose of planning. The
next section considers whether the information needed
for programme planning is available. Section four as
sesses the adequacy of the organisational structure,
overall work schedule, and whether management activ
ities are planned. The final section discusses individual
work planning for staff members, which is dealt with in
more detail in Module 3.
2.
TRAINING
Definition: Training is the process of continually improv
ing the knowledge, skills, and competencies of health work
ers.
Description and explanation of guidelines: The guide
lines are divided into four sections which address different
aspects of the training process. The first section deals with
the planning of training activities. The second section
assesses the training methods, and the third assesses training
content. The final section includes questions about the
adequacy of training resources.
3.
SUPERVISION
Definition: Supervision is the process of directing and sup
porting staff so that they may effectively perform their duties.
Supervisors provide leadership, support, guidance, training, and
assistance in the identification and solution of problems so that
service quality and effectiveness may continually improve.
Description and explanation of guidelines: The guide
lines address four aspects of supervision. The first section
can be used to describe or assess supervisory activ
Module 7: Management quality; introduction
IB
12
ities. The second section includes questions about supervi
sory methods, as well as a general assessment of the ade
quacy of supervision in a variety of technical and manage
ment areas. The third section addresses supervision of tech
nical service quality, and section four assesses supervisory
style. Section five looks at supervisory action taken, specif
ically work planning and problem-solving. The final sec
tion assesses whether vital information for problem-solv
ing is included in the supervisory records.
4.
PERSONNEL MANAGEMENT
Personnel management includes activities
which relate to recruiting, hiring and supporting staff, and
defining the roles of the individual. It also refers to standard
procedures related to compensation, benefits, and work
schedules.
Description and explanation of guidelines: The
guidelines are divided into four sections which address
different aspects of personnel management. The first sec
tion looks at essential personnel management issues that
reflect the quality of the personnel management system,
such as whether salaries are fair, and whether staff turnover
is kept at a reasonable level. The second section assesses
whether key personnel policies and procedures are in place.
The questions in section three' will help to assess the
adequacy of job descriptions. Section four addresses the
ongoing activity of work planning and performance assess
ment.
Definition:
5.
FINANCIAL MANAGEMENT
Definition: Financial management includes management
of and accountability for programme finances, budgeting for
planned activities, and, in some programmes, cost recovery
or fund-raising.
Description and explanation of guidelines: The
guidelines are divided into seven sections which address different
aspects of financial management. They permit a detailed
assessment of processes related to general accounting, cash
Module 7: Management quality; introduction
13
disbursements, accounts payable and purchases, payroll,
petty cash, financial planning and management, and sources,
and adequacy of funding.
6.
LOGISTICS MANAGEMENT
Definition: Logistic systems deal with the procurement,
storage, and tracking of supplies and equipment.
Description and explanation of guidelines: The
guidelines are divided into five sections which address dif
ferent aspects of logistics management. They are procure
ment, reception of materials, inventory control, stock issue,
and transportation.
7.
INFORMATION MANAGEMENT
An information system is organised around
key indicators that measure a programme’s progress toward
its goals. It is a systematic way of collecting, reporting, and
using data at all programme levels.
Description and explanation of guidelines: The
guidelines are divided into eight sections which address
various aspects of service delivery: planning the information
system; record keeping (health centre-level and district
level); compilation and tabulation and analysis of informa
tion (at health-centre and district-level); use of information
for management decision-making; reporting information
and feedback; ad hoc data collection; compilation and anal
ysis of ad hoc data collection; and use of information for
management decision-making.
Definition:
8.
COMMUNITY ORGANISATION
Definition: Community organisation is the involvement
of the community in the design, planning, promotion, or
delivery of health enhancing activities.
Description and explanation of guidelines: The
guidelines are divided into six sections which address different
aspects of service delivery. The first section is a profile of
the local health committee or community organisation. This
Module 7: Management quality; introduction
14
profile will help supervisors or health workers to describe
the context of community activities and to identify oppor
tunities and constraints. The second section looks at utilisa
tion, satisfaction, and participation. The third section looks
at indicators of quality, such as the representativeness of the
group and the level of the group’s activities. The fourth
section looks at the community’s role in programme im
plementation, while the fifth section assesses whether com
munities are playing a leadership role in activities. The final
section looks at the support received by community or
ganisations and co-ordination with other programmes or
community efforts.
Using service quality checklists for
management assessment
In addition to using the checklists provided in this module
for management assessment, the service quality assess
ment checklists in Module 6 can provide an important source
of information about the quality of management.
Service quality measures can be thought of as outcomes
of management activities and, therefore, often provide in
sights into the adequacy of the management system. This
relationship is especially clear in the areas of supervision
and training.
Service quality checklists used during regular supervision
can be reviewed by higher-level managers as a source of
information about service quality and performance. For
example, if the checklists filled out by a supervisor indicate
service delivery problems but do not record corrective action
taken, this might be identified as a problem area in supervi
sion by a higher-level supervisor. Following are some ex
amples of how service quality checklists can be used in
supervision:
• Secondary supervisors can conduct quality assessments in
the responsibility areas of their subordinate supervisors.
The results measure the outcome and effectiveness of
first-level management/supervision.
• Secondary supervisors can use checklists to carry out
supervision jointly with first-level supervisors. This will
Module 7: Management quality; introduction
15
allow the second-level supervisor to assess directly how
well a supervisor identifies and solves specific problems.
• Checklists can be used as a basis for a supervisory inter
view or performance review.
Service quality checklists can be used as a reference for
the development of detailed training assessment tools. Ex
hibit 3 shows a training assessment tool that combines the
detail of the service quality checklist for ORT with the
training quality criteria included in the management check
list. The asssessment tool could be used during observation
of training or to interview participants after training. Sub
sequent supervision with service quality checklists could
determine which training topics were not communicated
effectively, and the training content or methods in that area
could be adapted accordingly.
Module 7: Management quality; introduction
16
EXHIBIT 3: QUALITY ASSESSMENT
ORT training
This is an example of how service delivery checklists could be adapted
as tools for detailed assessment of a training course on ORT.
Medical history
E=explained, D=demonstrated, PC=practised, T=competency-based testing,
MT=included in take-home material, MN= included in manual.
E D PC T MT MN
Duration of diarrhoea?
E D PC T MT _MN
Consistency of stools?
E D PC T MT MN
Frequency of stools?
E D PC T MT MN
Presence of blood in stools?
E D PC T MT MN
Presence of vomiting?
E_D_PC_T_MT_MN_ Fever?
E D PC T MT MN.
Home treatments?
Physical examination
E D PC T MT MN
E D PC__T__MT MN
E D PC T
E—D—PC.—T
MT
MT
MN
MN
E
MT
MN
D
PC
T
Assess general status (alert or lethargic)?
Pinch skin, examine fontanel and mucus
membranes?
Weigh child?
Determine nutritional status to be sure the child
is not severely malnourished?
Take temperature?
Classification and treatment
E—D—PC—T—MT—MN— Determine the degree of dehydration (none,
moderate, severe)?
E—D PC T MT MN
Prescribe safe ORS solution?
E—D—PC—T—MT_MN— Recommend safe home treatment with ORS solution?
E—D—PC—T—MT—MN— Refrain from using antibiotics, except when stools
contain blood or mucus?
E—D—PC_T—MT—MN
Refrain from using anti-diarrhoeals?
E—D—PC—T—MT—MN— If child is dehydrated, administer ORS solution
immediately or refer child for ORT?
E—D—PC—T—MT—MN— Give sufficient amount of ORS solution?
E—D—PC—T_MT—MN— Plan to reassess child’s hydration status after an
appropriate interval?
E—D—PC—T—MT_MN— If dehydration is severe, rehydrate with intra
venous fluid or naso-gastric tube?
E—D—PC—T—MT—MN— If IV or NG tube are not available within 30
minutes of facility, try ORT?
E—D—PC—T—MT—MN— If child cannot drink, refer/evacuate for IV, NG
treatment?
Module 7: Management quality; introduction
17
ORT education
E D PC. T MT
E D PC T MT
E D PC T MT
MN
MN
MN
E
D
PC
T
MT
MN
E
D
PC
T
MT
MN
E
D
PC
T
MT
MN
E
E
E
D
D
D
PC
PC
PC
T
T
T
MT MN
MT _MN
MT MN
Tell mother to give extra fluids during diarrhoea?
Tell mother how to prepare ORS solution?
Tell mother how much ORS to give and how
often to give it?
Tell mother about appropriate feeding practices
during and after diarrhoea?
Tell mother about at least
signs of dehydra
tion?
Discuss at least
danger signs that indicate
need for further medical attention?
Show mother how to prepare ORS solution?
Verify that mother understands key information?
Ask mother if she has any questions?
Strengths and limitations of the module
It is important to note a few limitations of the module.
First, effective use of the tools provided in the module depends
on a management environment that is open to frank assess
ment of programme strengths and weaknesses. Second, those
involved in the assessment must have knowledge of the process
under discussion. For this reason it is very important to include
the staff members who actually carry out the task in the
assessment. Finally, there are limits to the extent to which
management assessment can be quantified, thus, the staff
members are still dependent on qualitative information to a
considerable degree. Even when performance can be quanti
fied, results cannot be generalised because they flow from a
specific management system with unique features.
In spite of these limitations, the management assessment
methods posed here are objective and concrete, and offer
considerable advantages over many types of performance
review and needs assessment methods currently in practice. The
process of assessment also provides an opportunity for communi
cation and a chance for a team to think together and gain insights
about management Finally, the identification of problem areas or
opportunities for improvement is sometimes enough to lead to
better performance. A management assessment is an effective way
to direct staff attention to the importance of management and to
help each member see opportunities to improve the system.
Module 7: Management quality; introduction
19
Management assessment procedures
This section describes an eight-step process of designing
and carrying out a management assessment.
Step 1: Specify the objectives of the management assessment
Step 2: Determine assessment methods
Step 3: Select and adapt appropriate checklists or guidelines
Step 4: Carry out the assessment
Step 5: Tabulate and analyse the data
Step 6: Present and review preliminary results
Step 7: Analyse the management process in more detail
Step 8: Take action to improve management
Step 1: Specify the objectives of the management assessment
The general objective of management assessment is to identify strengths
and weaknesses and to improve management which, in turn, will improve
overall programme effectiveness. In planning a management assessment
it is up to the manager or PHC team to determine the specific objectives
and scope of the assessment. These decisions are important because they
have implications on design, analysis, and documentation. The following
questions should be addressed at the outset (see page 22 for a worksheet
that you can use to summarize your answers):
• What is the purpose of the assessment? The purpose might be, for
example, needs assessment in a particular management area, with the aim
of identifying ways that the system could be improved. The assessment
might also be used to assess the performance of an individual, a team, or
a system.
Module 7: Management quality; procedures
¥
20
from a management assessment can be used by local managers, PHC
teams, health committees, the board of directors, regional or national
directors, and donors. Who will use the information will have an impact
on what information is collected, how much is collected, and how it is
reported. On the one hand, a report that is intended for use by national
directors and donors might require a large statistical sample and a formal
report as an end product. A local manager, on the other hand, might use
a small convenience sample and document the conclusions in a supervi
sory notebook.
o How will the information be used? The information collected can
be used in a variety of ways. It can be used by programme staff to develop
management improvement programmes and to better understand the root
causes of service delivery problems. It can also be used to focus training
efforts on the actual needs experienced in the programme. The specific
use of the information will have implications on what is collected and
how it is analysed.
® What will be the unit of analysis? What health facilities will be
included? The appropriate unit of analysis for management assessment
will depend on the objectives of the assessment and the nature of
the management function in question. Several options are discussed
below:
In many cases the health facility will be the
unit of analysis. Such management assessments often involve study of
management processes for only one health facility, with the aim of
making improvements at that level. This type of assessment permits
in-depth analysis of the local situation, participation of staff, and locally
appropriate solutions.
Single health facility.
Module 7: Management quality; procedures
fl W m fl fl fl fl fl fl
® Who will use the information gathered? The information generated
I? s>
management activity for assessment should be based on priorities identi
fied by managers and the PHC team. Results from routine monitoring,
service quality assessment, or other evaluations could be taken into
account. The focus of the assessment could be an entire management
system, for example, planning, or it could focus on a sub-task within
planning, for example, the mission statement.
fl fl fl fl fl fl fl fl V fl
• What management activities will be included? The selection of a
21
A group of health facilities. Management processes for a group of
health facilities of an area or region may also be of interest. Managers
may want to study the same management process in a group of facilities
to identify systematic management problems that will require interven
tion from the area or region for resolution.
Outputs related to the management function. Each management
system has outputs which may also be a unit for analysis. For example,
in the training system, outputs might be training courses or trainees.
These could be examined as a way of assessing the performance of the
training system.
• Over what period of time will the activities take place? Managers
must consider the above decisions determining the time and duration of
management assessment activities. Short rapid assessments may be
employed, or more in-depth studies may be undertaken. Also, some
activities may be carried out on an ongoing basis, while others will be
done once, or on an ad hoc basis.
• Are adequate resources available for the assessment? Ideally,
management assessment activities should be carried out with resources
that have been allocated to management and supervision. However,
additional costs, such as transportation, per diem, and supplies may be
needed. In designing studies, managers should assess whether additional
resources are available and keep in mind the importance of both the
financial and technical feasibility of carrying out assessments.
Step 2: Determine assessment methods
Quantitative or qualitative assessment?
This module presents two different approaches to management assess
ment. The use of PHC MAP checklists permits a comprehensive, quanti
tative assessment. This will help you to describe the management system
and its problems. Some of the problems will be easy to solve as a result of
the assessment, others will leave the team with many questions.
Why do these problems occur? How can they be corrected or pre
vented? These questions are too complex to be answered with a checklist
alone. They require a less structured format that allows people to share
their insights and experiences. The PHC MAP discussion guidelines are
Module 7: Management quality; procedures
22
Mu
WORKSHEET FOR PLANNING MANAGEMENT
ASSESSMENT
Step 1. Specify the objectives of the assessment
a. What is the purpose of the assessment?
To ensure a steady supply of drugs in the health centre
b. What is the scope of the assessment?
Management activity(ies): Logistics
Sub-tasks:
Procurement
Inventory control
c.
Who will use the information gathered?
Pharmacy, director of health centre
d. How will the information be used?
To determine if drug supplies are adequate and, if not, to identify
changes that should be made in the system
e.
What programmes or facilities (units) will be analysed?
1 health centre
f.
Over what period of time will the activities take place?
6 months
g. Are resources adequate?
Needs are minimal
£22
8»-'
Step 2. Determine assessment methods
a. Unit of observation: Pharmacy (no. days when drugs are not
available and the percentage of patients who
receive all needed medications)
b. Data sources:
Discussion with health centre staff, including
the person who manages the pharmacy.
c.
Sampling methods:
100% sample for last six months
« -j.
Step 3. Choose relevant checklists: Logistics - procurement (5-15);
inventory (24-39)
Modification required:
yes
Need to adapt questions so that they relate to drug supply. Need to add ques
tions to measure the number of days when drugs were available for essential
drugs, and to measure the percentage of patients who received the medicine
needed.
Module 7 Management quality; procedures
B-
B--
23
better suited to this kind of exploratory qualitative assessment.
Managers may choose the structured checklist approach or the more
flexible discussion to assess their management performance. This decision
will depend on the objective of the management assessment and, to some
extent, on the style of the manager. The two approaches can also be
combined, so that the team can benefit from the advantages of both
methods. For example, a manager or PHC team might first apply the
checklists to get a general idea of how things are going. Based on these
results, a group discussion could be held to assess the situation in more
depth and from different points of view.
• Information sources. Information about management services can be
collected from direct observation of job performance or inspection of the
health facility. A review of programme records is another source of
information. Interviews or surveys may also be helpful. These could be
carried out with individuals or groups and could be open or close-ended.
In choosing information sources, consider the reliability of the information,
the time it will take to collect it, and the cost involved.
Step 3: Select and adapt appropriate checklists or guidelines
While the checklists and discussion guidelines may be used as they are,
they will usually require some adaptation. Field tests have shown that it
should take no more than 2-3 hours to revise these tools. Adaptation can
include rephrasing questions, omitting items that are irrelevant, revising,
rearranging, rephrasing items to fit local conditions, and adding items that
are important to your programme. In some cases you may want to combine
items or sections from several checklists to form a new one.
Several managers have found it useful to make these changes in a group
session that involves the users, who are usually supervisors and adminis
trative staff. Group work helps to ensure that the key users become familiar
with the instruments and procedures and develop a sense of "ownership"
of the assessment. It is also quicker. When an instrument is prepared by
one person it is often circulated for comment, revised, and recirculated
several times. This is often unnecessary if the assessment is carried out by
the group.
Module 7: Management quality; procedures
24
Step 4: Carry out the assessment
After the assessment has been designed and the tools have been adapted,
the manager must take steps to carry out the assessment. Before the
assessment the manager should review the management checklists or
discussion guidelines that they will use to ensure that they are comfortable
with the format, procedures, and content.
• The group discussion. If group discussions are to be held, the manager
should give participants as much notice as possible and provide them with
a brief description of the purpose of the meeting and the kind of
information they will be asked to provide. This allows staff to prepare by
thinking about the topic beforehand and conferring among themselves.
Also, this will afford participants time to gather information to illustrate
their points of view, if they so desire. The ideal size for a group
discussion is 5-10 people.
Each group discussion should begin with a brief introduction and
explanation of the purpose of the discussion. Also, the person who leads
the discussion should explain the ground rules to the group before the
session. This is especially important if the group members have held other
kinds of meetings together. They should be reminded that this meeting
has a different purpose and structure. The following ground rules will
help the group stay on course:
Ground rules for group discussion1
£5-
i±s~
l?-
Everyone’s ideas and opinions are important.
There are no right or wrong answers.
Both positive and negative comments are welcome.
Participants should feel free to disagree with one another so that all points of
view are heard
Don’t wait to be called on; it’s a group discussion.
After the ground rules have been presented, the leader can use the
discussion guidelines to lead the discussion on a given management topic.
The leader of the group discussion can refer to the checklists if there is a
need to probe the issue in more detail. The yes/no type questions from
.£-■
g.
1 Adapted from Debus, M, Handbook for excellence in focus group research. Academy for
Educational Development, HEALTHCOM, Washington, DC, 1992.
Module 7: Management quality; procedures
25
the checklists can be easily modified to encourage discussion. For
example, if controversial issues are raised with a yes/no question, an
adversarial or combative tone may develop, leading some group members
to refrain from contributing.
Rather than asking a group of yes/no questions, such as, "Do staff
understand the programme mission?", try a more neutral wording, such
as, "Tell me what you understand about the programme mission." or, "How
well do you think the mission statement is understood?". Another
alternative to start a constructive discussion is to use two questions, such
as, "What aspects of the mission statement are understood well?"
and, "What aspects of the mission statement are not understood
well?"
The group leader should keep track of the time and guide the group
to new topics when it seems that enough information in a specific area
has been shared. Before moving to a new topic or question, the leader
should ask the group if anyone has any final comments to add. At the
end of the discussion, the leader should thank the group for participating
and give everyone in the group one last opportunity to comment on the
overall topic.
The leader should write a summary of the discussion, organised by
topic, soon after the discussion so that key issues will not be forgotten.
This information will be useful for identifying management problems,
their causes, and possible solutions.
• Visits to the health facility. If field visits are required to meet with
teams or individuals, arrangement for transportation will have to be made.
The schedule of regular activities at the facility should be taken into
account so that the assessment does not interrupt important activities.
Yet, some managers may want to make unannounced visits so that staff
do not make special preparations for the assessments.
If observation is to be carried out, it is usually a good idea to explain
what the observer will be doing and why, so as to avoid misunderstanding
and anxiety. Experience has shown that most workers want to improve
their performance and welcome constructive help and advice. But they
will also resist co-operating when they suspect that gathered information
will be used against them. Ideally, assessments should be carried out in a
supportive, constructive manner to help staff improve programme manage
ment. After the assessment, the checklist should be reviewed to be sure that
all questions are answered and that all answers are clear.
Module 7: Management quality; procedures
Step 5: Tabulate and analyse the data
ta
sj
ia ®
Module 7: Management quality; procedures
'a
if
a
to be made, it can be very helpful to develop an analysis plan. Calculations
such as the following can be carried out as warranted.
Total: Sum the number of observations for each variable (i.e., each
management service task).
Frequency distributions or counts: Add up the number of "yes" and
no responses for each variable (task) and compute the percentage
distribution: Take the number of each count ("Yes" and "No") and divide
it by the total number of observations x 100.
Threshold analysis: Set a minimal acceptable level for each item.
Those which exceed that level are identified as problems.
is & it & ii
• Rapid data analysis plan. If a large number of observations are going
i^i
The quantitative tabulation and analysis procedures suggested here are
similar to those described in Module 6. Supervisors and managers can hand
tabulate the data, often in minutes, depending on the number of observa
tions.
The information gathered during an assessment may be tabulated using
a simple matrix. Data is transferred from observation checklists to the
matrix, and can be summed up easily. If multiple observation checklists are
used, the tabulation can be done on the checklist, eliminating the need to
transfer the information to the tally sheet.
Exhibit 4 on the following page shows how a tally sheet was used to
record and tabulate 39 observations of the quality of the PHC drug supply
system in ten health centres. The question numbers correspond to those
of the Logistics management checklist in Appendix B.
The results show that there are some items that are either done by
everyone (e.g., No. 8: all health centres have a clear policy about who can
authorise requests) or by no one (e.g., No. 9: no one seeks multiple cost
estimates). Clearly, from this analysis, a number of items need attention.
It can be easier to understand these numbers if they are displayed
graphically, such as in Exhibit 5. In this graph the bars represent the
number of health centres that responded "Yes" to an item. The longer the
bar, the greater the number of positive responses, and vice-versa.
The manager may wish to set a minimum standard, or threshold, for the
overall programme. For example, that at least 6 centres respond positively
to an item, otherwise, it is below standard and deserves immediate attention.
Those programmes where no centre responds "Yes", deserve priority
attention.
p ii W U' & Ui
26
27
Exhibit 4: Summary of observations of drug supply
system
Question/ Facilities:
1
Variable
A
B
C
D
5
Y
Y
N
6
Y
Y
Y
7
Y
Y
N
8
Y
Y
Y
9
N
N
N
10
N
N
11
Y
Y
12
Y
13
14
E
F
N
Y
Y
Y
N
G
H
Y
N
Y
N
N
Y
Y
Y
N
N
N
N
Y
Y
Y
N
N
Y
Y
Y
Y
Y
N
15
N
N
N
N
24
N
N
Y
25
N
N
Y
26
Y
Y
Y
27
Y
N
28
Y
Total Yes
J
I
N
N
N
4
N
N
Y
7
N
N
N
N
3
Y
Y
Y
Y
Y
10
N
N
N
N
N
0
N
N
N
N
N
N
0
Y
Y
Y
Y
Y
Y
10
Y
N
Y
Y
Y
N
6
Y
Y
Y
Y
Y
Y
Y
10
N
Y
Y
N
N
Y
N
5
N
N
N
N
N
N
0
Y
Y
N
N
N
N
Y
4
N
N
N
Y
N
N
N
2
Y
N
N
N
Y
Y
Y
7
N
Y
Y
N
Y
Y
Y
Y
7
Y
N
N
N
N
Y
Y
N
N
4
Y
Y
29
Y
Y
Y
Y
N
N
N
Y
7
30
Y
Y
N
N
N
N
Y
Y
Y
Y
6
31
N
N
N
N
N
N
N
N
N
N
0
32
N
N
N
N
N
N
N
N
N
N
0
33
Y
Y
N
N
Y
Y
N
N
Y
Y
6
34
Y
Y
Y
N
N
N
Y
Y
Y
Y
7
35
N
N
N
N
N
N
N
N
N
N
0
N
N
N
0
36
N
N
N
N
N
N
N
37
N
N
N
N
N
N
N
N
N
N
0
38
Y
Y
Y
N
Y
Y
Y
Y
N
N
7
39
Y
Y
N
N
Y
Y
N
N
Y
Y
6
Module 7: Management quality; procedures
i
28
$ f| f| f|
f|
Exhibit 5: Drug supply: 10 health centres
In addition to analysing data by specific service tasks, a
scoring system can be developed to assess overall quality. For example,
each task that was carried out could receive a score of one point. The
total "quality score" would be the total number of points for a set of tasks
compared with the maximum possible score. If some tasks are much
more important than others, they can be given added weight (e.g., 1.5 or
2 points).
Breakdown by site: Compare one site or session with another. Totals,
counts, and percentages can be calculated for each site. This will help
managers to identify strengths and weaknesses at different sites.
Graphs: Results can be plotted on a graph to give a manager or
supervisor a summary of the data. This is a useful visual aid for
presenting information. Exhibit 5 shows an example of such a graph.
Scoring:
£3-
£3
if
O.'
Module 7: Management quality; procedures
29
Step 6: Present and review preliminary results
The results of a management assessment are likely to take the form of
a list of problems, potential problems, or areas for improvement. The
findings of the assessment should be summarised and reviewed with all
those who participated in the assessment. Often, such information sharing
leads to further insight into the nature of the problem. This information
not only makes the assessment more accurate, it is invaluable for managers
at the point when they attempt to develop plans for improvement. Here
are some guidelines for presenting and reviewing findings with the team:
• Which activities were carried out well? Manager should begin by
reviewing what staff members did well. This reinforces good performance
and establishes a constructive rapport.
• Which activities need improvement? Areas that need improvement
should then be reviewed, providing as much specific information as
possible. Some problems will be associated with quantitative data, others
will be described in more qualitative terms.
• Which problems can be easily corrected? Some problems are easy
to correct, have obvious solutions, and require little extra effort to do
correctly. Managers should act quickly on these by exploring with staff
ways that corrections can be made. Experience has shown that those
changes will be more acceptable and more likely to be implemented if
they are suggested by the staff. The manager should encourage staff to
take the initiative to make the corrections. In these cases further analysis
(Step 7) will not be necessary. The team can take immediate action for
improvement.
• Which problems should be treated as priorities? Management
assessment may identify more problems than a manager or management
team can realistically solve. Managers and their staffs should define the
criteria they will use to decide where to take action. For example, they
may choose to focus on problems that pose high risks to patients or staff,
or problems that occur frequently because of the number of people
affected.
• Which problems will be more difficult to correct? These problems
may need to be analysed more formally by a problem-solving group or
special study. The activities of the group would include in-depth problem
analysis of the management process.
Module 7: Management quality; procedures
30
Step 7: Analyse the management process in more detail
Difficult problems require in-depth analysis, based on the experience and
insight of all those involved in the process. This section presents 3
analytical techniques that can help teams work together to understand
management problems and their causes. It is very important to find the
root causes of the problem so that the action taken is a true solution rather
than a superficial fix. Beginning with thorough analysis, the PHC team
should be better able to develop a solution that is appropriate, effective,
and acceptable to all those involved. This process might be done at the time
of presentation of preliminary results, or during a separate meeting.
One simple technique for understanding
problems better is to search for the root cause by asking "why" five times.
Too often we focus on the first cause of a problem, trying to solve it before
asking about other causes. Thus, deeper problems go undetected. While
there is nothing magic about the number five, repeatedly asking why will
lead the team to find a number of causes, some that can be addressed,
others that cannot. Based on this thorough analysis of the situation, they
are better able to decide where and how to take action.
For this technique to be effective curiosity is required. Participants
must look at a familiar problem as if it were new, so that they may see it
in all its complexity. It also requires openness; rather than accepting the
familiar explanations, the team, and especially the manager, must be open
to new ideas that will come from the group. A third important element
is participation. All those who are involved in the process should be
involved or represented in the analysis. Finally, listening during this
process is very important. Participants will be more likely to share their
thoughts if they are in a considerate, listening environment.
• Ask "why?" five times.
• Fishbone diagram. Another tool for the analysis of causes and the
identification of root causes is a cause and effect diagram, commonly called
a fishbone diagram. This method is useful because it organises information
from a variety of sources, graphically representing the situation in a way that
is easy to comprehend. Generally, the major categories of causes (such as
human resources, equipment, facility and supplies, etc.) are listed on the
major branches or "bones", and all the possible causes related to that category
are listed there. The objective of the exercise is to look for the most likely
root causes of the problem and to try to reach consensus about which causes
of the problem should be the focus of a management improvement effort.
An example of a fishbone diagram dealing with supervision is shown on the
following page.
Module 7: Management quality; procedures
31
A process flow chart is another analytical tool
that can provide a great deal of insight into the management process. The
flow chart can be used to map out how a process is actually functioning.
This helps the team to understand the process better and to find ways to
streamline or improve it. Very often after making a flow chart of a
"familiar" process, team members will comment that they hadn’t really
understood how the process was working until they charted it. The flow
chart can also be used to map out the process as it should be. The
following exhibit on page 33 is an example of a flow chart of the process
for ordering drugs.
• Process flow chart.
Step 8: Take action to improve management
Management assessment and analysis is not useful unless it is followed
by action for improvement. Based on the findings of the assessment and
subsequent analysis of causes, the team should be able to identify and
implement ways to improve the quality of those tasks that are not done
well.
Exhibit 6: Fishbone diagram
Module 7: Management quality; procedures
32
The PHC MAP manager’s guide on problem-solving provides some
guidelines and experiences that may be helpful. Also, the PRICOR
Operations Research manuals describe procedures for designing and con
ducting studies to develop and test solutions to operational problems in
PHC.1
After action has been taken to solve a problem, it is important to confirm
that it was implemented correctly and that it had the desired impact. At
the time when a plan is made to take action, a plan to evaluate the
effectiveness of that action should be developed. It may be a very simple
check, carried out by the manager or a staff member, but it is an essential
element in management improvement. If the problem has not been solved,
further analysis will be needed to explore why, and a modified strategy for
improvement should be developed. Once the problem is solved and the
solution has become a standard part of programme operations, the PHC
team can move on to another management problem in an effort to improve
their programme continuously.
1 Blumenfeld, S., Operations research methods: a general approach to primary health care
PRICOR monograph series, methods paper 1. Bethesda, MD, Center for Human Services
1991.
Module 7: Management quality; procedures
33
Exhibit 7: Flowchart: Ordering drugs
Module 7: Management quality; procedures
35
Appendix A:
Management assessment discussion
guidelines
Planning, personnel, training, supervision, finances, logistics,
information, and community organisation
Planning
"Health planning is the process of defining community health problems, identi
fying needs and resources, establishing priority goals, and setting out the adminis
trative action needed to reach those goals."1
Introduction: Welcome the group and briefly give the purpose of the discussion.
Ground rules: Explain the following ground rules to the group:
Ground rules for group discussion
Everyone’s ideas and opinions are important.
There are no right or wrong answers.
Both positive and negative comments are welcome.
Participants should feel free to disagree with one another so that all points of view
are heard.
Don’t wait to be called on; it’s a group discussion.
Please speak one at a time.
These discussion guidelines are provided to help you to lead a group
discussion about your planning system. You may also refer to the detailed version
of the management checklists (Appendix B) as a resource for the discussion.
Discussion
• What works well in the way we do planning?
Guidelines
• What aspects of the way we do planning do not work well?
• What is your mission? How well is it understood by staff, managers, donors, and
community members?
1 On being In charge, WHO 1992.
Module 7: Management quality; appendix A
36
• What are the programme objectives?
• What kinds of information do you need to plan your activities? Is this information
available to you?
• How well are your job description and assignments understood by staff?
Key questions
• Is there a written mission statement that describes the purpose and overall goals
of the organisation?
• Does the programme plan directly address the overall programme mission?
• Are there specific objectives and programme(s) or activities for each goal?
• Are there clear referral policies for services not offered, secondary, and tertiary
care?
• Do you have access to the basic information needed for programme planning?
• Is there an organisational chart or plan that clarifies the responsibilities of staff
members and the relationships between them?
• Are there written technical norms for all services included in the programme?
• Does each staff member have a clear job description?
• Are work plans and staff assignments regularly reviewed and updated?
Module 7: Management quality; appendix A
37
Personnel management
Personnel management includes activities that relate to recruiting, hiring and
supporting staff, and defining the roles of each individual. It also refers to standard
procedures related to compensation, benefits, and work schedules.
Introduction: Welcome the group and briefly give the purpose of the discussion.
Ground rules: Explain the following ground rules to the group:
Ground rules for group discussion
Everyone’s ideas and opinions are important.
There are no right or wrong answers.
Both positive and negative comments are welcome.
Participants should feel free to disagree with one another so that all points of view
are heard.
Don’t wait to be called on; it’s a group discussion.
Please speak one at a time.
These discussion guidelines are provided to help you to lead a group
discussion about your personnel management system. You may also refer to the
detailed version of the management checklists (Appendix B) as a resource for the
discussion.
Discussion
• What works well in the way we do personnel management?
J
4
Guidelines
• What aspects of the way we apply personnel management do not work well?
• Are staff members satisfied with their jobs and work environments? What are
the sources of satisfaction? What are the sources of dissatisfaction?
• What personnel procedures and policies are in place in your programme? Are
these policies fair? Do they contribute to the effectiveness of the programme?
• What areas need to be addressed through new or improved policies?
• Do the job descriptions of staff members adequately reflect their actual day-to-day
activities?
• How do supervisors work with staff members to plan activities and improve
performance? What other things could supervisors do to support staff members
in this way?
Module 7: Management quality; appendix A .
38
Key questions
• Are there enough qualified staff members available? Do opportunities exist for
promotion and professional development of staff?
• Does the system offer adequate job security to staff?
• Is there good communication between staff at different levels?
• Is communication between different departments good enough to co-ordinate and
plan effectively?
• Is staff morale high?
• Does each staff member have a job description?
• Do job descriptions list all types of tasks that will be required of the staff member?
• Do staff members feel that their job descriptions are realistic?
• Do supervisors develop specific work plans with their staff at regular intervals?
• Do supervisors periodically review whether work assignments are completed?
Module 7: Management quality; appendix A
39
Training
Training is the process of continually improving the knowledge, skills, and
competencies of health workers.
Introduction: Welcome the group and briefly give the purpose of the discussion.
Ground rules: Explain the following ground rules to the group:
Ground rules for group discussion
Everyone’s ideas and opinions are important.
There are no right or wrong answers.
Both positive and negative comments are welcome.
Participants should feel free to disagree with one another so that all points of view
are heard.
Don't wait to be called on; it’s a group discussion.
Please speak one at a time.
These discussion guidelines are provided to help you to lead a group
discussion about your training system. You may also refer to the detailed version
of the management checklists (Appendix B) as a resource for the discussion.
Discussion
• What works well in the way we do training?
Guidelines
• What aspects of the way we do training do not work well?
• What kind of information do you use to plan or focus training?
• Do you use information about health worker knowledge, attitudes, and practices?
• Do you use information about community needs? Is this information available to
you?
• What training methods are used? Are they used correctly? Are they effective?
Is the content of the training appropriate for local norms?
• What resources are available to support training? What resources are needed?
Module 7: Management quality; appendix A
40
Key questions
• Is programme specific information (from MIS or supervisor) about service quality
used to plan or focus the training?
• Did the training include a pre-test of health worker knowledge and skills?
• Does training include a post-test of health worker knowledge and skills?
• Is there a follow-up assessment of training (about six months later) to assess the
impact of the training?
• Are training topics explained clearly?
• Are training topics demonstrated?
• Do trainees receive written materials?
• Are health workers satisfied with the training they receive?
• Will training be followed up through the regular supervision system?
• Will trainee performance in new skill areas be monitored through MIS?
• Is the training content complete and accurate according to local norms?
• Are resources adequate?
Module 7: Management quality; appendix A
41
Supervision
Supervision is the process of directing and supporting staff so that they may
perform their duties effectively. Supervisors provide support, guidance, training, and
assistance in the identification and solution of problems, so that service quality and
effectiveness may continually improve.
Introduction: Welcome the group and briefly give the purpose of the discussion.
Ground rules: Explain the following ground rules to the group:
Ground rules for group discussion
Everyone’s ideas and opinions are important.
There are no right or wrong answers.
Both positive and negative comments are welcome.
Participants should feel free to disagree with one another so that all points of view
are heard.
Don’t wait to be called on; it’s a group discussion.
Please speak one at a time.
These discussion guidelines are provided to help you to lead a group
discussion about your supervision system. You may also refer to the detailed version
of the management checklists (Appendix B) as a resource for the discussion.
Discussion
• What works well in the way we do supervision?
Guidelines
• What aspects of the way we do supervision do not work well?
• Describe your supervisory system? Who does it? How? Do staff and supervisors
feel that supervision contributes to programme improvements?
• What kinds of activities are carried out by supervisors during supervisory visits?
• How does the supervisor assess the quality of the technical services delivered?
• How does the supervisor work with supervisees to identify and solve problems?
• Do supervisors have a good rapport with staff? Why or why not?
• Do supervisees feel free to discuss problems with their supervisors?
• How are supervisory activities recorded? Are supervisory records used for follow
up, problem solving, or to help you in planning?
Module 7: Management quality; appendix A
42
Key questions
• Is there a plan or schedule for supervisory activities?
Do supervisors use the following methods during supervision:
• Observation of service delivery?
• Asking the service provider about what problems she/he has been having?
• Review of records, supplies, or the conditions of the facility?
• Do supervisors assess technical service quality through observation of service
delivery or competency-based testing?
• Do supervisors make comments aimed at improving technical service quality?
• Do they make comments aimed at improving counselling or health education?
• Do they demonstrate any technical skills to the supervisee?
• Do they establish a good rapport with the supervisee?
• Do supervisors help their supervisees to organise and plan their work?
• Are supervisory records kept?
Module 7: Management quality; appendix A
43
Financial management
Financial management includes management of and accountability for pro
gramme finances, budgeting for planned activities, and, in some programmes,
cost-recovery or fund-raising.
Introduction: Welcome the group and briefly give the purpose of the discussion.
Ground rules: Explain the following ground rules to the group:
Ground rules for group discussion
Everyone’s ideas and opinions are important.
There are no right or wrong answers.
Both positive and negative comments are welcome.
Participants should feel free to disagree with one another so that all points of view
are heard.
Don’t wait to be called on; it’s a group discussion.
Please speak one at a time
These discussion guidelines are provided to help you to lead a group
discussion about your financial management system. You may also refer to the
detailed version of the management checklists (Appendix B) as a resource for the
discussion.
Discussion
• What works well in the way we do financial management?
Guidelines
• What aspects of the way we do financial management do not work well?
• Are your financial records clear, easy to understand, and correct? How do you
use the programme budget? How do budgeted and actual expenses compare?
• How are regular financial reports used and for what purposes?
• How do you take sustainability, equity, and growth into account in the financial
planning process?
Module 7: Management quality; appendix A
44
Key questions
• Does the chart of accounts meet the current needs of the programme?
• Are accounting records kept up to date and balanced monthly?
• Are the accounts legible?
• Are the calculations correct?
• Are all transactions entered in the ledger?
• Is there a programme budget?
• Are there established procedures for review and approval of budgets?
• Are the budgets used as a tool for evaluating performance on a planned versus
actual costs basis?
• Are regular financial reports prepared?
• Does the administrator evaluate results by making annual comparison of "budget"
to "actual" financial performance?
• Is sustainability considered in the financial planning process?
• Is equity considered in the financial planning process?
• Is growth considered in the financial planning process?
Module 7: Management quality; appendix A
L-
45
Logistics management
Logistic systems deal with the procurement, storage, and tracking of supplies
and equipment.
Introduction: Welcome the group and briefly give the purpose of the discussion.
Ground rules: Explain the following ground rules to the group:
Ground rules for group discussion
Everyone’s ideas and opinions are important.
There are no right or wrong answers.
Both positive and negative comments are welcome.
Participants should feel free to disagree with one another so that al! points of view
are heard.
Don’t wait to be called on; it’s a group discussion.
Please speak one at a time.
These discussion guidelines are provided to help you to lead a group
discussion about your logistics system. You may also refer to the detailed version
of the management checklists (Appendix B) as a resource for the discussion.
Discussion
• What works well in the way we do logistics?
Guidelines
• What aspects of the way we do logistics do not work well?
• What procedures are in place for purchasing goods or services?
• Are these procedures followed? Are they effective?
• How are goods stored and monitored?
• What procedures are in place to determine what supplies are needed? Are these
procedures followed? Are they effective?
• What is the procedure for assuring the maintenance of the cold chain? Are these
procedures followed? Are they effective?
• What transportation is available for staff? Is it adequate?
Module 7: Management quality; appendix A
46
Key questions
• Does the institution have its own established checklists and procedures for the
procurement of goods and services?
• Before placing an order for goods and services, does the administrator review the
order to ensure that the item(s) are needed?
• Are supplies ordered regularly according to the defined procedures?
• When procedures are followed, are supplies received on time?
• Does the facility or organisation have established reception procedures?
• Does the institution have established procedures for inventory control?
• Is the inventory maintained according to the defined procedures?
• Is the storage area protected (from water, dust, etc.)?
• Are equipment and supplies labelled clearly and organised in an accessible way?
• Is there a PHYSICAL inventory taken to verify theoretical stock levels with actual
PHYSICAL counts?
• Does the staff have access to transportation?
• Is the fuel available adequate for field visits and other off-site activities?
• Is there a thermometer or cold chain monitor in the refrigerator?
Module 7: Management quality; appendix A
Information management
An information system is organised around key indicators that measure a
programme’s progress toward its goals. It is a systematic way of collecting, reporting,
and using data at all programme levels.
Introduction: Welcome the group and briefly give the purpose of the discussion.
Ground rules: Explain the following ground rules to the group:
Ground rules for group discussion
Everyone’s ideas and opinions are important.
There are no right or wrong answers.
Both positive and negative comments are welcome.
Participants should feel free to disagree with one another so that all points of view
are heard.
Don’t wait to be called on; it’s a group discussion.
Please speak one at a time.
These discussion guidelines are provided to help you to lead a group
discussion about your management information/monitoring system. You may also
refer to the detailed version of the management checklists (Appendix B) as a
resource for the discussion.
Discussion
• What works well in the way we do information management?
Guidelines
• What aspects of the way we do information management do not work well?
• What kind of information do you routinely collect? Is this information useful?
How do you use it?
• What kind of information do you give to your supervisor or manager? Does the
supervisor use the information collected?
• Are your information needs met by the current system? What kind of information
would you like to have that is not collected at present? Of the information you
collect now, what would you eliminate (discuss the types of information that you
don’t use)?
Module 7: Management quality; appendix A
48
BF
Key questions
K-
• Is there a list of indicators to be monitored at the district-level?
• Is there a list of indicators to be monitored at the health centre-level?
Sit-
Do these lists include indicators of
• Resource availability?
• Access?
• Utilisation?
• Coverage?
• Service quality?
• Outcome?
• Have information sources been identified for each indicator?
• Has the frequency of collection/compilation been established for each indicator9
• Has an analysis procedure for each indicator been established (including thresholds
or standards)?
• Have mechanisms for interpreting and discussing results been established?
• Do managers prepare and transmit reports of monitoring results to the appropriate level in a timely manner?
• Do managers utilise information to identify areas for improvement of district-wide
and local problems and strengths for specific interventions?
FA-
J;.,1
!;J8^-
E;
E.. '
Ej. (
gjZ
L
EE
Bj-
&
Module 7: Management quality; appendix A
tv.
49
Community organisation
Community organisation is the involvement of the community in the design,
planning, promotion, or delivery of health enhancing activities.
Introduction: Welcome the group and briefly give the purpose of the discussion.
Ground rules: Explain the following ground rules to the group:
Ground rules for group discussion
Everyone’s ideas and opinions are important.
There are no right or wrong answers.
Both positive and negative comments are welcome.
Participants should feel free to disagree with one another so that all points of view
are heard.
Don’t wait to be called on; it’s a group discussion.
Please speak one at a time.
These discussion guidelines are provided to help you to lead a group
discussion about community organisation. You may also refer to the detailed version
of the management checklists (Appendix B) as a resource for the discussion.
Discussion
• What works well in the way we do community organisation?
Guidelines
• What aspects of the way we do community organisation do not work well?
• Describe the communities served by the programme. What ethnic groups are
represented? What are their health needs? Describe the role of women. What
are the implications for health? What are the needs of socially disadvantaged
groups?
• In what ways does the health committee or community organisation support the
health centre and its activities?
• Is the community organisation strong and active? How do you know this?
• What kinds of activities are carried out by the community in support of the health
activities? Do community members provide leadership in the health area?
Module 7: Management quality; appendix A
50
Key questions
• Is there a health committee or community organisation affiliated with the health
centre?
• Does the community organisation meet regularly?
• Are meetings led by a member of the community?
• Are leaders chosen by the community?
• Are decisions made in a way that is satisfactory to group members?
• Are women involved in community organisation ?
• Does the community organisation have a good rapport with local officials?
• Are disadvantaged groups adequately represented?
• List under-represented groups
• Are the needs of socially or economically disadvantaged groups addressed by the
health committee or community organisation?
• Has the group undertaken activities in the past year?
• Are the activities clearly visible in the community?
• Does the community help to implement activities?
• Does the community play a leadership role in health activities?
• Does the community effort receive adequate technical assistance from local,
district, and outside agencies?
Module 7: Management quality; appendix A
51
Appendix B:
Management assessment checklists
Planning, personnel, training, supervision, finances, logistics,
information, community; organisation
Planning
"Health planning is the process of defining community health problems, identi
fying needs and resources, establishing priority goals, and setting out the adminis
trative action needed to reach those goals."1
This checklist is intended for use in the assessment of planning activities. Its
objective is to help managers to enhance the quality of their programmes by
identifying and resolving problems in the planning area. It can be adapted for use
in both vertical programmes and integrated PHC efforts. The questions below can
be answered through interviews, document review, observation of management
activities, or a review of the health facility. Some questions ask for the respondents
opinion about the quality or adequacy of specific tasks; in such cases, the perspec
tives of managers, health service providers, and community members should be
taken into account. Areas that are deemed inadequate can be further explored
through focused discussions with key informants. With modification, the checklist
can be used as a basis for an open-ended interview or group assessment.
1.
2.
3.
4.
__________
Health facility
Service provider
Observer/Supervisor
Date
Mission statement
A mission statement describes the purposes and overall goals of an organisation.
These questions will help you to determine whether the mission is clearly defined
and understood by programme staff, the community, and donors.
5.
YES _
6 ' YES
NO
NO
Is there a written mission statement?
;~f
Does the mission statement include a clear prufrary''
care strategy?
fa (
.
1 On being in charge, WHO 1992.
Module 7: Management quality; appendix B
§
ii5 £
L1?- f s? ? -s t
f;
<
52
7. YES___
8. YES___
9. YES___
10. YES___
11. YES___
12. YES___
NO___
NO___
NO___
NO___
NO _
NO___
Is the mission statement understood by the health centre staff?.
Is the mission statement understood by the community?
Is the mission statement understood by health centre managemer.
Is the mission statement understood by the board?
Is the mission statement understood by the donors?
Does the programme plan directly address the
overall programme mission?
Programme objectives
Objectives are the specific results that are expected from a programme or
activity. These questions will help you determine whether the objectives are defined
adequately for the purpose of planning.
13.
14.
15.
16.
17.
18.
YES
YES
YES
YES
YES
YES
19.
20.
YES
YES
21.
YES
22.
23.
24.
25.
YES
YES
YES
YES
26.
YES
27.
YES
28.
29.
YES
YES
30.
31.
YES
YES
32.
YES
33.
YES
Is the geographic area to be served clearly defined?
Are the age groups to be served clearly defined?
Are high-risk groups to be served specified?
Are the services offered specified?
Are there explicit programme objectives?
Did the community play a role in setting goals and
objectives?
NO
Are the objectives reviewed and revised on a regular basis?
NO
Do government programmes and/or donors understand
and agree with the goals and objectives?
NO
Are coverage objectives for each service stated and
quantified?
NO
Are coverage objectives understood by staff?
NO
Are objectives for service quality stated and quantified?
NO
Are service quality objectives understood by staff?
NO
Are objectives for improvements in knowledge in specific
PHC areas stated and quantified?
_ NO
Are objectives for improvements in knowledge understood
by staff?
_ NO _ Are objectives for behaviour change in specific PHC areas
stated and quantified?
NO
Are behaviour change objectives understood by staff?
. NO
Are objectives for health status improvement stated and
quantified?
NO
Are health status objectives understood by staff?
NO _ Does the programme include integration of PHC service
delivery?
NO
Are programme staff aware of other PHC services
offered in the area?
NO
Does the programme avoid duplication of activities
through communication or collaboration with these
services?
NO
NO
NO
NO
NO
NO
Module 7: Management quality; appendix B
53
34. YES
NO
35. YES
36. YES
NO
NO
Are there clear referral policies for services not offered,
both secondary, and tertiary?
Is there a clear policy about community involvement?
Is programme evaluation included in the plan?
Information needed for programme planning
The following questions will help you to assess whether the programme has
access to the basic information needed for programme planning.
37. YES
NO
38. YES __
39. YES
NO
NO
40 YES
NO
41. YES
NO
42. YES
NO
43. YES
NO
44. YES
NO
45. YES
NO
46. YES
NO
Do you know how many people overall are to be served
through the programme?
Do you have a map of the service area?
Do you have a breakdown of the age and sex of the
population?
Do you have current information about the health
status of the population (birth rate, IMR, CMR, MMR,
and causes of death)?
Do you have current information about the priority health
needs of the population?
Do you have information about the economic status
of the population?
Do you have information about the educational
level of the population (literacy, what languages are
spoken)?
Do you have information about the ethnic composi
tion of the area?
Do you have information about key health practices for
the ethnic groups served by your programme?
Do you know current levels of coverage for specific
services?
Programme planning
The following questions will help you to assess whether the organisational
structure, schedule, and planning activities are adequate.
Organisational structure
47. YES
NO
48. YES
NO
Is there an organisational chart or plan that
clarifies the responsibilities of staff members and
the relationships between them?
Are there written technical norms for all services included
in the programme?
Module 7: Management quality; appendix B
54
49. YES _ NO
50. YES___ NO___
Are service delivery strategies for each service
made explicit i.e. through clinic sessions, household
visits, mobile units?
Is there an explicit strategy for educational activities?
Scheduling
51. YES
NO___
52. YES___ NO___
53. YES___ NO___ _
54. YES___ NO___
55. YES___ NO___
Is there a regular schedule of clinical sessions at the health
facility?
Is there a regular schedule for clinical outreach activities?
Is there a regular schedule for household visits?
Is there a regular schedule for educational sessions
at the health centre?
Is there a regular schedule for community outreach
education?
Other management activities
56. YES___ NO
57. YES___ NO___
58. YES___ NO___
59. YES___ NO___
60. YES___ NO
61. YES___ NO
62. YES___ NO___
63. YES___ NO
Is there a plan for providing training?
Is there a supervision plan?
Is there a system for procurement, storage, and transport
of supplies (logistics)?
Does the plan include a management information system
that monitors service delivery and management activities?
Is there a financial monitoring system?
Is there a budget for the activities planned for the year?
Is funding adequate for the activities planned in the
coming year?
Is there a long-term funding strategy?
Work planning for individual staff members
The following questions will help you determine if staff members clearly
understand their responsibilities.
64. YES
65. YES
NO
NO
66. YES
NO
67. YES
NO
if
Does each staff member have a job description?
Do staff members regularly receive specific staff
assignments in major task areas?
Do staff members understand how their assignments
are related to programme mission and objectives?
Are work plans and staff assignments regularly
reviewed and updated?
Module 7: Management quality; appendix B
55
Personnel management
Personnel management includes activities which relate to recruiting, hiring and
supporting staff, and defining the roles of the individual. It also refers to standard
procedures related to compensation, benefits, and work schedules.
This checklist is intended for use in the assessment of personnel management.
Its objective is to help managers enhance the quality of their programmes by
identifying and resolving problems in the personnel management area. It can be
adapted for use in both vertical programmes and integrated PHC efforts. The
questions below can be answered through interviews, document review, observation
of management activities, or a review of the health facility. Some questions ask for
the respondent’s opinion about the quality or adequacy of specific tasks; in such
cases, the perspectives of managers, health service providers, and community
members should be taken into account. Areas that are deemed inadequate can be
further explored through focused discussions with key informants. With modifica
tion, the checklist can be used as a basis for an open-ended interview or group
assessment.
Health facility
Service provider
Observer/Supervisor
Date
1.
2.
3.
4.
Personnel essentials
The following questions address some essential personnel management issues
that reflect the quality of the personnel management system.
-J
5. YES
6. YES
NO
NO
7. YES
NO
8. YES
NO
9. YES
NO
10. YES
NO
11. YES
NO
12. YES
NO
Are there enough qualified staff members available?
Do opportunities exist for promotion and professional
development of staff members?
Does the system offer adequate job security to staff
members?
Are salaries and benefits adequate to attract competent
well-trained staff members?
Are salaries and benefits adequate to retain competent
and well-trained staff members?
Do staff regularly receive their salary on the days
when they expect it?
Is staff turnover at an acceptable level (one which does
not hamper the implementation of planned activities)?
Do staff members meet or exceed performance
expectation?
Module 7: Management quality; appendix B
IB
56
13. YES___ NO___
14. YES _ NO___
15. YES___ NO___
16. YES___ NO___
17. YES___ NO
18. YES___ NO__ .
Are staff members well-informed about the overall
programme plans and objectives?
Is there good communication between staff members
at different levels?
Is communication between different departments
enough to co-ordinate and plan effectively?
Is there a good rapport between staff members and
clients or community members?
Is staff morale high?
Do staff members like their jobs?
I --
es
£p-
r—
44}-
Policies and procedures
The questions below will help you to identify personnel policies and procedures
that need attention.
Do written policies exist for:
19. YES___ NO
20. YES___ NO__ _
21. YES__ _ NO___
22. YES___ NO.__
23 YES
NO
Hours of work?
Vacation and holidays?
Overtime?
Benefits?
Salaries and raises?
fe-
Are clear procedures followed for:
24. YES___
25. YES___
26. YES___
27. YES___
28. YES___
29. YES___
30. YES___
31. YES___
32. YES___
NO___
NO___
NO___
NO___
NO___
NO__ _
NO
NO
NO___
EE
Recruiting staff?
Selecting staff?
Hiring staff?
Promoting staff?
Disciplining staff?
Firing staff?
Filing a grievance?
Are personnel actions and reviews documented?
Are records consulted and used for management?
P T
fef*
MH--.-
0-
Job descriptions
The following questions will help managers and staff members assess the
adequacy of their job descriptions.
in
Does each staff member have a job description?
Do job descriptions list all types of tasks that will
be required of the staff member?
Does each job description list the training, knowledge,
and skills required to carry out the job?
Do job descriptions include checklists about what
proportion of time should be spent on each type of task?
uz
33. YES _ NO___
34. YES___ NO__
35. YES___ NO___
36. YES___ NO___
Module 7: Management quality; appendix B
jSE
^3
57
37. YES___ NO___
■J
38. YES___ NO___
3
3
3
39. YES___ NO___
40. YES___ NO__ _
41. YES___ NO___
42. YES
NO___
:3
Do managers respect the boundaries established by job
descriptions? Do they refrain from asking their subordi
nates to perform activities that are not part of their job
descriptions?
Do managers offer opportunities for professional
development to their supervisees?
Are job descriptions revised as roles change?
Do staff members feel that their job descriptions are
clear and complete?
Do staff members feel that their job descriptions are
realistic?
Are staff members actively involved in defining
roles and responsibilities?
Work planning and performance assessment
In addition to having clear job descriptions, health workers should schedule
activities or plan work on a periodic basis. This area overlaps, to some extent, with
supervision. The questions below deal with the organisation, structure, regularity,
and definition of the activity. Specifics about methods are included in the PHC
MAP checklists on supervision.
3
X
3
3
JS’
43. YES
44. YES
NO
NO
45. YES
NO
46. YES
NO
47. YES
NO
48. YES
NO
49. YES
NO
50. YES
NO
51. YES
NO
52. YES
NO
Do all staff members have an immediate supervisor?
Do all staff members know who their immediate
supervisor is?
Do supervisors develop specific work plans with
their staff at regular intervals?
Do supervisors periodically review whether work
assignments are completed?
Do supervisors assess performance quality on a regular
basis?
Do supervisors help staff members to set, review,
and revise priorities?
Do supervisors regularly review the training needs
of staff members?
Do supervisors take constructive action to improve
performance?
Are supervisors and staff members satisfied with
the level of responsibility they have?
Are supervisors and staff members satisfied with
the authority (decision-making ability) they have?
Module 7: Management quality; appendix B
58
Training
Training is the process of continually improving the knowledge, skills, and
competencies of health workers.
This checklist is intended for use in the assessment of training activities. Its
objective is to help managers enhance the quality of their programmes by identifying
and resolving problems in the training area. It can be adapted for use in both vertical
programmes and integrated PHC efforts. The questions below can be answered
through interviews, document review, observation of management activities, or a
review of the health facility. Some questions ask for the respondent’s opinion about
the quality or adequacy of specific tasks; in such cases, the perspectives of managers,
health service providers, and community members should be taken into account.
Areas that are deemed inadequate can be further explored through focused
discussions with key informants. With modification, the checklist can be used as a
basis for an open-ended interview or group assessment.
1.
2.
3.
4.
_____
Health facility
Service provider
Observer/supervisor
Date
Training plan
The following questions will help you assess whether the training plan is
adequate.
5.
6.
YES
YES
_ NO
NO
7.
YES
NO
Is there a plan for training activities?
Is programme-specific information (from MIS or
supervision) about service quality used to plan or
focus the training?
Do health workers participate in at least one training
or refresher course every year (or two years)?
Training methods
A variety of training methods must be employed for effective training. These
questions will help you assess whether the training methods used are adequate.
8. YES
NO
9. YES
10. YES
NO
NO
Did the training include a pre-test of health worker
knowledge and skills?
Did the training address gaps identified in the pre-test?
Does training include a post-test of health worker
knowledge and skills?
Module 7: Management quality; appendix B
59
11. YES___ NO___
12. YES___ NO___
13. YES___ NO___
14. YES___ NO___
15. YES.__ NO___
16. YES___ NO___
17. YES___ NO___
18. YES __ NO___
19. YES___ NO___
20. YES _ NO
21. YES___ NO___
22. YES___ NO___
23. YES__ .NO__
Are measures taken to address the gaps identified
in the post-test, if necessary measures might include
refresher course, individual attention, or intensive
supervision?
Is there a follow-up assessment of training (about
six months later) to assess the impact of the training?
Are training topics clearly explained?
Are training topics demonstrated?
Do participants have an opportunity to put new
knowledge and skills into practice during training?
Is adequate time given to discussion and questions
from participants?
Do trainees receive written materials?
Do trainees find the written materials they receive useful?
Do trainees have an opportunity to evaluate the
training?
Are health workers satisfied with the training they
receive?
Does training include a variety of methods?
Will training be followed up through the regular
supervision system?
Will trainee performance in new skill areas be monitored
through MIS?
Training content
The following questions will help you assess the adequacy of the training content.
24. YES
NO
25. YES
26. YES
NO
NO
Is the training content complete according to local
norms?
According to local norms, is the training content correct?
Is the material presented appropriate to the skills,
educational levels, and abilities of the trainees?
Are staff members adequately trained in the following areas:
27.
28.
29.
30.
31.
32.
33.
34.
35.
36. __
Household visits
Antenatal care
Delivery
Postnatal care
Child spacing
Immunization
Growth monitoring
Oral rehydration therapy
Acute respiratory infection
Malaria
Module 7: Management quality; appendix B
60
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
YES
YES
YES
YES
Tuberculosis
Curative care
Water and sanitation
Planning
Training
Community organisation
Logistics
Financial management
MIS
Personnel Management
NO _
Is training for health workers adequate?
NO
Is training for community health workers adequate?
NO
Is training for supervisors and managers adequate?
NO
Is training/orientation of health committee
members adequate?
Resources
Good training requires the availability of resources to support the training, such
as space, audio-visual materials, books, etc. These questions will help you to assess
the adequacy of the available resources for training.
51. YES___ NO___
52. YES___ NO___
53. YES___ NO___
54. YES
NO .
Training manuals
55. YES___ NO___
56. YES
NO
57. YES___ NO___
58. YES___ NO___
Is there a space adequate for training activities
available to staff?
Are there audio-visual aids (blackboard, flip charts,
or slide projector)?
Are there reference materials available to trainers?
Are there reference materials available to trainees?
Is there an adequate supply of training manuals?
According to local norms, is the material in the
training manual complete?
According to local norms, is the material in the
training manual correct?
Is the material in the training manual appropriate
for the type of health worker being trained?
Take home materials
59. YES
NO
60. YES
NO
61. YES
NO
62. YES
NO
fe-
te
E?'
KT
?S~
&
E"
(j£-
. „
Li-
|#-
££
Is there an adequate supply of take-home materials
for trainees?
(.
According to local norms, are the take-home materials ~
complete?
j—
According to local norms, are the take-home materials ~
correct?
Are the take home materials appropriate for the type
L?of health worker being trained?
Module 7: Management quality; appendix B
61
Supervision
Supervision is the process of directing and supporting staff members so that they
may effectively perform their duties. Supervisors provide leadership, support,
guidance, training, and assistance in the identification and solution of problems, so
that service quality and effectiveness may continually improve.
This checklist is intended for use in the assessment of supervision activities. Its
objective is to help managers enhance the quality of their programmes by identifying
and resolving problems in the supervision area. It can be adapted for use in both
vertical programmes and integrated PHC efforts. The questions below can be
answered through interviews, document review, observation of management activ
ities, or a review of the health facility. Some questions ask for the respondent’s
opinion about the quality or adequacy of specific tasks; in such cases, the perspec
tives of managers, health service providers, and community members should be
taken into account. Areas that are deemed inadequate can be further explored
through focused discussions with key informants. With modification, the checklist
can be used as a basis for an open-ended interview or group assessment.
1.
2.
3.
4.
Health facility
Service provider
Observer/Supervisor
Date
Supervisory schedule
The following questions will help you assess whether the supervisory schedule
is adequate.
5. YES___ NO___
6. YES _ NO___
7. YES___ NO__
8. YES___ NO
9. YES___ NO___
10. YES___ NO
Is there a plan or schedule for supervisory activities?
Are there written checklists or protocols for supervision?
Do supervisees meet with their supervisors at least
every____ (no. of months or weeks per local policy)?
Does the supervisor have staff meetings every____
months/ weeks?
When supervisory activities are cancelled, are they
re-scheduled?
Are supervision schedules (and schedule changes)
communicated to health workers?
Supervisory methods
Good supervision encompasses a variety of methods. These questions will allow
you to determine which methods the supervisor is using, and will help you to assess
the quality of supervision.
Module 7: Management quality; appendix B
11. YES
12. YES
NO
NO
13. YES
NO
14. YES
15. YES
NO
NO
16. YES
NO
Observation of service delivery?
Observation of counselling or an outreach health
education session?
Asking the service provider about what problems
she/he has been having?
Team approach to problem identification and solution?
Review of records, supplies, or the conditions of the
facility?
Community-level assessment of the outcomes or
impacts of interventions?
Do the following areas receive adequate attention during supervision?
17.
Household visits
18.
Antenatal care
19.
Delivery
20.
Postnatal care
21.
Child spacing
22.
Immunization
23. _ . Growth monitoring
24.
Oral rehydration therapy
25.
Acute respiratory infection
26.
Malaria
37.
YES
. NO
38.
YES
NO
39.
YES
NO
40.
YES
NO
41.
YES
NO
27.
Planning
28.
Training
29. ——Community organisation
30.
Logistics management
31.
Financial management
32.
MIS
33.
Personnel management
34
__Tuberculosis
35.
Water and sanitation
36
Curative care
Are health workers given adequate support through
supervision?
Are community health workers given adequate
support through supervision?
Is the health committee or other community
organisation given adequate support through the
supervisory system?
Is the community participating in the supervisory
system to the extent appropriate?
Are supervisors receiving adequate support from
higher-level managers?
Supervision of technical service quality
These questions will help you assess whether the supervisors are supervising
the quality of the services being provided.
42.
YES
NO
Do supervisors assess technical service quality through
observation of service delivery or competency-based
testing?
Module 7: Management quality; appendix B
3
Do supervisors use the following methods during supervision?
ft ft ft ft ft ft ft ft ft ft ft VI ft ft ft ft IB! ft ft ff ft ft
62
63
3
3J
3
-J?
m
4S
i2*
-X<
□J
43.
YES
NO
44.
YES
NO
45.
YES
NO
46.
YES
NO
Supervisory style
These questions will help you assess the supervisory style of the supervisor.
47. YES
NO
48. YES
NO
49. YES
50. YES
NO
NO
51. YES
NO
52.
YES
NO
53.
YES
NO
54.
YES
NO _,
55.
YES
NO _
56.
YES
NO
_
Do supervisors help their supervisees to organise and
plan their work?
Do supervisors help service providers to identify
problems?
When problems are identified, do supervisors make
recommendations or take action?
Do supervisees feel free to discuss problems with the
supervisor?
Do supervisors make recommendations, respond, or
take action on the problems or issues raised by the
supervisee?
Supervisory records
Recording the supervisory visit is essential to ensure consistency and follow-up.
The following questions will help you assess whether adequate records are being
kept.
57.
58.
7
Do supervisors allow the supervisee adequate time
to talk about problems he or she has experienced?
Do they refrain from criticising the service provider
in front of patients?
Do they establish a good rapport with the supervisee?
Do they establish a good rapport with clients or
community members?
Do they praise good performance?
Work planning and problem solving
One role of the supervisor is to assist the supervisee plan his/her work and solve
problems. These questions will help you assess the degree to which the supervisor
fulfils this role.
3
jg
Do supervisors make comments aimed at improving
technical service quality?
Do they make comments aimed at improving counselling
or health education?
Do they demonstrate any technical skills to the
supervisee?
Do they verify that written protocols are available
to the supervisee?
YES _ NO __.
YES
NO
Are supervisory records kept?
Are identified problems recorded?
Module 7: Management quality; appendix B
59.
60.
61.
YES
YES
YES
NO
NO
NO
62.
YES
NO
Are actions taken recorded?
Are records used for follow-up?
Are records used to plan other activities, such as
training?
Are follow-up activities recorded?
Module 7: Management quality; appendix B
Financial management
Financial management includes management of and accountability for pro
gramme finances, budgeting for planned activities, and, in some programmes,
cost-recovery or fund-raising.
This checklist is intended for use in the assessment of financial management
activities. Its objective is to help managers enhance the quality of their programmes
by identifying and resolving problems in the financial management area. It can be
adapted for use in both vertical programmes and integrated PHC efforts. The
questions below can be answered through interviews, document review, observation
of management activities, or a review of the health facility. Some questions ask for
the respondent’s opinion about the quality or adequacy of specific tasks; in such
cases, the perspectives of managers, health service providers, and community
members should be taken into account. Areas that are deemed inadequate can be
further explored through focused discussions with key informants. With modifica
tion, the checklist can be used as a basis for an open-ended interview or group
assessment.
Health facility
Service provider
Observer/Supervisor
Date
1.
2.
3.
4.
General accounting
The fiscal health of a programme/facility relies on well kept, accurate accounting
books. These questions will help you determine if a basic accounting system is in
place.
5. YES___ NO___
6. YES___ NO _
7. YES___ NO__ _
8. YES___ NO___
9. YES___ NO___
10. YES__ _ NO___
11. YES___ NO___
Is a chart of accounts used?
Does the chart of accounts meet the current needs of
the programme?
Are accounting records kept up to date and balanced
monthly?
Is someone responsible for daily transactions and entries?
Are the accounts legible?
Are the calculations correct?
Are all transactions entered in the ledger?
Cash disbursements
Disbursements are monies paid out of the programme/facility account. These
questions will help you assess the adequacy of the disbursement procedures.
12. YES _
NO
Are all disbursements made by cheque?
Module 7: Management quality; appendix B
66
13. YES
NO___
14. YES___ NO___
15. YES___ NO___
16. YES___ NO___
17. YES___ NO__
18. YES___ NO__
Are pre-numbered checks used so that missing cheques
can be accounted for?
Do the signatories sign cheques only after they are
properly completed and justified with supporting
documentation?
Does the administrator approve and cancel the
documentation in support of all disbursements?
Are all voided cheques retained and accounted for ?
Does the administrator review the bank reconciliation?
Are vouchers prepared for all disbursements ?
Accounts payable and purchases
These questions will help you assess the adequacy of purchasing procedures.
19.
YES
NO
20.
YES
NO
21.
YES
NO
22.
YES
NO
Does someone other than the bookkeeper always
do the purchasing?
Are suppliers’ invoices regularly compared with
recorded liabilities?
Are vouchers always prepared and approved before
payment?
Are purchase orders always approved before they are
sent to suppliers?
£"
gL’.
8E
Eg
{S.
LiPayroll
These questions will help you assess whether adequate payroll procedures are
used.
23.
YES
NO
24.
YES
NO
25.
YES
'NO
Are employees required to account for the hours
they worked?
What do you receive as supporting documentation
to calculate employee salaries?
Do employees sign a "pay slip" to indicate receipt
of payment (if payment is not a cheque)?
Petty cash
Petty cash can be the most difficult monies to control. These questions will help
you to assess whether the established procedures are being followed in the use of
petty cash.
26. YES
27 YES
NO
NO
28. YES
NO
29. YES
NO
Is the petty cash box locked at all times?
Are arrangements made for access to the cash box
during the custodians absence (for lunch etc.)?
Is the fund checked by surprise counts made by
another employee independent of the custodian?
Has a maximum figure for individual payments from
the fund been established?
Module 7: Management quality; appendix B
&
fcS..
jjt.
£
S3
67
30. YES___ NO
31. YES___ NO
32. YES___ NO.__
33. YES___ NO___
34. YES___ NO
35. YES___ NO___
36. YES___ NO___
Are vouchers and supporting documents checked at the
time of reimbursement by a responsible employee?
Does the custodian verify the amount of the fund?
Are vouchers voided so as to preclude their reuse ?
Are the amounts of the vouchers spelled out in words
as well as written in numerals?
Are Petty Cash receipts pre-numbered?
When replenishing petty cash, does custodian fill out a
written request and attach al! supporting documents
to this request?
Does person authorising replenishment verify that all
disbursements have been properly justified before
granting the request?
Receipts
These question will help you to assess whether receipts are adequately handled
and documented.
37. YES _
NO
38. YES
NO
Are funds received deposited in a separate bank
account (not co-mingled with other accounts)?
Recorded on a cumulative basis?
Financial planning and management
A budget is an essential tool for programme management. These questions will
help you assess whether the budget is being used properly in programme manage
ment.
38. YES___ NO
39. YES___ NO___
40. YES___ NO___
41. YES___ NO___
42. YES___ NO___
43. YES _ NO
Is there a programme budget?
Did the staff participate in the development of budgets?
Are there established procedures for review and
approval of budgets?
Was the budget reviewed and approved by senior
management and donors?
Does the budget reflect the goals and objectives of
the programme?
Are the budgets used as a tool for evaluating
performance on a planned versus actual costs basis?
Does the current budget include adequate funding for:
44. YES___
45. YES___
46. YES___
47. YES___
48. YES___
49. YES___
NO___
NO___
NO___
NO___
NO
NO___
Staff wages and benefits?
Supplies?
Equipment?
Transportation?
Other?
Are monthly financial reports prepared?
Module 7; Management quality; appendix B
IB
68
50. YES
51. YES
_ NO
NO
52. YES
NO
53. YES
NO
54. YES
NO
Does the administrator review monthly financial reports?
Do monthly reports show budgetary expenditures,
encumbrances, and availability by category of expense?
Does the administrator prepare budgets and standards
to aid in planning?
Does the administrator evaluate results by making
annual comparison of "budget" to "actual" financial
performance?
Does the administrator ensure that receipt and
expenditure of funds is properly identified on a
cumulative basis?
Sources and adequacy of funding
These questions will help you assess the sources of funding, reliability, and
adequacy.
55. YES___ NO___
56. YES___ NO___
57. YES___ NO___
58. YES___ NO___
59. YES___ NO___
60. YES___ NO___
6L YES___ NO___
62. YES____ NO___
63. YES___ NO__ _
64. YES___ NO___
Does the programme receive funds from the community
(fees or contributions)?
Does the programme receive funds from the government-’
Does the programme receive funds from international
donors?
Does the programme receive funds from other sources?
Is funding adequate for the next year of operation?
Is funding adequate for the next three years of
operation?
Is the funding source or mix of sources reliable?
Is sustainability considered in the financial planning
process?
Is equity considered in the financial planning process?
Is growth considered in the financial planning process?
Module 7. Management quality; appendix B
69
Logistics management
=3
—-j
_
—®
Tjj
jj)
-5)
42
4?
_____________________________________________
Logistic systems deal with the procurement, storage, and tracking of supplies
and equipment.
This checklist is intended for use in the assessment of programme logistics. Its
objective is to help managers enhance the quality of their programmes by identifying
and resolving problems in the logistics area. It can be adapted for use in both
vertical programmes and integrated PHC efforts. The questions below can be
answered through interviews, document review, observation of management activities, or review of the health facility. Some questions ask for the respondent’s
opinion about the quality or adequacy of specific tasks; in such cases, the perspecfives of managers, health service providers, and community members should be
taken into account. Areas that are deemed inadequate can be further explored
through focused discussions with key informants. With modification, the checklist
can be used as a basis for an open-ended interview or group assessment.
------------------------------------------------------------------------------- —
Health facility
Service provider
Observer/Supervisor
Date
1.
2.
3.
4.
35
Procurement
These questions will help you to assess the adequacy of the procurement system
and its operations.
-at.__ .
5. YES___ NO___
■
6. YES___ NO___
X
7. YES___ NO___
8. YES__ NO___
9. YES___ NO___
10. YES
NO___
11. YES___ NO___
4
12. YES___ NO___
Does the institution have its own established checklists
and procedures for the procurement of goods and
services?
Is someone responsible for initiating procurement
requests within the institution?
Is a standardised procurement request form used?
Is there a clear policy about who can authorise requests?
When items are purchased, are multiple cost estimates
sought from potential suppliers?
Has the person who makes the decision received
training in accordance with established policies for
cost analysis and selection criteria?
Is verification obtained from the accounting department
to ensure that sufficient funds are available in the budget
prior to each procurement?
Before placing an order for goods or services, does the
administrator review the order to ensure that the item(s)
are needed?
4J
Module 7: Management quality; appendix B
70
13. YES
NO
14. YES
NO
15. YES
NO
For large procurements, is additional support and
attention given to the procurement planning process
employed?
Are supplies regularly ordered according to the defined
procedures?
When procedures are followed, are supplies received on
time?
Reception of materials
These questions will help to assess the adequacy of the reception of equipment
and supplies.
16.
YES
17.
18.
YES
YES
19.
20.
21.
YES
YES
YES
22.
YES
23.
YES
Does the facility or organisation have established
reception procedures?
NO _
Is someone responsible for receipt of materials?
NO
Is there a standardised form for reporting reception
of materials?
NO
Is the reception report reviewed by manager(s)?
NO _
Are received goods inspected for defects?
NO _
Are received goods compared against purchase orders
to be sure that the order has been filled correctly
(quantity and items requested)?
NO _
Are equipment and supplies recorded in stock records
immediately after completion of reception procedures?
NO _
Are reception procedures carried out?
NO
Inventory control
These questions will help you to assess the adequacy of the inventory control
system for equipment and supplies.
24.
YES _ NO
25.
YES
NO
26.
27.
28.
YES
YES
YES
_ NO
NO
NO
29.
YES
NO ,
Does the institution have established procedures for
inventory control?
Is the inventory maintained according to the defined
procedures?
Is the size of the storage area adequate?
Is the storage area protected (from water, dust, etc.)?
Are equipment and supplies labelled clearly and
organised in an accessible way?
Is it possible to lock the storage area?
Supplies
30 YES
31. YES
NO
NO
Is there a clerk responsible for tracking supplies?
Are stock records (cards or register) maintained for
all items in stock?
Module 7: Management quality; appendix B
71
32. YES___ NO___
33. YES___ NO
34. YES___ NO___
35. YES___ NO
36. YES__
NO
37. YES___ NO___
38. YES___ NO
Are records updated after each transaction to reflect
accurately stock levels for a particular item at any given
point in time?
Are there established procedures for reordering stock
items?
Is a physical inventory taken to verify theoretical
stock levels with actual physical counts?
Is such an inventory carried out at least every___
(weeks or months)?
Is there a supervisor on hand to observe the counting
and ensure that the inventory is carried out properly?
Does a second person count supplies to ensure that
the count was accurate?
Are expiration dates of medicines checked during
the inventory?
Equipment
39. YES___ NO___
Is there a permanent property record for all equipment?
If yes, does the record include:
40. YES___ NO__
41. YES _ NO___
42. YES___ NO___
43. YES___ NO___
44. YES___ NO___
45. YES__ _ NO___
46. YES___ NO___
47. YES___ NO___
•
48. YES _ NO___
49. YES___ NO___
50. YES___ NO___
51. YES___ NO___
52. YES___ NO___
53. YES___ NO___
54. YES _ NO___
Date of acquisition?
Serial number (if any)?
Name and address of the vendor?
Amount paid for the property?
Location of the property?
Actual condition?
An inventory control number?
Are there established procedures for the assignment
of equipment?
Does the organisation carry out an annual physical
inventory of equipment?
If yes, was an inventory completed during the past year?
Are results of the inventory compared with the.property
records for verification?
At the time of the inventory is equipment reviewed to
assure that it is in good condition and that the
technology is up-to-date (where appropriate)?
Are there established procedures for lost, damaged,
or stolen property?
Are there established procedures for the disposal of
property?
Are there established procedures for the transfer of
property within the organisation?
Module 7: Management quality; appendix B
72
Stock issue
These questions will help you to assess the adequacy of the system for issuing
supplies.
55. YES
NO
56. YES
57 YES
NO
NO
58. YES
NO
59. YES
60. YES
NO
_ NO
61. YES
NO
Is there a standard request form to be filled out before
items can be released from inventory?
Is there an authorisation procedure in place?
Are disbursements of supplies recorded in inventory
records at the time of transaction?
Is a receipt prepared at the time the material leaves
the storeroom?
Does the recipient of the materials sign for them?
Is health centre staff satisfied with the performance
of suppliers?
Is health centre staff satisfied with the performance
of the personnel responsible for procurement, inventory
management, and disbursement?
Transportation
If the programme includes community outreach or community based service
delivery, or if satellite health posts are part of the programme, an appropriate
transportation system should be in place. These questions will help you to assess
the management of transportation resources.
62.
63.
YES
YES
NO
NO
64.
YES
NO
65.
66.
YES
YES
NO
NO
Does the staff have access to transportation9
Is the fuel available adequate for field visits and other
off-site activities?
Is there a schedule or appointment book kept for health
centre vehicles?
Is there a maintenance schedule for vehicles?
Is there a mechanism for acquiring spare parts?
Module 7: Management quality; appendix B
73
Information management
An information system is organised around key indicators that measure a
programme’s progress toward its goals. It is a systematic way of collecting, reporting,
and using data at all programme levels.
This checklist is intended for use in the assessment of management information
systems. Its objective is to help managers enhance the quality of their programmes
by identifying and resolving problems in the management information systems area.
It can be adapted for use in both vertical programmes and integrated PHC efforts.
The questions below can be answered through interviews, document review,
observation of management activities, or review of the health facility. Some
questions ask for the respondent’s opinion about the quality or adequacy of specific
tasks; in such cases, the perspectives of managers, health service providers, and
community members should be taken into account. Areas that are deemed
inadequate can be further explored through focused discussions with key infor
mants. With modification, the checklist can be used as a basis for an open-ended
interview or group assessment.
Health facility
Service provider
Observer/Supervisor
Date
1.
2.
3.
4.
Planning the information system
Health service indicators monitor the performance of a system or programme.
An information system is a group of these indicators that reveal the status of the
programme. These questions will help you determine if a basic information system
is in place.
5.
YES
6.
YES___ NO___
NO___
Is there a list of indicators to be monitored at district
level?
Is there a list of indicators to be monitored at health
centre-level?
Do these lists include indicators of:
7. YES___
8. YES___
9. YES___
10. YES
11. YES___
12. YES___
13. YES___
NO___
NO__ _
NO___
NO___
NO___
NO___
NO___
Resource availability?
Access?
Utilisation?
Coverage?
Service quality?
Outcome?
Have information sources been identified for each
indicator?
Module 7: Management quality; appendix B
74
14. YES___ NO___
15. YES___ NO___
16. YES___ NO___
Has the frequency of collection/compilation been
established for each indicator?
Has an analysis procedure for each indicator been
established (including thresholds or standards)?
Have mechanisms for interpreting and discussing
results been established?
rF-
Record keeping - first level
In order for the information system to work, information collected at the most
peripheral level must be complete and correct. These questions will help you assess
the completeness and precision of the information being collected at the first level.
Direct service delivery
17. YES
18. YES
NO
NO
19. YES
NO
20. YES
NO
21. YES
NO
Is data on the size of the target population available?1
Do health workers maintain records on services
delivered to specific individuals (with information
on age, weight, diagnosis (classification), treatment,
referral)?
Do health workers maintain records on the number
of health education sessions, outreach clinics, vaccination
sessions, etc.?
Do health workers maintain records on high-risk cases
for follow-up?
Do health workers maintain records on the number
of deaths, the number of cases of immunizable
diseases, the number of malnourished children?
Support services
22. YES
23. YES
NO
NO
24. YES
NO
Do health workers maintain records on stock inventories?
Do health workers maintain records on the integrity
of the cold chain?
Do supervisors maintain supervision records with
information on performance of specific health workers?
B-'
S':
S
,ES
rg".
t-q
Compilation, tabulation and analysis of information - first level2
While information is generally collected with the express purpose of being sent
to the central level, it can also be very useful to the health worker. These questions
will help you identify whether the health worker is using the information at the first
level.
...
gz
1 This could be collected from census data or from a population-based information system.
2 The first level refers to health centres/health posts or other level of primary data collection and
compilation.
Module 7: Management quality; appendix B
t
75
25. YES
NO
26. YES
NO
27. YES
NO
28. YES
NO
29. YES
NO
30. YES
NO
Do health workers routinely compile/tabulate information
from service records for monitoring?
Do health workers calculate the value of indicators on
resource availability for specific interventions?
Do health workers calculate the value of indicators
on utilisation of specific interventions?
Do health workers calculate the value of indicators
on high-risk follow-up for specific interventions?
Do health workers calculate the value of indicators
on coverage with specific interventions?
Do health workers calculate the value of indicators
on quality of worker performance for specific interventions?
Use of information for management decision-making
These questions will help you identify how the health worker is using the
information collected/tabulated/analysed.
31.
YES
NO
32.
YES
_ NO
33.
YES
NO
_
Do local-level health managers utilise information to
identify programme problems and strengths for scientific
interventions?
Does the community participate in interpretation
of results?
Do local-level health managers utilise information
for training purposes (training, supervision, change
of strategy)?
Reporting information and feedback
This will help you assess whether the local managers are sending the reports to
the central level.
34.
YES
NO
Do local-level managers prepare and transmit reports of
monitoring results to the appropriate level in a timely
manner?
Additional data collection (surveys) - second level
These questions will help you assess the adequacy of additional information that
is being collected.
35.
YES
NO
36.
YES
NO
37.
38.
YES
YES
NO
NO
Do managers plan information collection on KAP
and impact?
_
Do managers prepare sampling plans for rapid
(household, exit, intercept) surveys?
Do managers train/prepare training for data collectors?
Do managers verify data collected?
Module 7: Management quality; appendix B
76
Compilation, tabulation, and analysis of information - second level1.
This will help you assess whether second level managers are using the information received from the first level
39. YES___ NO___
40. YES___ NO
41. YES___ NO___
42. YES _ NO
43. YES___ NO___
44. YES___ NO___
Do second-level managers compile information
transmitted from health centres for monitoring?
Do second-level managers calculate the value of
indicators on resource availability for specific
interventions on a district-wide basis?
Do second-level managers calculate the value of
indicators on utilisation of specific interventions on
a district-wide basis?
Do second-level managers calculate the value of
indicators on high-risk follow-up for specific
interventions on a district-wide basis?
Do second-level managers calculate the value of
indicators on coverage with specific interventions
on a district-wide basis?
Do second-level managers calculate the value of
indicators on quality of worker performance for
specific interventions on a district-wide basis?
j-
s
3..
Use of information for management decision-making
These questions will help you assess how the second level manager uses the
information received from the first level.
Do second-level managers utilise information to
identify district-wide and localised problems and
=strengths for specific interventions?
46. YES
NO
Do second-level managers utilise information for training
I*
purposes (training, supervision, change of strategy)?
jial
Reporting information and feedback
45.
YES
47.
YES _ NO
48.
YES _ NO
NO
Do second-level managers prepare and transmit reports
of monitoring results to the appropriate level in a timely
manner?
Do second-level managers provide feedback to local-level
managers on the results of district-wide monitoring?
1 The second level refers to district or regional levels of compilation and analysis, as well as the organisation
of coverage, KAP, and impact surveys.
Module 7: Management quality; appendix B
g-
S'-
77
Community organisation
Community organisation is the involvement of the community in the design,
planning, promotion, or delivery of health enhancing activities.
This checklist is intended for use in the assessment of community organisation
activities. Its objective is to help managers enhance the quality of their programmes
by identifying and resolving problems in the community organisation area. It can
be adapted for use in both vertical programmes and integrated PHC efforts. The
questions below can be answered through interviews, document review, observation
of management activities, or a review of the health facility. Some questions ask for
the respondent’s opinion about the quality or adequacy of specific tasks; in such
cases, the perspectives of managers, health service providers, and community
members should be taken into account. Areas that are deemed inadequate can be
further explored through focused discussions with key informants. With modifica
tion, the checklist can be used as a basis for an open-ended interview or group
assessment.
1.
2.
3.
4.
Health facility
Service provider
Observer/Supervisor
Date
Profile of community organisation
This profile will help supervisors or group facilitators to describe the context of
community activities and to identify opportunities and constraints. The information
should be used to anticipate needs for support rather than to judge the community
or programme.
5.
YES
NO
7.
8. YES
NO
9.
YES
NO
10. YES
11. YES
NO
NO
12. YES
NO
6.
Is there a health committee or community organisation
affiliated with the health centre?
How many members are on the health committee or
community organisation?
What is the size of the population represented?
Are there other community organisations active in
the area?
Do any of these groups carry out PHC or social welfare
projects?
Are there active co-operatives in the area?
Do social and political conditions favour community
organisation?
Is the local leadership supportive of community
organisation efforts?
Module 7: Management quality; appendix B
IB
U
78
Utilisation/Acceptance
Satisfaction
til
Health services
Ui
Service utilisation, satisfaction, and participation
Information on the satisfaction of community members with the services
provided can be invaluable in programme planning. The following will help you
assess community satisfaction, utilisation, and participation in the services provided.
For the programme areas listed below indicate whether the community utilises
the service, whether they are satisfied with the service, and whether they participate
in the planning or implementation of services.
Participation
tsi
13. Antenatal care
14. Delivery
ibj
15. Postnatal care
16. Child spacing
t i U iii H !■! i
17. Immunization
18. Growth monitoring
19. Oral rehydration therapy
20. Acute respiratory infection
21. Malaria
22. Tuberculosis
23. Curative care
24. Household registration
0j
25. Community health education
26. Promotion of services
oi
27. High-risk ID/follow-up
aii
Other activities
28. Water and sanitation
H M tii t*
29. Gardening/nutrition
30. Infrastructure development
31. Income generating projects
32. Literacy projects
33. Other
JE
Module 7: Management quality; appendix B
79
Indicators of quality
The following questions will help you assess the quality of the community
organisation.
34. YES
35. YES___
36. YES___
37. YES___
NO
NO _
NO___
NO___
38. YES _ NO _
39. YES___ NO___
40. YES___ NO_
41. YES _ NO _
42. YES___ NO___
43. YES _
NO _
44. YES _
45. YES _
46. YES _
NO _
NO _
NO _
Does the community organisation meet regularly?
Are meetings led by a member of the community?
Are leaders chosen by the community?
Are decisions made in a way that is satisfactory to
group members?
Are decisions made carried out?
Are group members active outside of attendance at
meetings?
Do group members make positive contributions to
activities?
Are new members welcome?
Is participation in a community organisation
voluntary?
Do more than half of the organisation’s funds come
from the community?
Are women involved in community organisation ?
Are women involved in training and decision - making?
Does the community organisation have a good
rapport with local officials?
Are diverse members of the community represented in terms of:
47._______
48._______
49._______
50._______
51.
52. YES _
ethnicity
income
religion
caste
other
NO _
53. YES _
NO _
54. YES _
NO
55. YES _
56. YES
57. YES___
58. YES _
NO _
NO _
NO___
NO _
59. YES___ NO___
(
(
(list groups
(
(
Are disadvantaged groups adequately represented?
list disadvantaged groups
Are the needs of socially or economically disadvantaged
groups addressed by the health committee or
community organisation?
Are the needs of socially and economically disadvantaged
groups addressed by the health programme?
Has the group undertaken activities in the past year?
Are the activities clearly visible in the community?
Were cancelled activities re-scheduled?
Was the community informed in advance about
cancellations and schedule changes?
Does the group profiled here avoid duplication with other
community groups in the area?
Module 7: Management quality; appendix B
80
6^
Has the group profiled here ever co-ordinated with or
carried out an activity jointly with another community
group?
74.
Data
collection
and compilation
for delivery?
MIS?
75.
Provide
assistance
during service
73.
Procurement
and management
of drugs
and community
supplies? organisa
Were
any
of
the
following
improvements
achieved
through
76. Other?
tion
72.
Management of finances?
61.
New needed services are available
62. The acceptability of services (clinic hours, waiting time, staffing)
has
improved
71.
Receive
training provided by the health programme?
63. An active community health worker programme is in place
64. More outreach and home visits are carried out
65.
Community projects have been successful
70
Helpsuccessful
to carry out
community needs assessment?
66. List
projects:
60.
YES
NO
Implementation
These questions will help you assess the ways in which the community actively
participates.
premiums)?help to implement activities in the following ways:
Does the community
67.
Publicising education or clinical sessions?
68. Contributing labour or resources to community projects?
69. Contribute funds to support programme (through fees or insurance
Leadership
These questions will help you assess the degree to which the community takes
on a leadership role in the health activities.
Does the community play a leadership role in health activities in the following
ways:
77.
Determining the organisation’s goals and objectives?
78.
Setting priorities based on community assessment?
83.
approving,
or evaluating
paid staff?
79.
Planning
activities?
84. Selecting,
Setting
financial
management
policy?
or
promoters)?in the design or development of training?
80.
Participating
81Participating in problem analysis and problem solving?
82.----------- Selecting, approving, or evaluating unpaid staff (health volunteers
Module 7: Management quality; appendix B
81
85. Set policy about management of logistics and supplies?
86. Analyse and interpret MIS data?
87.
Evaluation of staff or programme?
Co-ordination and support
Active, sustained community organisation requires the support of local health
officials/workers and outside agencies. These questions will help you assess the
degree of local and outside support for community organisation.
Does the community effort receive adequate assistance from local, district, and
outside agencies in the following areas;
Local District Outside
88. Technical support for PHC services?
89. activities?
Technical support for water and sanitation
----------------- ---------
Technical support for agricultural efforts which
promote better nutrition?
91. Technical support for other key activities?
90.
92.
YES
NO
93.
YES
NO
94.
YES
NO
Are there adequate incentives for community health
workers to co-operate with the health committee or
community groups?
Are there adequate incentives for health centre staff
to organise and support community organisation?
Are there adequate incentives for managers and
higher-level staff to encourage and support community
organisation?
Module 7; Management quality; appendix B
83
Appendix C: Worksheet
WORKSHEET FOR PLANNING MANAGEMENT
ASSESSMENT
Step 1.
Specify the objectives of the assessment
a.
What is the purpose of the assessment?
b.
What s the scope of the assessment?
Management activity(ies):
Sub-tasks:
c.
Who will use the information gathered?
d.
How will the information be used?
e.
What programmes or facilities (units) will be analysed?
f.
Over what period of time will the activities take place?
g.
Are resources adequate?
Step 2.
Determine assessment methods
a.
Unit of observation:
b.
Data sources:
c.
Sampling methods:
Step 3.
Choose relevant checklists:
Modification required:
Module 7: Management quality; appendix C
References and bibliography
• Ishikawa, K. Guide to quality control. Asian Productivity Organization,
Tokyo, Japan. 1982.
• McMahon, R. et al. On being in charge: A guide to management in primary
health care. World Health Organization, Geneva, Switzerland. 1992.
• PRICOR Project, Center for Human Services, Primary health care thesau
rus, Volumes I and 11. Bethesda, Maryland. 1992.
'w
ftft
f | II)
ffi
$
®
• Scholtes, P R. The team handbook: How to use teams to improve quality.
Joiner Associates, Inc., Madison, Wisconsin. 1988.
if i f i f if $ if
84
Module 7: Management quality; references & bibliography
85
Acronyms and abbreviations
AIDS
AKF
AKHN
AKHS
AKU
ANC
ARI
CBR
CDR
CHW
CMR
EPI
FP
GM
I EC
IMR
IV
KAP
MIS
MMR
MOH
NG
NGO
ORS
ORT
PHC
PHC MAP
PNC
PRICOR
SSS
STD
TB
TBA
TT
UNICEF
URC
USAID
WHO
Acquired immune deficiency syndrome
Aga Khan Foundation
Aga Khan Health Network
Aga Khan Health Service
Aga Khan University
Antenatal care
Acute respiratory infection
Crude birth rate
Crude death rate
Community health worker
Child mortality rate
Expanded Programme for Immunization
Family planning
Growth monitoring
Information, education, communication
Infant mortality rate
Intravenous
Knowledge, attitudes, practice (behaviour)
Management information system
Maternal mortality rate
Ministry of Health
Naso-gastric
Non-governmental organisation
Oral rehydration salts
Oral rehydration therapy
Primary health care
Primary Health Care Management Advancement Programme
Postnatal care
Primary Health Care Operations Research
Salt-sugar solution
Sexually-transmitted diseases
Tuberculosis
Traditional birth attendant
Tetanus toxoid
United Nations Children’s Fund
University Research Corporation
United States Agency for International Development
World Health Organization
Module 7: Management quality; acronyms
PHC MAP MANAGEMENT COMMITTEE
Dr. Ronald Wilson • 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, India
Dr. Nizar Verjee • 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 Murthy • 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. Al Henn • African Medical and Research 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. Paul Richardson
Dr. David Nicholas
Dr. Wayne Stinson
Ms. Maria Francisco
Dr. Neeraj Kak
Ms. Lori DiPrete Brown
Ms. Pam Homan
Dr. Lynne Miller Franco
Ms. Mary Millar
MODULE 7
USER’S GUIDE
Health <„e M.mgeme„,
p„gramne
- Media
10645.pdf
Position: 922 (8 views)