We'll use the example of the community-directed treatment

with Ivermectin to review this diagnosis.

It's important to recognize, of course,

that there are different people involved at different levels,

but we'll focus pretty much at this time on

the the district in community level for getting the program organized.

Technical factors include the drug itself,

the knowledge and skills to administer the drug,

the logistics for getting the drug out to the community,

the supply and delivery system.

Logistics include also community visits supervision,

acquiring the drug from the state headquarters.

Technical factors also involved information system, record keeping,

reporting, management of side effects and drugs for those side effects, and referral.

In summary, technical factors include

those elements dealing specifically with the interventions,

the drug providing the service,

as well as with management factors,

how the system or service is structured.

The human element, in the case of community-directed treatment,

we have district and front-line health staff and their attitudes toward the work,

toward community members, toward community participation.

We have the relationship between

the district staff and the national staff and state staff,

who they rely on for their own training and drug supplies.

Their attitudes of superiority,

inferiority enter into the picture.

We have the relationship between the district staff and community members,

especially in this program because communities are

expected to provide volunteers for training.

We have relationship between the health staff and any NGOs involved.

USAID APOC, the African Program for Onchocerciasis Control,

requires, and in most countries,

that an NGO such as Helen Keller International Sight Savers,

Global 2000 River Blindness Program work

together in partnership with a national organization.

So the relationships between these people is important to maintain.

Even within the health department,

the people who are directly involved in

onchocerciasis and those who are not is important.

Are there feelings of concern or jealousy that people in

one program are getting more attention or more benefits and people in other programs?

So, all of the human relationship issues are

concerned here and the human element of organizational diagnosis,

the informal communication, the attitudes,

the cliques that form.

We can see a picture of a community health assistant at a front-line health facility.

She was involved in keeping the stock of

Ivermectin and the village-based workers or community.

Directed distributors would come to her to get their supplies.

She participated in the training and supervision.

They submitted their returns to her.

So she was a key person in this program.

It's important when we're doing our diagnosis of organizations to

recognize that health staff behave in certain ways.

What we're concerned about is not health behavior per se,

but job performance behavior.

And we can use our various models of individual behavior,

social learning, health belief, et cetera,

to try to understand why health workers behave the way they do in organizations,

why they contribute, why they withhold their services.

And issues concerning their knowledge are technical factors.

The issues concerning their attitudes toward the work

and toward other staff are part of the human element.

The reinforcing factors, oftentimes,

are part of the human element.

The attitude between staff and supervisors, their relationship.

We started off this module talking about

the environment as one of the key words in understanding organizations.

The environment concerns, not just the physical,

but the cultural, the economic environment.

In this particular case,

we need to be aware of community beliefs and

perceptions about onchocerciasis and its management,

their local explanatory models.

We need to be concerned about

community expectations of the health department and what they want from services.

We have people in some communities say, "Well,

if the government wants us to take this Ivermectin,

then they should organize it themselves."

Whereas other people were saying,

"We want the work together with the health department.

We want them to take us as partners and equals."

So we have to be aware of these expectations.

The environment concerns, also the accessing of resources in terms of human resources,

in terms of energy resources,

financial resources to run the program.

And in particular with onchocerciasis,

we need to be very much conscious of the geography,

the distribution of villages,

the distance to them,

the type of terrain that they're in.

All of these affect how the program is organized and delivered.

The fourth element of organizational diagnosis is the space time coordinates.

As we noted, the example of the small clinic in Uganda,

it's part of a larger district health system.

And this implies that there does need to be coordination which,

we said was a key part of the organizational definition.

There does need to be organization,

not just within that particular unit,

but among the different units that comprise a District Health Service.

Coordination with time, even in one unit,

needs to account for the fact of when clients would be available,

when resources would be available,

coordination, different timings or different activities.

One interesting coordination that inadvertently occurred in some of the clinics

in Kenya was that they would start off their clinic with the health talk.

The staff would wait until they had what they

called a critical mass of people before they would start to talk.

At the same time,

the mothers found the talk boring,

and they would wait in the market across the road from

the health center and watch until the talk was over,

and then they would all start rushing in.

So, although the timing was considered important by the health workers,

the activity that they were doing actually

disrupted their schedule because the mothers didn't like it.

Because of the human element,

poor communication between the health workers and the mothers,

they never learned until much later

that the mothers were avoiding this health talk and offsetting,

confusing the whole time schedule for the clinic.

Timing of inputs is very important.

With the CDTI, training needs to occur before the drugs come,

but the timing is important because if training occurs too far in advance,

the village health workers may forget.

This happened the first time we tried to get the community-directed treatment organized.

We were told that we would probably get drugs from the state health department,

sometime in October.

October came, November.

The villagers had been contacted.

They were wondering what was going to happen.

We went ahead and held the training in December,

and then they said they were changing the size of the drugs.

They will no longer be a large six-milligram tablet.

They would have to be divided for some patients

because half a tablet was given as a standard dose.

And so, we would have people receiving a half,

one and a half, or two depending on their height.

They changed it to three milligram tablets to make it easier to administer.

But these were not made available in the country until two months later.

By the time they were available,

many of the village health workers had forgotten their instructions,

so there had to be a retraining.

Another thing about timing that's very important to public health is

relating timing of disease transmission with intervention.

Ideally, if the greatest impact is going to be had with

Ivermectin reducing the microfilariae loads in the skin,

then treatment should begin just before the rainy season,

before the black fly,

that is the vector transmitting the disease,

hatches and starts biting people.

The same thing happens with guinea worm.

It does very little good to distribute filters in March or April,

in the dry season,

and transmission season starts in October.

Timing is important because,

if people are encouraged to come to a clinic for immunization,

and yet the supplies are not made available in time,

that they will become disappointed and won't come back another time.

The location of the different components of the service require coordination.

The district headquarters where drugs are kept may be far from the village.

Effort is needed to make sure that

Ivermectin stocks are available in the local health clinics.

In particular, the Ivermectin Program

involves players who are based in Ouagadougou and Burkina Faso.

That's the headquarters of the African program for Onco psychiatrists control.

The Mark De Zan donation committee is located in Atlanta.

The Ministry of Health for a given country or state,

located in the capital.

The district health teams are located in

their own districts and then there are facilities located outside.

All of these different groups,

bodies need to be coordinated.

Finally, we have the fifth element of organizational diagnosis, that's policy diagnosis.

In this particular case,

the main policy is the use of a community-directed approach.

To achieve onchocerciasis control,

the policy requires collaboration by

national control programmes in the ministry with non-governmental organisations.

To ensure technical competence and financial accountability,

there do need to be national Onco programs with national task forces.

To serve as independent supervisors.

There are requirements of making a financial commitment for up to 15 years.

And there are different issues at the district level,

for allocation of resources for onchocerciasis,

for immunization, for family planning, for environmental sanitation.

And so, all these different levels policies are made.

But the important issue is to look at who makes the policy,

who is supposed to interpret the policy and,

who is expected to implement the policy,

and do people have the resources to do that within the organization.

Other important issues of policy at

the organizational level include issues of personnel policy,

issues of resource policy,

organizations have policies about how they get contracts to supply drugs,

policies about in-service training opportunities for staff.

These various kinds of management policies

also influence people's satisfaction with the work,

the human element, et cetera.

One major aid in our organizational diagnosis,

is the drawing of organograms.

Organograms represent the official structure of the organization.

And once we have that,

we can also start to look at the unofficial,

somewhat invisible interaction power structure communication with an organization.

It's important to sit down with members of

the organization to draw out the organogram and interpret what it means.

Just as we said, it's important to involve

community members in mapping their own community and

interpretating the distribution of different resources facilities,

amenities, groups within the community.

It's important for people in the organization to sit down and look

at what the organizational chart is supposed to mean,

what it tells us about the supposed interaction in the organization,

and what it what is really happening,

and look at that contrast that can help people move from a pre

contemplative to a contemplative stage in understanding their organization.

The first organogram looks at a program for

urban water supply and sanitation rehabilitation in Uganda,

funded by the World Bank.

The World Bank dealt with two different ministries directly.

Financial assistance is always channeled through the Ministry of Finance,

or a comparable group,

a central bank, and the

technical assistance in this case went to

the Ministry of Lands Mines and Natural Resources.

They set up a special project unit for

the urban water supply and sanitation rehabilitation.

That project unit worked directly with

seven city councils to see what could be done to upgrade

the water and sanitation systems that had

fallen into poor repair during years of fighting,

before Idi Amin was overthrown.

The World Bank was specially concerned about

the issue of peri urban slums that were mushrooming around many cities.

And noting that it was often possible to put in

stand pipes and water into these for general community use,

but that the overall health benefit would not be achieved if poor sanitation existed.

So this this project was supposed to have a sanitation component that

included the construction of ventilated improve pit latrines,

which are latrines basically with a vent vent pipe.

Hot air rises and the smell and hot air from latrine will go

through the pipe and not up the hole in the middle of latrine.

This is something that discourage many people from using latrines.

The hot air and the smell.

So if the ventilation pipe could remove this these would be more acceptable, supposedly.

The World Bank work with

another bilateral donor that gave money to a engineering company,

a contractor, to build these latrines in

addition to making the other improvements in the water supply.

Now because of the health implications of this project, particularly sanitation,

and the recognized need to involve

communities in such innovations so that they will accept them,

the World Bank encouraged

the Ministry of Lands and Mines to liaise with the Ministry of Health.

And their particularly their health education division to

get qualified staff to work on that component.

So although the Ministry of Health was not directly in line with the project,

it was requested to second the health educator to work with the project unit.

It took many months before the health educator was

even given a desk in the project office.

The health educator had a lot of trouble getting transportation to go out

to the different communities in the seven towns.

And consequently, the health educator is often left behind.

The contractor was putting pressure on the project office

to move ahead with the latrines because they

wanted to finish their work and leave the country in time.

They wanted to avoid being charged any penalties for not completing.

And so, the people who,

in the unit themselves were engineers,

were able to relate to the contractor staff who were engineers,

better than they could relate to a public health person.

And so they tended to side with the contractors and they went ahead in

many cases and constructed the latrines without proper community organization.

Needless to say, many of them were not kept and maintained well,

abandoned and the project failed because of poor communication between different types

of staff and a lack of

a concrete working relationship established and enforced by the donor,

the World Bank, requiring that

health education be given its proper place in the whole project.

Again, these are not things that you can see directly from the organogram,

but you can certainly see that while the main donor relates to two specific ministries,

it's an indirect secondment relationship between health and the project.

This in and of itself should raise questions about how are they going to work together.

And then in reality by sitting down and

showing this and discussing with the different parties involved,

either together or separately,

the details are filled in.

Another example of a program being complicated

by a variety of inputs from different agencies,

is seen in the next slide.

PVO, is Private Voluntary Organization,

and the U.S. Agency for International Development,

has been operating as part of its child survival programs and commitment.

A program to encourage PVOs to establish projects in developing countries.

To help set up and strengthen primary health care and child survival activities.

This looks at what happened with a particular PVO.

The focal issue is really at the local government or district level,

because in Nigeria in particular,

where this case occurred,

the responsibility for primary health care rests with the District Health Department.

The District Health Department, of course,

is part of the local government administration.

Within the District Health Department,

there are outlying health clinics, health centers, dispensaries.

These determine what would be called PHC or health districts,

if there are about five clinics and there are

about five districts dividing up the local government accordingly.

And from these districts,

village health workers are trained and supervised.

So the idea is that,

the local government health department is the unit at which PHC is implemented.

Now PHC is implemented using guidelines from the Federal Ministry of Health.

And then also, it's supposed to be provided with

technical assistance from the PHC department in the State Ministry of Health.

Nigeria has three tiers of health care and constitutionally,

each level of government has its own unique responsibilities.

Consequently, the State Ministry of Health does not provide secondary services,

but not primary service.

The general hospitals and some specialis\zed hospitals are run by the state.

But the state is responsible for training and technical assistance.

The local government is

responsible for direct service delivery at the primary care level.

Interestingly enough in Nigeria,

the local government health workers and

any local government staff above the level of a cleaner,

or a messenger, clerical staff,

is hired not by the local government itself,

but by the local government service commission in a particular state.

So the health staff are not accountable directly to the local government councilors,

or the local government chairmen.

They're only accountable to

the State Service Commission that hires them and they can be transferred at will.

Also, financially, the local governments are not dependent on the state.

They get most of their financial support

through direct subvention from the Federal Ministry of Finance.

Now when the PVO in question sought a grant from AID for this project,

they went to the field,

they identified some state and some districts,

and developed a proposal.

They were going to work together with the state, primary healthcare department,

to provide technical assistance and of course with AID involvement,

some financial assistance to help get PHC off the ground.

Particularly, the child health components of it in a set of local governments.

The PVO, national headquarters got the grant from AID.

They set up a national office in Nigeria because they had more than one project going.

And then they set up a field office for this particular state project.

JHU isn't there because at that time,

Johns Hopkins served as provider of technical support,

proposal review and project evaluation for AID.

Although they didn't have much directly to do with

this particular project other than training

the staff to carry out baseline and follow up surveys and help analyze that.

And as you can see, many different groups are involved and particularly,

at the local level,

people were influenced in part by technical supervision from the state,

by federally developed guidelines,

by federal sources of funds,

by state sources of personnel.

When the PVO stepped into the situation,

they tried to liaise with the State Ministry and

they got a couple of staff seconded to the project.

But after the Ministry made it clear that what they

expected from the project was per diems, financial support,

and transportation, and the project said this type of support

is used by the project to deliver services and assistance to the local government,

not to be handed over to the state,

then the state, people lost interest and didn't go out to the field with him.

In fact, unfortunately, the state lacked vehicles.

When we visited, we found that the vehicle given to the guinea worm program by donors,

vehicle given to immunization program by donors,

all of those were sitting up on blocks behind the ministry and had not been functioning.

So the ministry had no transportation.

They did not have enough money for staff per diems to send them

out to the field to do the technical supervision that was expected.

And so, only the two seconded staff

that worked with the project were able to do any work.

So the ministry itself was not involved.

Even at the local government level,

there was not much activity from the local government administration.

Oftentimes, they would, the local government chairmen and counselors,

would take the vehicles allocated to the PHC department and use them

for attending meetings in the Capitol or for their own personal requirements,

picking up children from school,

going shopping, et cetera.

So the health department was out on the limb and so without the PVO at that time,

they were not able to implement.

Ironically, at the end,

there was supposed to be three phases.

The first phase the PVO would work together technically

and financially to help the LGA launch

primary Health Care and related child health activities

in one of the several health districts in the local government.

Then with only technical assistance,

the local government health department would continue

and start these activities in a second.

And then the PVO would step back and observe and report to IDD the ability of

the local government health department to

organize on its own the services in a third Health District.

Before the end of the program,

only one district with PVO support had been achieved for a number of reasons.

One, if you look at the issue of finance in rural local governments,

96 percent or more of the local budget,

recurrent budget, is covered by the federal subvention.

There is no money left over for programming.

Local governments, in theory,

can raise money through head taxes,

through paying rents if they own like market stalls and other kinds of licenses.

In fact, rural local governments are not able to make much money.

And so there is no money available for programming for

the local government to do the extra health districts.

And again, the local administration is more concerned with taking

resources from the health department than it was in giving resources.

The states, the local government service commission,

constantly was transferring staff.

The PVO train the district health team.

In other words, the head of Environmental Health,

pharmacy, curative services MCH.

And within some months,

most of the people who have been trained were transferred.

And more people will come in more training and more be transferred.

When complaints are made to the State Ministry of Health,

which had no direct connection with

the State Service Commission and asking them to intercede,

the State Ministry said, " Well, this is normal.

You don't want people to stay in one area too long so they won't

become too familiar with the community and take advantage of them."

So in the end, the PVO,

in order to make AID guidelines and

deadlines and report what had happened after three years,

went ahead with the couple of 600 staff they had,

carried out the program implementation,

training village health workers,

getting home base records,

other kinds of training for oral rehydration,

family planning and immunization services,

did their follow up survey,

reported their results, and the program ended.

We visited other local governments and

other states where similar PVO activities had happened in the past,

and found that there was very little evidence

except for a few community members remembering the program.

Local government staff, it changed completely.

The resources that had been set up had disappeared.

And this is a typical thing that happens by unrealistic pressures and expectations

by the donor's inability of the PVOs to really

control the resources on the ground because they're unstable.

The guinea worm program provides a similar sort of parallel structure.

The national task force relates to and supervises the National Secretariat,

their zonal offices and their field staff.

At the same time technically,

the local governments are supposed to implement

primary health care and guinea worm therefore was placed with them.

There was the expectation that because the government had set a national health policy

favoring primary health care

the year before the guinea worm eradication program was launched,

that it would be politically correct to work with

a national primary health care in the context of primary health care for this effort.

The idea was that efforts would be more sustainable if they

worked through this local health department that was responsible for primary health care.

There were two problems with that.

One, an eradication program should not be sustained.

You want quick action.

And two, the local PHC departments in fact,

were only PHC in name.

When the new policy came in,

they change their name from health and medical to PHC.

But the staff had not been retrained and re-oriented.

It was still the same health inspectors in charge of

disease control that now were responsible for guinea worm.

They worked fine when the guinea worm program

in the early years gave them money for case searches per diems.

But when it came time to make the program ongoing,

regular part of village based primary health care

with village based workers detecting cases,

treating people, distributing filters,

the local health staff lost interest because they weren't gaining anything from it.

And so, the guinea worm program field staff

had to take over more and more responsibility.

Policy-wise, the local governments were expected to support

these field staff with fuel and housing.

Many times, they didn't,

and the zonal staff spent time trying to

convince the local government to support these people.

Sometimes, the local government guinea worm coordinator would request the money but

then wouldn't disperse it to

the field staff because they were in a different organisation.

So even though policies were made to distribute,

even though policies were made that local government should be involved,

they were not interested.

It didn't meet their organisational needs.

The final slide in this section looks at duplication that can occur.

We find one of our students last year presented

this as an organizational problem that she had to deal with.

She was working with University Foundation that wanted

to provide TB control in a large urban area.

And they set up a program with manager epidemiologist coordinator.

Various kinds of health staff that were under

the university's terms of service for staff.

At the same time,

the county health department in which the program was going,

had its own TB control program.

The person in charge of the TB program was under the communicable diseases and so it was

a relatively junior person organizationally whereas

the TB program manager in charge of

a major research project had much more status and and training.

The TB program had its own case management staff and nurse educators.

They were on a different scheme of service or different pay scale,

et cetera, then, the university research staff.

And so there was a lot of difficulty to decide what was going to happen,

how services were going to be provided,

and it became more of a political issue than a research issue.

As noted again by looking at these,

you can see some of the potential problems.

You can see issues of potential duplication of services.

You can see problems of poor communication,

multiple partners leading to poor communication.

But again, these organograms are just like community maps.

You need to draw them together with members of the organisation,

discuss them so that they can come to realization of what should be and what is

actually happening and begin the process of contemplating and planning for change.

What is an Organization? (Part 1)

Understanding and Strengthening Health Systems

Conoce a los instructores