Examples of different types of problems requiring different strategies come
from the program for patient case detection in tuberculosis control.
You may find that staff do not respond well to patients,
patients' family members, or to supervisors.
They are not receptive.
They are argumentative.
Maybe the underlying reason is that staff were
recruited based on their ethnic group or religion,
who knows who, connections, etcetera.
And therefore, they don't feel accountable to their clients.
They figure that they have the job,
nobody is going to disturb them,
it doesn't matter, and in fact,
the clients may be disturbing their time for reading
the newspaper so that they're not very receptive to the patients.
The solution for this will be looking at how people are recruited,
how can we introduce an objective recruiting criteria so that people who
actually want the job and are willing to do the work are recruited.
Training may be addressed at interpersonal relations training.
But again, the staff may not be motivated to attend the training,
and they may not get anything from it if their basic recruitment conditions are
beholding to a certain individual of
their ethnic group or whatever for the job and they don't feel that they have to change.
A problem that's been observed in case detection is
inaccurate or delayed sputum diagnosis.
You get a false negative when the person is not treated,
a false positive, the person is worried.
The results don't come in time,
and the patient gets frustrated and doesn't come back to the clinic.
This may have to do with the fact that reagents and equipment are lacking.
If that's the case,
then there needs to be effort to have a better supply system,
ordering system, management system of resources.
If it has to do with the fact that
the health worker is not up-to-date on diagnostic techniques,
then training would be appropriate.
So, it's important to find out why.
Just because a problem exists,
it doesn't mean that the person lacks knowledge or skills.
Another problem may be that there have been changes in treatment protocol,
possibly Directly Observed Treatment has been
recently introduced into that health center,
the staff may not have been informed and therefore,
they are not maintaining the right treatment, they're losing patients.
In this particular case,
continuing education would be very important so
that staff know what the new treatment is about,
what its goals are, how it functions,
and what skills they need to carry out this Directly Observed Treatment?
Let's look at an example of how training could fit into the program planning process.
WHO has what they call a Mother-Baby
Package that they're promoting for local health services.
They have various activities in this program to strengthen health services,
develop and manage human resources,
assure that there are the appropriate equipment supplies and drugs for safe delivery,
for child immunization, assuring that there is quality of care,
that people receive appropriate counseling and instructions and information.
And health education is supposed to be part of the program for outreach to the community,
so people know the services exist and can take advantage of them.
Human resource and development issues in
this Mother-Baby Package include improving the basic training for midwives,
deploying adequate staff at the front-line and referral levels.
As we mentioned before,
training will help improve the quality of staff.
But if there are not enough staff compared to the workload,
if there are not enough staff to cover different shifts,
training will not address them.
Another component of getting the Mother-Baby Package off the ground is
ensuring that the staff have legal backing for the new procedures they're performing.
When new cadre of staff are trained to fill in gaps,
they may be expected to do jobs that may be legally the province of physicians.
The idea of prescribing, for example,
should not be carried out by front-line health workers such as health assistants,
community midwives, but they may be the only staff available in the health center.
Procedures such as developing standing orders, medical review,
and supervision may make it possible for this front-line staff to perform new roles.
And so, these issues need to be worked out so that the best care is
available by the workers who are actually at the front-line level.
Another thing in this package recognizes in terms of human resource management
is that the conditions of service for front-line staff need to be improved.
They need to be properly remunerated.
They need proper conditions of service,
opportunities for in-service training,
proper accommodation or allowances for transport and accommodation.
These are the kind of things that will make front-line staff want
to stay in the community and improve maternal and child health.
In concluding section B,
one has to remember that although we said that
only 15 percent of health worker performance problems can be addressed by training,
this 15 percent is still not a small number.
Training must be put in a broader context of personnel and organizational management and
use strategically in a thorough and systematic manner so that
we will be able to effectively use training
if we think about it in the context of broader personnel and
organizational management and thereby be able to carry out
training in a thorough and systematic manner using it most effectively where it's needed.
In order to do all this,
organizations do need training policies,
and we will address this in section C..
William Brieger, DrPHProfessor, Health Systems Program of the Department of International Health
