Assessment of health workers and volunteers performance levels in the Onchocercias Control Program in Mulanje District, Southern Malawi

Abstract

Introduction: This is an intervention study entitled ‘Assessment of Health Workers and Volunteers Performance Levels in the Onchocerciasis Control Program in Mulanje District – Southern Malawi.’ Its aim was to identify the levels of performance of health workers and volunteers in the Mulanje Onchocerciasis Control program in order to facilitate the design and implementation of interventions to improve or strengthen its effectiveness. The objectives of this study were: 1. To assess the current levels of community, health center and district based health workers and volunteer’s performance levels in the Mulanje Onchocerciasis control program. 2. To identify the performance gaps in relation to the desired or expected performance of health personnel and volunteers in the program in Mulanje District. 3. To determine possible factors contributing to the performance gaps in the program 4. To identify the root causes of the performance gaps in the program in Mulanje. 5. To design and implement interventions to close performance gaps. 6. To monitor the implementation process and evaluate the immediate effectiveness of the interventions on performance gaps. Methodology: The study was carried out in Mulanje District of Southern Malawi, which is an Onchocerciasis endemic area. The main source of information was health workers involved in the program as supervisors and implementers at different levels. Information was also obtained from volunteers called Community Directed Distributors (CDDs). Both quantitative and qualitative data collection methods were used to collect information from respondents. These methods included administering a semi-structured questionnaire mostly with open-ended questions (ANNEX: 1) to health workers and a checklist for data reviews (ANNEX: 3) from CDDs registers. Main Findings: The following have been identified to be the main gaps from the results of the assessment in the Onchocerciasis control programme in Mulanje: 1. 24 (100%) of the CDDs do not accurately record and report on census update information including data on Mectizan drug distribution to the population. 2. 20 (83.3%) of the volunteers distribute drugs to less than 80% of the population they cover. 3. 14 (14.9%) out of 47 (100 %) of the health workers indicated that low levels of incentives and motivations for volunteers is the most frequently experienced problem by the health workers. 4. 34 (72.3%) of the health workers conduct poor quality of supervision. 5. 15 (65.5%) of the CDDs serve more than the maximum number of clients of more than 120 people per volunteer. 6. 18 (38.3%) of the health workers have low levels of knowledge about their roles and responsibilities in Onchocerciasis control activities. 7. 11 (24%) of the health workers have low knowledge and skills in managing side effects resulting from Onchoserciasis control drugs. Root Causes: Identified gaps were prioritized and later analyzed for root causes. Amongst the root causes identified were inadequate training in Community Directed Treatment with Ivermectin (CDTI); poor data recording and reporting; poor supervisory skills (inadequate supportive supervision); poor feedback system to the volunteers; lack of training in supportive supervision for health workers. The selection and design of interventions were based on these root causes. Main Interventions: The following were the main interventions carried out based on the identified gaps and root causes: • In order to reduce inaccuracy in data recording and reporting by CDDs, a three-day innovative training for the CDDs in CDTI recording and reporting was carried out by supervisors. • Interventions to improve the quality of supervision for the health workers comprised of training of thirteen supervisors as trainers of Trainers (TOT) in supportive supervision in Onchocerciasis control. After the TOT training 60 health workers were trained in order to gain skills and knowledge in conducting supportive supervision. This enabled the supervisors to conduct supportive supervision of Health Surveillance Assistants (HSAs) and volunteers in the progrmme.Other interventions carried out in the study have been outlined in the (Table 4.2 ; ANNEX 5: table 4.3, ). Results of interventions: The main results of the interventions were as follows: There has been improved recording and reporting in CDTI registers during the recent data updates; Because of the feedback system put in place there has been improved feedback to the lower level to improve motivation of both the staff and volunteers although the issue of incentives has not been concluded as it required wider consultation; Knowledge and skills gained during the training in supportive supervision has enabled health workers to conduct monthly supportive supervision which has improved general performance of health workers and CDDs (Drug distribution for October – December, 2005) Discussion: The study has succeeded in identifying important gaps and carried out interventions based on these gaps to reduce the performance gaps resulting in some improvements in the performance of the health workers and volunteers. The study has shown that it is possible to improve performance through applying performance improvement process in Onchocerciasis control program, if efforts are made to follow the process properly as outlined in the PRIME II Project (FIG 1: PI Process Framework Model Diagram ,adapted from PRIME II Project 2003). Conclusion: There are three major gaps identifies during the assessment. These included inaccurate recording and reporting on population census data by volunteers; low coverage of drug distribution to endemic population; and poor quality of supervision by health workers. The major factors identified as contributing to these gaps were lack of training in supportive supervision and data recording; and poor supervisory skills by health workers. The main results of interventions carried out were: Improved knowledge and skills in supportive supervision and health workers employing acquired skills to conduct supportive supervision to the lower levels. This resulted in improved output indicators such as increased coverage of population treated with Onchocerciasis drugs during October to December,2005 mass treatment period from 66% {2004} to 80.5% (2005). Recommendations: The findings, interventions, results and discussions lead us to make the following recommendations: • The DHMT should ensure the interventions are sustained and monitored to continue improving the performance. • The gaps for which no interventions were implemented due to shortage of resources including time should be considered for further interventions as these are also likely to negatively contribute to performance. • More health workers should be trained in supportive supervision since this intervention is considered to have produced more effective results in improving the performance of volunteers and health workers in the program.