The importance of local leadership and how to promote it

1. Support to the measurement of health program performance:a capacity development strategy in Papua New Guinea (PNG)Chris Morgan, Centre for International HealthMacfarlane Burnet Institute for Medical Research & Public Healthcmorgan@burnet.edu.auC. John Clements, Independent Consultantjohn@clem.com.au

2. Some of what we have learnt working on health development in PNG over the past 10 years, including: • The importance of local leadership and how to promote it • Use of health information for downward accountability • What outsiders can do, especially a technical health NGO like Burnet Taking a health systems perspective

3. Burnet in PNG: bilateral aid contracting and work as an NGO with communities and government health services • Past roles on two national AusAID bilaterals: • Womens’ and Children’s Health Project (1998-04) • National HIV/AIDS Support Project (2000-06) • Started NGO work to support Family Health Services (especially immunisation) in NDOH, July 2004 • Burnet PNG office in Port Moresby opened Jan 2007 • Current work: • Responding to Measles and other diseases – support to government and PNG IMR • Tingim Laip – community mobilisation for HIV prevention • PASHIP – support to sexual health with ENB PHO • Improving immunisation and newborn survival - in East Sepik with WHO, UNICEF and NDOH • Other research projects and consultancies

4. Strategic approaches to capacity development in immunisation and maternal/newborn health • Born from frustrations and small wins experienced in large bilateral health aid • Started with one winnable target - measles, expecting later expansion • Original design for our NGO work comprised several approaches: • Support to health program performance monitoring • Development of tools and training health staff in new approaches • Advice on good health policy The first approach seemed to work better, perhaps because it embedded key principles of participation and accountability?

5. Evolution of the strategic approach • Observed a paucity, in the health system, of activities to measure performance or outcomes and then revise programs • Felt we could help the National Department of Health (and other agencies with a mandate for health program monitoring - like Institute for Medical Research) to measure health system performance and other critical issues • Part of the problem may be the history of measurement done by outsiders, so aim to: • Strive to do the measurement together, and • Leave revision of the system to local actors

6. Example 1: measuring cold chain performance • Review in 2001 found many vaccines stored inappropriately, heat damaged, suspected freezing damage – at every level from national store (particularly bad) to the rural health centre • AusAID bilateral (Burnet a technical partner) had • Introduced new vaccine distribution system • Supplied new cold chain equipment • Staff training in vaccine handling • BUT could not test performance • We helped national vaccine manager run a time-temperature trial using TinyTalk • Results showed problems (esp freezing) that could be fixed with new procedures • Manager then ran his own tests in later checks on the system

7. Example 2: national coverage survey • Regular surveys are needed to check measured immunisation coverage against routine health information data, but in PNG: • No survey had been done for more than a decade, • previous surveys had been done by outsiders at large expense and • a tabled proposal in 2004 mirrored this approach • We helped design a survey that would cost about 1/8 th and could be implemented by national managers, local staff and volunteers

8. Example 2: national coverage survey outcomes • It took twice as long as planned • Had to negotiate hard to get errors re-measured • Despite the “good news” that the survey confirmed the accuracy of routine health information (a surprise to us all!) it took two years for official publication • But: You know, at first I was a bit suspicious of what Burnet were doing … I couldn’t really see the point of it. But now, after a year I can see my staff have really gained new skills and are using them…. Another thing – in the past these coverage surveys have been done by … someone else from outside. But this survey is one that we have done ourselves, pretty much with our own resources. I reckon that when we need to, we’ll be able to do this one again by ourselves. It’s good to be able to monitor our own progress.” National EPI Manager

9. Example 3: Strengthening birth-dose vaccination in health facilities • Birth-dose vaccination against hepatitis B works 10x as well if given in first 24 hours • Provincial hospitals in PNG had this as policy, and had been reporting doses given, for several years, but were unaware of their own coverage rates • Small activity done by NDOH technical staff with Burnet support, and WHO $ that: • Surveyed barriers to vaccination, but also • Educated on the biological rationale for the first 24 hours • Showed own hospital coverage rates (usually poor) to staff • Outcome was • rise in rates of birth-dose vaccination in those hospitals • NDOH staff presented internationally, next steps? …and births at home?

10. Example 4: Village health volunteers and better maternal and newborn health • Enhancing pregnancy outcomes trial • Research into village health volunteers giving micro-nutrients and intermittent presumptive malaria treatment to pregnant women • Done by IMR with strong NDOH involvement • Did show positive outcomes in nutrition and birth-weight • Many methodological problems, but thus proven under ‘real world’ conditions • Improving immunisation and newborn survival • Evolved from discussions of birth-dose vaccination in NDOH • A NDOH-partnership trial in one district in East Sepik • CHWs and VHVs: • give Unjiect vaccine to home births • Also educate on breast-feeding, infections • give nutrition supplements to mother

11. Example 5: Impact and operations research into the 2003-5 measles campaign • 2003 measles campaign worth measuring in depth because: • Designed to work differently to earlier “National Immunisation Days” • Although it took three times as long as planned provinces reported very high coverage - a surprising success in PNG • Grant from Global Forum on Health Research • 95% to PNG IMR, with support from Burnet and CICH • NDOH guided sites and topics, aimed beyond superficial evaluation • In-depth multiple qualitative interviews at community and district level • Findings: • Impact on coverage and measles, and minimal negative effects • Most successful where districts had autonomy and involvement • Social mobilisation aspects could have been much better • Coverage good, but not as good as claimed - still a success though

12. Example 5: Outcomes of research into the 2003-5 measles campaign • Research findings incorporated into the operational guidelines for the 2008 measles campaign • Very strong district focus in the 2008 campaign, in the face of conflicting advice from global experts • Burnet asked to contribute to social mobilisation for the 2008 campaign - something that was not in original project plans • Definitely less measles the past few years • Disappointing dissemination beyond immunisation planners, as IMR researchers left • But good input to other learning on how to support local leadership in health

13. Example 6: Local health managers in difficult environments, seminar Apr 07(supported by AusAID) • Aimed to capture and highlight the viewpoint of the local leader, so invited district and national health managers from PNG, Vanuatu, Samoa, Palau, Timor Leste (and multilateral reps from WHO, SPC, AusAID), which found: • “Local health managers” (a diverse group) have to juggle: • local realities, • national policy, eg technical, decentralised management • global development trends and are • often the final end-point of development efforts • District and national perspectives are very different. For example, local managers prioritised: • Manager empowerment and control of local budget • Well trained staff available for health management • Transportation, facilities and communications

14. Some managers succeed, even in dysfunctional systems - it is possible for both implementation and development programs to tap into their strengths • PNG Measles campaign 2003-5 success determinants • District autonomy on timing and interventions • District involvement in planning • Sharing resources across districts • Local action plans • Successful local leaders do more than manage: • Leadership, motivation and championing • Problem-solving and conflict resolution • Networking and partnerships often outside the health sector • Delegation - example from immunisation training

15. How to support local leadership for health, (while fixing dysfunctional systems)? • District-led activities that maximise opportunities for local problem solving • the next measles campaign will allow opportunity to strengthen community health at the same time • Operational research as a development tool • providing local managers with ideas and funding to experiment • Allow progressive engagement, grants should not be “one-off” • Re-labelling of development in health professional terms • Tools for delegation • Forums tailored to the local level, • encouraging the sharing of surprising successes, and • qualitative case-studies and narratives to capture complex, situation-specific lessons “positive deviance”

16. Trying to marry evidence-based practice with local leadership • Menus as well as prescriptions • Most local leaders who can absorb external assistance will welcome a carefully presented menu of options rather than another manual • Help desks as well as supervisors • Eg the best national support to immunisation, whether a campaign or routine, was a properly staffed help desk. • Self-education from accessible resource centres is as effective as in-service training

17. Aid structures that promote local leadership and participation • Health development often looks to require reform of a national health system, but this is complex, time consuming and may not pay dividends when done as a structured project • New mechanisms such as “facilities” and “partnerships” that provide grant programs at least allow local action while the system is being reformed • Also copes with the “absorption capacity” dilemma • The example of maternal mortality reduction • At least, aid programs working centrally on health systems must have some direct interventions at the local level to • Pilot new ideas • Provide alternate flow of resources when needed • Gain real information from the grass-roots

18. Generation and use of information to support local leadership and downward accountability • Provide methods to hear the perspective of local health leaders, especially those who have succeeded despite of adverse systems and context; • Use the information from this perspective to work for more relevant change in health systems; • Research means for successful local managers to share the stories and lessons learnt, with central planners and other managers; • Help local managers to learn skills for leading and building teams, and for researching their performance and environment. • Best done through person-centred means: action learning, coaching and mentoring.

19. Generation and use of information to support local leadership and downward accountability • External support can target the person of the local health leader to support leadership (as opposed to management) functions such as: • Research: to understand local health priorities, and put health threats, including those of epidemics, into a local perspective; • Communication: of effective interventions, especially to communities and leaders; • Reflective implementation of services: with an emphasis on performance and quality monitoring and improvement. • Delegation and building the local health team; • Local collection, dissemination and use of information, eg at district-level, can legitimately take precedence over national health information needs, and over global planners • Especially given the difference in detail and usability between national and local analyses

20. Conclusion: information and performance monitoring has risks and benefits • Building research or performance monitoring capacity through a person-centred approach risks loss of capacity if the person moves on • So ? aim for saturation or promotion of “stick and stay” • Delays in formalising data are common, because of the commitment entailed and the potential unpopularity of bad news • E.g. maternal mortality, measles cases • But this reflects the leverage that information creates, and its role in accountability • Support to information and performance monitoring, is a role for technical NGOs • Must mix research with and capacity development • Must prioritise local leadership