Tropical Doctor >
Volume 38, Number 4 >
Pp. 197-201
Articles |
* Health Adviser, DFID Nepal, PO Box 106;
Chief of Programme Communications, UNICEF-Nepal, UN House, GPO Box 1189;
Communications Adviser, SSMP-Nepal, Department of Health Services, GPO 7830;
Country Director, TCIC/Ipas, GPO 7830, Kathmandu, Nepal
Correspondence to: S Clapham, Health Adviser, DFID Nepal, PO Box 106, Kathmandu, Nepal Email: s-clapham{at}dfid.gov.uk
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 Top SUMMARY IntroductionService provider attitudesAddressing service provider...Monitoring changesDiscussionReferences |
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| Introduction |
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TopSUMMARYIntroductionService provider attitudesAddressing service provider...Monitoring changesDiscussionReferences |
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This purpose of this paper is to look at ways in which the negative attitudes of service providers were addressed within the project in order to improve a quality of and access to professional midwifery services – primarily emergency obstetric care (EmOC). The information was gathered from field observations, project monitoring, evaluation and reporting and viewed in the context of international literature.
The Nepal Safer Motherhood Project (NSMP) was implemented in two phases from 1997 to 2003, as a joint venture between the Ministry of Health and Population (MoHP) and the UK Department for International Development (DFID). Initiated in three districts, activities were later extended to nine of Nepal's 75 districts, accounting for 13% of the population. Two complementary components, addressing (1) quality and availability of services and (2) access to services (social, economic and geographical factors affecting utilization) were designed for the purpose of increasing the utilization of professional care during labour and delivery.
The 2006 Nepal Demographic and Health Survey indicates that over the last decade Nepal's maternal mortality ratio has been reduced from 539/100,000 to 281/100,000 live births.6,7 However, this still means that approximately six women a day die from pregnancy-related causes. When NSMP was designed, national monitoring data showed an average 95% unmet need for EmOC,8 with only 3.5% of births attended by any kind of health worker.9 This showed that there was an urgent need to improve the quality and accessibility of services.
| Service provider attitudes |
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TopSUMMARYIntroductionService provider attitudesAddressing service provider...Monitoring changesDiscussionReferences |
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The reasons behind service provider attitudes are complex and multi-facetted. A health system is influenced by the context of societal culture and values, which in Nepal is structured around strong caste, ethnic and gender hierarchies and dynamics, producing considerable social discrimination as an accepted part of normal life.12 Discriminatory behaviour among health service providers towards lower caste and ethnic minority groups is recognized, and known to influence health-seeking behaviour.12–14 Clients report patronage among service providers, who provide better care for family and friends.15 Not only does this result in under-use of services but also wide inequalities across ethnic and caste groups, with higher castes accounting for a much larger proportion of health service users.16 The social attitudes in Nepal have resulted in a culture of ke game – a belief that if destiny is predetermined, challenging the status quo is unproductive, leading to apathy and even cynicism.17
In addition to cultural influences, other factors also shape the health system, such as inadequate financial resources and geographical challenges. NSMP worked to strengthen the services, thereby gaining valuable insights into how health system functioning impacted on staff morale and attitudes to their work.15,18,19 In 1997 only 30% of government sanctioned posts were filled. Even by 2003, when almost all posts were filled within the NSMP working districts, there were still insufficient nurses to meet hospital needs20 as allocation was, and still is, often irrational and not based on need.
As a result, service providers feel overworked and/or overwhelmed by responsibility for situations in which they have received inadequate training and experience. They may also be transferred at short notice with no explanation – often as a result of patronage (some postings are considered ‘hardship’, while others are viewed as rewards) – with little consideration of the facility's needs. Promotion is generally not based on merit, but on length of service or connections. Thus, effort is not rewarded and service providers feel insecure and unsure of how long they or their manager will remain in post.
There are few opportunities for professional and career development, encouraging service providers to pursue other income-generating activities, such as private practice, with the attendant compromises in the time and energy given to their public service responsibilities.21 The lack of a culture of teamwork means that service providers find it difficult to identify and solve problems as a group – authority lies with senior staff, generally doctors, who tend to be male and high caste, unused to considering the opinions of others, and lower level staff lack the confidence to express their ideas. The capacity of staff to provide quality services is often further hampered by poor quality, badly maintained buildings, coupled with inadequate supplies of drugs and insufficient equipment. Technical supervision visits are infrequent, with little attempt made to understand local realities. Finally, the knowledge that communities perceive public sector services as unreliable and of poor quality affects service provider attitudes in a negative feedback loop. Thus, there is a preference for alternatives, such as traditional healers (among poor families), and private practitioners (for those who can afford them), making public service providers feel under-valued.
The outcome of these cultural influences and health service related factors is an attitude among many service providers of ‘I have a job which gives me status and security’ rather than ‘I do a job which provides a service to people’.22 The staff feel powerless and de-motivated which leads to high levels of absenteeism and poor quality work and further compounds the situation. Such negative and, to an extent, self-protecting behaviour translates into careless treatment of clients, particularly the lower castes and women, and leads to a sense of power exercised over others, rather than services given.23
| Addressing service provider attitudes |
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TopSUMMARYIntroductionService provider attitudesAddressing service provider...Monitoring changesDiscussionReferences |
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The foundation for change programme
Foundation for change (FFC) was arguably the most influential initiative. This organizational development programme combined the approaches of western management with eastern philosophies to bring about changes in both individual behaviour and organizational culture. FFC draws extensively on the ‘appreciative inquiry’ approach, which has become known as the ‘theory of affirmation’,24 challenging ke garne via a process of analysis of personal, societal and institutional barriers to change. It identifies the successes and motivational influences that can be built on – rather than looking for faults – promoting a sense of individual responsibility and potential and appealing to people's higher self-vision and values. FFC works on relationships and attitudes, encouraging mutual respect and a belief in the ability to change, highlighting the benefits of personal and professional development and improved teamwork.
FFC worked as a catalyst for the effectiveness of other initiatives. Over a 10-month period, it was implemented through a series of workshops in each facility. By relating directly to daily experiences, it brought immediate noticeable results at three levels:
The infection prevention programme
Infection prevention was the first initiative introduced, for two reasons. First, the needs assessments18 identified this as a serious technical need and, second, it could be addressed in an inclusive manner to produce early wins. The strategy included on-site training fitted around work commitments, development of protocols, provision of basic infection prevention materials and follow-up coaching. Hospital management boards were engaged in the process from the beginning.
Significantly, the benefits were unexpectedly far wider than just the achievement of a cleaner, safer facility. By creating a forum to bring all staff (clinical, administration, management and support) together around a topic that was uncontroversial, yet important, a good entry point was developed for exploring and addressing other management issues. The forum and initial infection prevention focus challenged hierarchical structures in a non-threatening manner. Gradually, the concept of different cadres working together for a common goal took root, drawing all staff into discussions about the development of hospital standards and a plan of action. Thus, a more inclusive management approach evolved. These changes led to increased levels of motivation, positively affecting staff attitudes towards their work and their clients.15
The interpersonal communication programme
Needs assessments for both phases of NSMP18,19 highlighted poor interpersonal communication, which is clearly linked to staff attitude. The assessments revealed that:
Project monitoring showed initial improvements in the interpersonal skills of most providers. Later monitoring indicated a need for additional inputs to reinforce and build upon these good practices, which was addressed through continued coaching by NSMP district based staff, and inclusion of the topic in other initiatives. Senior nurses and doctors were encouraged to coach other staff as a specific component of their responsibilities. By the end of NSMP, there was evidence of the training influencing hospital staff attitudes towards clients and improved interactions (particularly feedback to junior staff).26
The QoC approach
NSMP designed a locally appropriate QoC model, which functioned as an iterative learning process and encompassed a broad concept of QoC, both biomedical outcomes and client and provider satisfaction.27 The aim was to promote accountability and increase the desire among all staff to provide a good service, based on three key principles: appreciative inquiry; involving all staff as equals; and enabling staff to develop their own potential. Supported by NSMP staff, a QoC team was created in each hospital to regularly review QoC issues, using checklists to identify barriers and develop and share local action plans for implementing improvements. A number of significant problems were addressed, either at no cost or using only local funds, with NSMP providing some resources to deal with infrastructure and supply needs. Positive results included: increased provision of 24-hour blood supply services; funding for more essential drugs; improved staffing numbers; and, ultimately, increased caseloads.20 An evaluation of the QoC approach in 2004 revealed progress of varying degrees across all project districts, acknowledging that sustained fundamental change would require more time.15
| Monitoring changes |
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TopSUMMARYIntroductionService provider attitudesAddressing service provider...Monitoring changesDiscussionReferences |
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Project reviews
An independent review of the first phase of NSMP in 200028 and an evaluation in 200415 indicated a number of improvements, including improvements in client provider interactions and teamwork among and between different cadres.
Key informant monitoring
Based on the work of Hawkins and Price,29 KIM was established to facilitate communication between NSMP staff and the wider community, to monitor perceived changes in the social context and access to midwifery and obstetric services.30 As a continual process of dialogue and reflection, KIM fosters in-depth understanding over time of the social realities of communities and is used to monitor the impact of initiatives on perceptions of change. Since 2001, three rounds of KIM interviews have been conducted. The first round indicated that women were not choosing to go to hospitals and local health institutions, in part, because they found the service providers rude and often unavailable. By contrast they said traditional healers, traditional birth attendants and pharmacies were widely utilized because they were always polite, responsive and available, even at night. By the third round of interviews, two years later, women reported health staff to be more regularly available, more polite and understanding, counselling pregnant women ‘very nicely’ and referring them to higher institutions when necessary. A general trend of increased use of health workers for birth attendance was noted, and they were reported to be going into the homes of low caste women, which previously they would have been unwilling to do. These results also reflect the effects of other project initiatives to increase awareness and demand for services.23
Ascertaining the views of the wider community
During initial needs assessment in 1997, NSMP filmed discussions with three communities to ascertain their feelings about barriers to care.31 In 2000, one of these communities was revisited and their responses to questions about reductions in barriers to care and the reasons for this were filmed. A clear appreciation was expressed for the increased respect with which they were treated at the local hospital.32 Feedback aired on local NSMP supported safe motherhood radio programmes also highlighted increased user satisfaction.33
Establishment of district based meetings for information exchange
At meetings between community representatives and hospital management, community views about QoC were fed back and hospitals explained their problems. For example, when communities commented that services were not always available when needed, hospital staff responded that clients often presented too late for effective treatment. This honest exchange led to increased understanding and responsiveness of both parties. The involvement of health staff in community activities and interactions between providers and clients promoted mutual appreciation and improved relationships.
| Discussion |
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TopSUMMARYIntroductionService provider attitudesAddressing service provider...Monitoring changesDiscussionReferences |
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Inputs to improve service delivery included ‘hardware’, which boosts service provider morale and increases the respect of clients for the facility, and ‘software’, i.e. clinical and management training which increases staff self-esteem and confidence. Although we are confident that improving interpersonal care is a major contributory factor, given the range of interventions and contextual influences, it is difficult to ascertain the extent to which improved attitude contributed to the overall increase in utilization. It is not possible to divorce the impact of one initiative from another as they are mutually reinforcing. The impact of the initiatives described may also have been affected by other indirect influences, such as increasing levels of education and political awareness.
The experience of NSMP indicates that, despite deep set societal hierarchical structures and a weak health sector, a combination of complementary inputs with opportunities for feedback between communities and facilities can contribute to substantial changes in apparently entrenched attitudes among service providers, generating improved understanding between facilities and the communities they serve. This reinforces global knowledge that addressing attitudes will influence service use.10
NSMP learnt that ‘early wins’ (such as infrastructure improvements and infection prevention training) are essential, providing immediate encouragement and generating a belief that things could be different. Follow-up and support ensured the momentum was maintained and staff felt acknowledged and rewarded for their efforts. The provision of more opportunities for community/service provider interaction and transparency, with accurate communication of community perceptions and an increased availability of health information promoted mutual appreciation of the problems by each. It also made counselling easier, as women understood explanations more quickly, reducing the potential for miscommunication and irritation.
The learning from by NSMP is being scaled up via the MoHP national Safe Motherhood Programme, with support from other donor programmes, including the current DFID five-year Support to the Safe Motherhood Programme, the design of which was influenced by lessons learnt by NSMP about the need to address service provider attitudes in order to increase service utilization.
Disclaimer: The views expressed within this article are the authors' alone and do not represent their agencies.
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TopSUMMARYIntroductionService provider attitudesAddressing service provider...Monitoring changesDiscussionReferences |
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