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NEWS |
| 24 Dec 2010 |
 JICA TQM Consultant invited as Guest Speaker for the Seminar on Bio Medical Waste Management in Gwalior (24th December 2010) .. .....Details |
| 16 Dec 2010 |
 The Common Review Mission visits Damoh district (16th - 22nd December 2010) .. .....Details |
| 6 Dec 2010 |
 National Dissemination Seminar of JICA MP RH Project held at NIHFW, New Delhi .. .....Details |
| 19 Nov 2010 |
 JICA Consultants oriented the Data Officers of DoHFW on use of GIS .. .....Details |
| 13 Nov 2010 |
 JICA team invited for the Partners Forum on Womens and Childrens Health, New Delhi .. .....Details |
| 19 Oct 2010 |
 JICA TQM Consultant invited to present a paper at the Asian Network for Quality Congress Delhi 2010 .. .....Details |
| 12 Oct 2010 |
 Dr. Kiran Ambwani, Deputy Commissioner (FP), MoHFW, GoI, visits Tikamgarh for the District level planning for MCH centres of Sagar division .. .....Details |
| 9 Sept 2010 |
 Dissemination Seminar held to share the findings of the Terminal Evaluation Mission .. .....Details |
| 8 Sept 2010 |
 Joint Review Meeting of JICA Project held on 8th September 2010 .. .....Details |
| 30 August 2010 |
 JICA TQM Consultant presented a poster at the Global Maternal Health Conference .. .....Details |
| 17 August 2010 |
 Madhya Pradesh becomes the first State to start the Public Health Management course at State owned Health Institute (SIHMC), Gwalior .. .....Details |
| 14 June 2010 |
 JICA TQM Consultant invited to present paper at Lal Bahadur Shastri National Academy of Administration, Mussoorie .. .....Details |
| 15 June 2010 |
 Chief Representative, JICA India Office visited Project site .. .....Details |
| 24 May 2010 |
 JICA Consultant nominated by DoHFW, GOMP, for Training of Master Trainers on BEmONC at New Delhi .. .....Details |
| Abbreviations |
COUNTERPARTS |
 |
| Ministry of Health & Family Welfare |
| Department of Health & Family Welfare |
Thoughts and Smarts
Manager of Small Things
Micro-Planning: Logic behind sequence of
analytical tools
Multi-layer Marketing Approach for ANM
Training
SECI model
explains how we implemented ANM Training
Twice Tried Sessions
Nut Island Effect –excellent teams working in isolation would create
catastrophe
Quality-Quantity Management: a metaphor from “Sholey”
Trikaal (three tenses) for
Supervision
Manager of Small Things
Management of a training course is not complicated but
requires logistics in detail. The following is a list of details which may
escape from the mind of inexperienced managers, but if mismanaged, the
result might be serious.
Security: Some governmental training centres are located far from the centre
of town. It is the organizers’ responsibility to assure the security
Water tanker: Water is vital especially during the hot season. Health of the
hostellers and hygiene of the hostel depends on the availability of safe
water. In case the pipe water service is unreliable, the manager should make
sure that sufficient quantity of water is stored in the tank of the hostel.
If the water supply is not enough even for storing in the water tank, then
emergent supply by water tanker should be arranged.
These are small but crucial things for the trainees. Manager should be a
guardian, if not a guard man, of the trainers and trainees. He knows well
that small mistake could result in a serious consequence.
Micro-Planning
Micro-planning has been developed as a major input of SLIS.
It was highly appreciated by the field workers of health (ANMs, LHVs, MPWs,
and Male Supervisors) because of clarity in planning procedures, and
usefulness of the outcome.
The objective of micro-planning is to rationalize the field work, so that
the targets of immunization and ANC checkup are met by the smallest number
of working days.
Three dimensions need to be considered for micro-planning: time, space and
population. Work load at a village depends on its population and the
distance from the station or, in case several villages are covered in one
day, the distance between the two adjacent villages. Village profile is a
record showing the population size, castes and tribes, availability of
helpers like AWWs and ASHAs, etc. The geographical location of the villages
is best described by maps. Villages on the map should be grouped so that
each group (village cluster) can be reached and worked in one day. To make a
monthly work plan, it should be kept in mind that every Tuesday is reserved
for Immunization session. If Tuesdays are not enough, then Fridays are the
second choice.
The following table shows what kind of information is contained in the three
essential tools (map, village profile and calendar). The standard load of
work per day is expressed by circling villages. Micro-planning is, in one
way, transformation of geographical and demographical information into a
time frame.
Information to be contained in the tools for micro-planning
| Step | Tool | Dimension | ||
| Space | Workload | Time | ||
| 1 | Village Profile |
Sheet = Village | Work load per village = in proportion to village population |
N.A |
| 2 | Map of Catchment Area |
Position of Villages, Distance between them; villages of the same cluster are circled |
Villages grouped into Daily workable cluster | Each village cluster will be covered in one day |
| 3 | Blank Calendar | N.A. | N.A. | Rows(6) = Days of week Columns(4) = Weeks Sheet = Month Days for regular meetings etc. have been filled. |
| 4 | Standard Calendar |
N.A. | Village Cluster filled in each cell | As above; showing destination (village cluster) of each day for field work |
| 5 | Monthly Calendar | N.A. | Village Cluster in each cell | As above; Adjusted by monthly variation of working days (excluding the days for meetings, holidays; road accessibility is also considered) |
Multi-layer Marketing
Fareed Uddin, TQM Consultant of JICA/MP-RH Project, has ample experience in marketing. He used to sell large numbers of office devices to the government and other large organisations in Madhya Pradesh and Chattisgarh. His challenge was to convince a wide range of people at different levels of the organization, from workers (bottom) to senior decision makers (top). He has developed a sequence for approaching different levels of people, as listed below:
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To build rapport with the end users (bottom)
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To assess the end users’ workload and estimate the time and money that could be saved if the device was introduced (needs assessment)
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To get information on budget and policies from the financial officers (feasibility analysis, middle)
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To convince the Middle management on the benefit of new devices in terms of quality and efficacy of work (middle)
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Follow up at senior most level for final decision (top)
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Customization of product according to the needs (bottom)
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Receive order (final operations of the marketing deal, middle)
Performing the seven steps means moving back and forth
between the different levels. (bottom-middle-top-bottom-middle). Marketing
of this type is more complex than “sales” of personal items to the payers
who are the users too.
Joining JICA as Project Operations Manager, Fareed found his marketing
experience useful for organizing the ANC training to ANMs. Each of the seven
steps was reflected. It should be noted, however, that their order would be
changed to the following:
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Getting information on Budget and Policies (top): ANM Training had been identified as an essential component of State policies of RCH-II/NRHM as well as the JICA Project. Such prescription may be typical to an international cooperation for social development.
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Assessment of training needs (bottom): Prior to the actual Project, the State had prepared SBA Training Modules in collaboration with UNICEF. Dr. Aboli Gore, who had developed and field-tested the modules in Dhar district, joined JICA as the HRM consultant.
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Discussion with Middle Management (middle): JICA consulted the two Districts (Damoh and Tikamgarh) and confirmed that ANC training has been included in their plans. CMHOs supported the idea, and faculties of ANM Training Centres agreed on the training plans as well as the teaching materials proposed by JICA. In the year 2006, training for ANMs of Damoh district was conducted in Sagar district, since Damoh did not have an adequate facility. For the year 2007, the Joint Director of Sagar Division instructed the faculty of Sagar district to initiate the first batch in Damoh.
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Operationalisation (middle): Training courses were conducted by three groups of people: (1) the faculty of ANMTC took charge of teaching in the class room under technical support from JICA consultant, (2) District Gynecologist lead the hospital-based skill training, and (3) JICA Project Operation Manager took charge of logistics and administration. Importance of meticulous management is described separately in Management of Small Things. Consequently, the faculty of ANC Training Centre, Sagar had training practice under JICA’s consultation.
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Building rapport with the end user (bottom): Training courses provided an excellent opportunity for rapport building between trainers and trainees. Mutual respect and understanding was rewarding for both the sides. Most trainees appreciated the quality of the training and friendly approach of the trainers. To be called by name is one example which made the trainees realize the importance of their individual performance. The rapport was even reinforced afterwards, when JICA consultants visited their work areas in Blocks, Sectors and even some SHCs.
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Customization of product according to the needs (bottom): To encourage the trainees’ acquisition of confidence as well as knowledge and skills, tools and methods were developed and tested through the training courses. The following factors were put into consideration for the customization: language, teaching methods, entertainment, scheduling (see Twice Told Training), hand-holding and coaching. Also, ANC card was tested in the field.
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Assessment of job requirement (bottom): The second step of ordinary marketing became the second last step of the training due to the remoteness of the trainees’ working locations, even from each District training centre. Introduction of the ANC card was a challenge for JICA, since it might have created additional workload. However, it was welcomed by many ANMs, who found it useful for service delivery. Some LHVs gave JICA useful suggestions for improving the recording system.
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Follow up at the senior most level (top): The results of pre- and- post tests were quickly shared with the State authorities, who then became convinced that the training was useful at least in terms of knowledge enhancement. Otherwise, skepticism regarding the training was still being heard from many of them. As for the reporting system, JICA team accumulated data from field observations, in order to make a proposal to the State on how to streamline the information system. Training became an entry point for policy advocacy.
ANM is a huge market. They are numerous and working close to
the community. Despite their value, they have been neglected, mainly because
of the remoteness of their stations. ANMs were highly motivated by the JICA
training, learning their value and roles.
Epilogue: Two marketing persons visited a backward province. One reported,
“There is no market here, because no one is wearing shoes.” He never
bothered visiting the place again. The other reported, “There is a huge
potential market, because no one is wearing shoes.” He went back there and
tried whether his hypothesis was correct or not. Whatever the result, he
learnt it through action.
SECI model explains how we implemented ANM Training
Nonaka and Takeuchi (1995) attribute the success of Japanese enterprises in the 1980s to dynamic involvement of “tacit” knowledge (know how, feeling, etc. that cannot be expressed by words or numbers), as opposed to western culture’s inclination to “explicit” (objective and analytical) knowledge. They conclude that spiral of the four types of “Knowledge conversion” (SECI) was the key to success in those companies in Japan:
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Socialization: sharing experience and feeling (from tacit to tacit) ; sympathetic
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Externalization: making concepts (from tacit to explicit) ; conceptual
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Combination: building a system of knowledge (from explicit to explicit) ; systemic
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Internalization: learning by doing (from explicit to tacit); operational
This model is useful to describe our approach in Training and Coaching of ANMs on Ante Natal Care (ANC).
1. Socialization: Sympathetic Knowledge
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Training was planned and managed by a team of consultants who travelled together. Intensive discussions and getting together gave them an opportunity to share tacit knowledge.
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The trainees appreciated sympathetic attitude of JICA consultants as shown by:
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Calling them by their particular name (individual recognition).
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Eating from the same table with the trainees (companionship).
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Singing together in the evening (cultural exchange).
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By jointly visiting the duty stations of ex-participants for coaching, the consultants became sympathetic to the ANMs working in difficult conditions. Any positive thoughts and ideas expressed by the ANMs, despite their difficulties, were highly appreciated.
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Observing that consultants were trying to improve the field situation, the ANMs and LHVs trusted the consultants, and the latter were encouraged.
2. Externalization: Conceptual Knowledge
The following concepts were shared within the team of consultants:
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To create One out of Zero (emphasis of qualitative change rather than scale)
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Don’t compromise with Quality.
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To Operationalize (plan and practice in the field reality).
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To make ANMs competent and confident.
3. Combination: Systemic Knowledge
Being under the umbrella of the National Programs (NRHM/RCH-II), JICA
Project relied on the existing documents on what to do (policies,
guidelines, modules, etc.). The saved time and energy was used for working
on how to do. The following are some sub-systems specifically developed by
JICA.
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Pre- and post-tests for monitoring knowledge enhancement
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Skill check list for ensuring quality of services
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Introduction of ANC cards for systematic record keeping
4. Internalization: Operational Knowledge
The following tools and methods were developed for the purpose of
facilitating ANMs to internalize the knowledge and technique:
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Practical sessions in the clinic
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Special hardware such as teaching stethoscope.
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Entertaining the trainees:
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Quiz (excitement of competition, quick answering)
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Snakes and Ladders (excitement of progress and falls, questioning by chance)
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Minimum necessary Repetition: try-check-retry (click Twice Trained Sessions)
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Reference:
Nonaka, I., H. Takeuchi. 1995. Knowledge-Creating Company: How Japanese
Companies Create the Dynamics of Innovation. Oxford University Press.
Polanyi, M. 1966. The Tacit Dimension. London: Routledge & Kegan Porter.
Twice Tried Sessions
In the course of the six-day training on Ante Natal Care (ANC) to ANMs and LHVs, the Poster Session and Role Play are each performed twice. This repetition costs at least four extra hours in the class room as well as in the preparation on the previous evening. The reason for repeating them twice is to make the trainees confident of what they have learnt. The following is the standard procedure of try-analyze-retry:
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Trainees make their first trial with written instructions only.
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Feedback on the presentation is given to the trainees by the remaining trainees as well as the tutors.
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Points to be taken are explained in a structured manner.
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Trainees are given a second chance for presentation.
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The presentation is marked and a prize is given to the winning group.
In our experience, the second presentation is always far
better than the first. In the second poster session, messages are clearer,
letters easier to read, diagrams and illustrations more attractive, trainees
show more confidence and speak louder. Confidence is what JICA Project wants
the trainees to bring home, because skills used without confidence may be
useless and even dangerous.
Quality, the major concern of JICA/MP RH Project, is affected by quantity.
The batch size, for example, should not exceed the manageable scale.
“Creation of a meaningful One out of zero” is what the Project seeks before
“covering a big target number.” This is why we made a small start on the
Project. However, training also needs repetition. How to accommodate the
right number of repetitions in the limited training schedule may be a
perpetual challenge.
The Kaizen school of Japan has identified the three MU words in Japanese to
be avoided:
Muri = impractical, irrational, almost impossible.
Muda = unnecessary, and
Mura = inconsistent.
Kaizen practice is a perpetual improvement for seeking rational
(economical), practical (feasible) and standardized methods. The number of
repetitions in each training session should be assessed in view of the
avoidance of the three MUs.
Nut Island Effect –excellent teams working in isolation
would create catastrophe
Nut Island sewage treatment plant in Massachusetts, USA, had a team of especially dedicated workers who performed difficult and dangerous work without complaint. However, this dream team failed to prevent a catastrophic accident of spilling billions of gallons of raw sewage into Boston Harbor in 1982. Paul Levy, former Executive Director of the Massachusetts Water Resources Authority, analyzes that, ironically, the catastrophe happened because of the high working ethic of the team, rather than instead of it.
After comparing this case with other similar cases, Levy generalizes the “Nut Island Effect” by the following five steps which are commonly observed:
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The dedicated team members enjoy a great deal of autonomy and develop their proud and distinct identity.
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Senior management takes the team’s self-sufficiency for granted and ignores the team’s request for help. The team eventually felt betrayed by management.
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Resentment and partisan mentality takes hold in the team, who stays off management’s radar screen. Management takes the silence as a sign that all goes well.
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The team develops their own rule of conducts, while management fails to expose the team to external perspective and practice. Neither of them is aware of grave deficiencies in the team’s performance.
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Catastrophe happens in the scale beyond the team’s capacity.
This article contains a highly alarming message for the JICA/MP Reproductive Health Project, which has capacitated and empowered LHVs and ANMs to the level beyond expectation of their supervisors. As a consequence, these Front Line Health Workers (FLHWs) may be developing “proud and distinct identity.” If so, how could be isolationism and catastrophe avoided?
Levy suggests the following four measures of “how to stop the Nut Island Effect before it starts :-
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To install performance measures and reward structures tied to both internal operations and companywide goals.
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Senior management must establish a hands-on presence by visiting the team.
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Team personnel must be integrated with people from other parts of the organization.
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Outside people-managers and line workers alike-need to be rotated into the team environment.
In the context of the JICA/MP RH Project, these four points may be translated as follows:
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To design the HMIS for measuring FLHWs’ contribution to RH outcomes.
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To encourage senior management to visit the front line more frequently.
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To facilitate integration of FLHWs with the community and other line departments as well as within Health Department.
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To advocate for staffing of Public Health Nursing management.
Source: Levy, P.F. The Nuts Island effect: When good teams go wrong. In: Harvard Business Review on Teams That Succeed. p. 167-186. Harvard Business School Press. Boston, 2004.
Go to TopQuality-Quantity Management: a metaphor from “Sholey”
Quality and quantity are the two opposing or complementary
aspects in management. The different styles of management are clearly
depicted in the famous Hindi film “Sholey”. Gabbar Singh, the anti-hero,
represents the Quantitative Management when he asks his subordinates:
Kitne admi the? (how many were they?).
His hidden message: --- Is it really true that so many of my men were
defeated just by those two? If they were just two, why did you come back,
all three of you? Gabbar Singh relied on a simple arithmetic that the
strength of the army is proportional to the number of troops.
In contrast, Thakur Sahib relied on the quality of the two. He knew that:
Dono ke dono pakke badmash hain. Badmash hain, lekin bahadur hain,
imandar bhi hain. (Both of them are villains. Villains, but they are
brave, and trustworthy too.) As a result, the two extraordinary brave and
spirited outlaws defeated more than 30 ordinary outlaws.
Of course this is a legend. In reality, the difference in quality may never
be so prominent. One thing is true, however, that both quality and quantity
are required. The formula should be:
Effect = Quality x Quantity.
JICA Reproductive Health Project launched almost simultaneously with RCH-II
and NRHM. The both national programs (RCH-II/NRHM) have abundant resources.
This is why, the planning and monitoring of RCH-II/NRHM have been more
focused on quantity than quality, such as number of facilities, manpower,
service opportunities, etc. Meanwhile, JICA has worked on improvement of the
quality. However, even quality should be quantified for the purpose of
management in scale.
Since July, 2008, JICA has been producing several formats for quality
assessment of health facilities. The topics include SBA Quality Monitoring
formats, Twelve Steps for Organization of the Maternity Wing, Bio-Medical
Waste Management, etc. These assessment tools are essential for counting
kinte achchhe aspatal hain? (How many health facilities are proper?).
In general terms, to count the units with certain level of quality is how we
conduct the Quality-Quantity Management.
Go to Top
Trikaal (three tenses) for Supervision
Writing Supervisory Reports is not easy. A report could mislead readers if the writer does not follow the basic rule of grammar. For example, the phrase “follow up” could be used both for the action of checking previous results, as well as, for the need of checking sometime in future. The diagram attached hereto may give some clarity. It shows that a supervisor has three main responsibilities: Assessment, Handholding and Suggestion.
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Assessment (of the Past): this is to ensure that proper actions were taken as per the former Suggestions. If not, the supervisor should analyze what the main cause was.
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Handholding (Present): This is to fill the technical or managerial gap found by the Assessment. It should not be just verbal instructions. By handholding, the supervisor should show how to do it and ensure that the workers have acquired practical knowledge and skills.
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Suggestion (for Future): Supervisor suggests the workers the tasks to be done before the next supervisory visit. The results will be assessed during the next supervisory visit.
Because of the different time frame of the three actions, the whole sequence of repeated supervision makes a zigzag pattern in the diagram.
Go to Top