Application of the PtD supply chain management theory of change


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For the first time, the People that Deliver (PtD) Building human resources for supply chain management Theory of Change (ToC) has been used to examine community health workers (CHWs) in their capacity as members of the supply chain workforce. With support from the United States Agency for International Development (USAID), a diagnostic was carried out in Liberia to explore barriers related to staffing, skills, motivation and working conditions from the perspective of community health assistants (CHAs) and their supervisors.

The findings and related recommendations have been detailed in a recently-published report.

PtD executive manager Dominique Zwinkels said: “The ToC diagnostic in Liberia has been valuable on two fronts: not only has is revealed performance bottlenecks and recommendations to improve the supply chain-related performance of CHAs but it has also given us an opportunity to reflect on the limitations of the Theory of Change itself.”

Findings: CHAs are skilled but not supplied

According to Arthur Loryoun from VillageReach, who supported PtD in Liberia, there are a number of factors hindering CHA performance: “CHAs can improve key health-related behaviours but community-level stockouts are just one of many persistent challenges that impede their ability to deliver health services.”

Focus group discussions with CHWs and their supervisors drew upon the four pathways (staffing, skills, motivation and working conditions) outlined in the ToC, which describes the conditions necessary to ensure that workers at every level perform optimally to fulfil all necessary functions of an effective supply chain system. In total 24 CHAs and 24 community health services supervisors were interviewed.

The findings show that CHAs have the knowledge and skills necessary to deliver health services in their communities, provided they have access to all necessary supplies. Most CHAs, however, lack the supplies needed to fulfil their roles, including personal protective equipment. Likewise, the availability of essential medication remains a persistent challenge at community level, resulting in referrals to health facilities, many of which are not taken up owing to the distance and cost.

“CHAs are motivated and the communities appreciate their work when commodities are available,” Arthur Loryoun added.

Pride and respect are key motivators for CHAs, as is a desire to promote community health. The discussions, though, highlighted that a lack of commodities at community level erodes community confidence in the CHAs.

Recommendations: Pay, career progression and protective personal equipment

The recommendations detailed in the report are organised along the four pathways of the ToC. An adequate supply of essential supplies – especially those necessary to prevent infection such as gloves and sharps containers – should be provided to CHAs, as should a mobile device with SMS capability to help CHAs respond to emergency situations.

Given the desire of both CHAs and CHSSs to continuously learn and develop, career pathway options should be considered. Health insurance coverage and leave be provided to all CHAs and they should receive their monthly stipends on time and in the correct amount.

The recommendations also suggest that each CHA be responsible for a maximum of 60 households, which is not currently the case, and given that six years have passed since the inception of the programme it would be advisable to conduct a training needs analysis to determine whether any skills gaps remain.

Read the report here