Performance Management at the Health Centre

Kakumbi Rural Health Centre
Kakumbi Rural Health Centre

We had a meeting at Kakumbi Rural Health Centre last month, chaired by the Public Health Officer, Mr Chulu. He had just returned from a regional meeting which discussed how well each health centre was meeting its targets. I was fascinated by his report on our failings, which had been pointed out by the health planners.

Extrapolating from the data of the last census, six years ago, the health planners expect us to deliver 44 babies each month in the clinic. Mr Chulu had plotted our data on a bar chart, showing how miserably we had performed. One month, we only managed 19 deliveries. An arrow drew our attention to this shorter column, with a speech bubble saying, “What happened here, team?” My facetious answer was, “Not a lot, nine months previously.” This went down like a lead balloon.

We discussed other possible reasons for our underperformance. More women might be giving birth at home or in the local hospital where they can do Caesarian Sections. But our referral rate for C-Section is just 2%, not enough to account for the discrepancy. Home births do occur, because women living far from the health centre do not want to walk or bicycle (!) in labour at night, as they are frightened of meeting hippos or elephants en route. We know about these births because the women bring their newborns for vaccinations at the health centre or outreach Mother and Child Health clinics. We did not know how many there were because we had not been asked for these figures. All it needed was to compare our immunisation ledger with our birth ledger.

There was a suggestion that the reason for some clinics’ “poor” performance was that the women were voting with their wombs. In other words, if the women did not like the attitude of midwives, or felt they were not being respected, they would not attend. They would reject the services of a dirty or inefficient clinic. This caused some murmurings of dissent among the clinical staff at the meeting.

Baby Clinic - far from unpopular with the mothers
Baby Clinic – far from unpopular with the mothers

Health planners sometimes forget the human factor. For example, on the Thai/Myanmar border, more Karen babies are born in the final quarter of the year than in all the other three quarters put together. This is because the first quarter of the year is a slack period in the agricultural calendar. Putting it bluntly, the farmers have more time and energy to have sex during these months. I reckon that nine months from now there will be fewer births because of the present Football World Cup. “What happened here (to your) team?”

I asked Mr Chulu how the Ministry came up with these figures. He didn’t know how they had arrived at the numbers, but felt he had to accept their accuracy. Our locality is not typical of Zambia. It is a boom town, with lots of people coming to the area because of the jobs provided by the tourist industry. There are more single men, more commercial sex workers, higher rates of HIV infections and more disposable income. We discussed whether this might have been taken into account by the planners, but decided it probably hadn’t.

Kakumbi is the lucky recipient of a Swedish International Development Agency programme to support obstetrics. By the end of the year, we will have a new maternity block and a shelter for women at the end of their pregnancy who live far from the health centre.

Family planning animator
Family planning animator

After half an hour’s fruitless discussion we moved on to the second item on the agenda. This was our over performance in Family Planning. We regularly use up our entire stock of DepoProvera injections half way through the month, and have to requisition further supplies from less successful Family Planning clinics in the area.

Female Condoms for All
Female Condoms for All

“Wait a minute,” I interjected. “If we are seeing more women for Family Planning, this is going to reduce the birth rate. Surely this is an additional reason explaining the gap between the numbers of observed and expected deliveries.”

“Well, yes it could, doctor,” said Mr Chulu. “But the planners say we are still exceeding our targets in prescriptions of the contraception pill and DepoProvera.”

“Is that a bad thing,” I asked.

“Yes, because they haven’t increased our supplies of Family Planning items. You don’t understand how we do things in Zambia. We should be meeting the targets set by HQ, not exceeding them or falling short.”

Good grief, I said to myself. Is stultifying bureaucracy and the dead hand of the civil service the heritage we Brits have bequeathed to this brave new country? It is worse than the CQC.

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