• Summary
• Credits

1. Understanding the Concept
2. Evidence-Based Practices
3. Adaptability
4. Links with Other Services
5. Minimizing Paperwork
6. Physical Factors
7. Service Hours and Scheduling
8. Client Flow
9. Division of Labor and Job Design
10. Social Factors
11. Implementing the Concept
12. Bibliography

• INFO Project
• Order
• Online Reports
• Upcoming Reports
• POPLINE

This issue was prepared in collaboration with the Maximizing Access and Quality (MAQ) Initiative of the United States Agency for International Development's Office of Population and Reproductive Health. The MAQ Initiative supports research and evidence-based interventions to promote access and quality of reproductive health and family planning services.

Published by the INFO Project, Center for Communication Programs, The Johns Hopkins University Bloomberg School of Public Health, 111 Market Place, Suite 310, Baltimore, Maryland 21202, USA.

Health care workers do a better job and are more satisfied with their work when they know what they are expected to do and have the authority to do it. Also, staff members can be more effective and the organization can accomplish its objectives better when the organizational culture and managerial structure promote teamwork and focus on serving clients.

As appropriate, delegate responsibility to the lowest-level front-line provider. With suitable training, nurses and midwives can perform many procedures, such as inserting implants or IUDs (2, 34, 38, 98). Regulations or policies that restrict such practices to physicians can limit clients’ access to these services. Training and authorizing nurses and midwives to insert IUDs or counsel for sterilization can be a straightforward way to increase access to services (see box at right).

Align authority with responsibility. Many health staff believe that they are responsible for performing duties but have little authority to make decisions or to solve problems that could help them do their jobs better (41, 68). When staff members are empowered to make the decisions that their jobs require, they can better solve every-day problems themselves, rather than needing to seek guidance or permission from supervisors (30, 31, 52). At a district health center in Dar es Salaam, Tanzania, clients felt embarrassed seeking treatment for sexually transmitted infections (STIs). Employing her authority, the clinician in charge decided to eliminate the requirement that STI clients first meet with the admitting provider. Instead, clients could go directly to the office that offered STI-related services. This change increased confidentiality and reduced the likelihood that clients would find the experience uncomfortable and thus avoid seeking services (114).

Empowered providers are more committed to their work and feel more control over it, rather than seeing themselves as just following instructions or orders (39). To enable staff to make decisions and take action, managers can clarify responsibilities through written job descriptions, let staff know that management expects and appreciates initiative and participation, and provide training and supervision to build decision-making skills.

Relate job responsibilities to the goals of the organization. Managers can clearly define and document staff members’ responsibilities, explain the organization’s mission to them, and involve them in interpreting what this mission means to their own work (84). When supervisors and providers work together to define responsibilities, providers are more likely to understand what is expected of them and to act accordingly.

Where formal job descriptions are unavailable, the organization’s mission statement or an institutional motto or slogan can provide temporary or complementary solutions to help staff members understand how they are expected to perform (4, 39). A study in Kenya found that providers and supervisors in high-performing health care facilities typically knew the organization’s mottoes, such as “serve our clients and they go home happy,” “do it yourself,” and “good to be part of a family.” These slogans encouraged staff to be sensitive to clients’ needs, fostered self-initiative, and provided general performance expectations, even in the absence of written job descriptions or well-defined roles (90).

Promote teamwork and avoid hierarchical thinking.Often organizations have too many layers in a hierarchical structure, too little coordination, or poor internal communication. This structure can block good performance.

In particular, hierarchical organizations tend to promote only vertical flows of information, typically downward from top managers through supervisors to service providers and other subordinates. Vertical communication can ensure that roles and reporting relationships are well-defined (77). But also sharing information and coordinating activities horizontally—that is, among workers at the same level in different units—can help promote teamwork and problem-solving (111).

For instance, people from different departments who do different jobs can work together in cross-functional teams (25, 59). By bringing together all the people involved in a process, horizontal teams often can assemble a more complete picture of what to do than can a purely vertical hierarchical organization. Also, teams can examine the entire system for weaknesses and recommend better solutions (see box right).

Disclaimer: The information provided on this web site is not official U.S. Government information and does not represent the views or positions of the U.S. Agency for International Development or the U.S. Government.