Nurse Rachanee, a nurse-midwife in a rural health post, was gathering the post's service statistics for her annual report to the Ministry of Health. As she compiled information on the referrals made to the health center by the program's family planning volunteers and traditional birth attendants (TBAs), she noticed that one of the TBAs who had been trained in a recent group of five had only made three referrals, while each of the others had made at least twenty. Nurse Rachanee frowned, and as she thought back to when she had trained the TBAs six months ago, she remembered that this TBA, Nuansai, had been less enthusiastic than the rest. She made a note to herself to ask Nuansai about this on her next supervisory visit.
Three weeks later, Nurse Rachanee arrived in Nuansai's village. After sharing a cool drink, Nurse Rachanee asked how things were going. Nuansai said that she had assisted in a number of successful deliveries, but that in the past two months two infants had died. "They were both very small, poor things," said Nuansai
Nurse Rachanee asked to watch while Nuansai conducted a client visit, and they walked to a nearby home for a post-natal visit to a mother of three children under the age of four, who had delivered the previous week. After examining the mother and the baby and talking to her about breast-feeding, Nuansai told her that for her own health and that of her children, she ought to consider waiting two years before having another. She gave the mother a clear and simple explanation of the various methods of contraception, and when the woman showed great interest, Nuansai gave her a referral slip for the health post.
As they returned to Nuansai's house, Nurse Rachanee said, "You did a very good job there. Your examination was thorough, and you emphasized the importance of breastfeeding. Your explanation of family planning was excellent. I think she really will come to the health post for contraception. But I must tell you, I am puzzled. Your presentation was so good, you are obviously very effective at referring people for family planning, and yet you have had only three referrals come to the health post in the past six months. Can you tell me why this should be?"
Nuansai looked a little uncomfortable with the question, and after a few minutes of discussion Nurse Rachanee realized that Nuansai hadn't referred many women for family planning because she felt that if the women had fewer babies, she would have less work and thus less income.
Nurse Rachanee now had to decide how to handle this performance problem. Should she send Nuansai for further training in family planning referral? She decided to use the "Decision Tree" to uncover the cause of the problem, which would determine whether training was necessary or not.
What is the performance problem?
Nuansai is not referring eligible clients for family planning.Is it important?
Yes. Some women are having children very closely spaced, so some of their children are born with low birth-weight and are more likely to die. For the health of both the mothers and the children, births should be spaced at least two years apart.Does Nuansai have the skill to carry out the task? (Could she do it if her life depended on it?)
Yes. She made a very good presentation on family planning and knows how to refer women to the health post.Is Nuansai doing this job well? Is there a disadvantage to her doing this job well?
No, she is not doing this job well, so this question does not apply.Is Nuansai doing this job poorly? Is there an advantage to her doing this job poorly?
Yes. As Nuansai sees it, if she doesn't refer women for family planning, they will have more babies and she will have more births to attend and thus more income.Are there obstacles to performing the job well?
Yes. She doesn't see the value of referring women for family planning.
Solution: Remove the obstacles.
After going through this thought process, Nurse Rachanee sat down with Nuansai to discuss the issue.
"You know all the health reasons why women should space births, and I heard you explain them to your client today," said Nurse Rachanee. "I understand your concern about losing some income if your clients have fewer babies, but I think you should consider how referring eligible women for family planning can help you. If you tell mothers how spacing births can improve their health and their babies' health, they will know that you care more about their well-being and their health than you do about being paid, and they will respect you more." Nuansai looked interested, but a little doubtful. "They will probably tell their friends about this nice traditional birth attendant who cares about them and their babies," Nurse Rachanee continued, "and you will find you have even more clients. We can talk with the other TBAs and see what their experience has been. Will you give it a try?"
"Very well," said Nuansai. "If their income has not decreased, I will try it."