M&L - Where We Work

The Leadership and Management in Health Project in Nicaragua is M&L's largest field-supported program, and one of its most comprehensive. In the last six months the program has continued to provide comprehensive technical assistance to six public sector and non-governmental organizations: the Ministry of Health (MOH), the Ministry of the Family (MiFamilia), the Ministry of Education, the National Social Security Institute (INSS), the municipal government of Waslala, and Profamilia, Nicaragua's IPPF affiliate. M&L's work in leadership and management development is enabling USAID/Nicaragua’s social sector partners to identify and address strategic institutional challenges.

Multi-Sector Work: Transfer of an Institutional Modernization and Reform Approach from One Ministry to Another

M&L began working with the MOH at the central level in April 2003. In close cooperation with the World Bank and the InterAmerican Development Bank's "Modernization of the Health Sector Project," M&L played the lead technical role in designing the MOH's institutional reform and modernization program. Central to M&L's approach is introducing a new way of operating within the MOH by simplifying structures, clarifying roles and responsibilities, and establishing clear results and process indicators for monitoring performance. This massive redesign has been completed, with an implementation plan developed and approved by the government.

The results of M&L's work with the MOH include: the legal reform of the MOH under a new, decentralized structure; all key tools and processes for the modernized and decentralized MOH developed and ready for implementation; human resource and financial systems decentralized; and a finalized 2006 budget and Annual Operating Plan based on a service-contracting model.

M&L began working with MiFamilia in January 2004, using the same institutional reform and modernization process and methodology applied with the MOH. Since January, M&L has assisted in: the development of the Service Delivery Model, which is used to coordinate and organize most of the donor assistance; the design and operationalization of the planning system; the design of the special social protection system; and the development of leadership capacity among senior central level staff 15 Delegations (MiFamilia is organized into 23 Delegations, or departments). M&L also facilitated the introduction of the Quality Assurance Project's rapid quality improvement approach into the MiFamilia delegations.

M&L will continue to work with MiFamilia. Expected results are: a fully operationalized and streamlined special protection program and social assistance program; a plan for integrating the social protection programs; costing of key services; development of a monitoring instrument for services; and a management performance monitoring system that will integrate quality, cost, and productivity data.

The Ministry of Education (MOE) is the newest M&L client. M&L worked with the Ministry in leadership development and institutional reform from July to December 2004. For the leadership development program, the Ministry chose the introduction of a competency-based curriculum as its organizational challenge. In February 2005, the MOE will introduce its new competency-based curriculum into several hundred schools—as many as 10 percent of all schools in the country—while creating an environment conducive to change as a result of the leadership training.

The MOE will carry out institutional reform with World Bank financing. Based on our experience with the MOH and MiFamilia, M&L is designing the Terms of Reference for the World Bank. Over the next six months M&L will provide oversight of the contracted management consulting firm for the Ministry to assure the quality of the technical assistance. The result will be a well-designed restructuring of the Ministry that facilitates decentralization and is consistent with the new competency-based curriculum.

M&L has built on the PROSALUD Bilateral's Fully Functional Service Delivery Point approach, adapting it to the MOH context and implementing it as a comprehensive health management system called "AMAS." This system has been applied in all MOH primary health care facilities and has contributed to clearly identified improvements in service quality. For example, two recent studies have revealed improvements in coverage of maternal and child health services. M&L and the MOH are ensuring that the AMAS approach is incorporated into the institutional reform and modernization process discussed above.

Preliminary data from the Nicaragua MOH for 2004 shows the impact of the application of AMAS on primary health care in eight SILAIS.

MOH Indicator	Improvement Range Among Facilities
Growth and development surveillance rate for children under one year of age	4.6 % – 53.4 %
Growth and development surveillance rate for children aged one to four years	1.7 % – 21.7 %
Immunization coverage (BCG) for children younger than one	2.8 % – 40.5 %
MMR immunization coverage for children younger than one	5.9% – 55 %
Prenatal care utilization rate	6.3% – 42.2%
Delivery in MOH facilities	1.4% – 35.1%
Early infant health care ( first month of life) coverage rate	6.3% – 51.9%
Family Planning coverage rate	3.7% – 28.4%

Leadership development has been central to the dual challenges of improved service delivery and institutional modernization among M&L's client organizations. In the MOH, M&L's Leadership Development Program has directly trained over 2,000 managers and health personnel and facilitated the training of close to 2,000 more with funding leveraged from other donors. The leadership program was implemented by M&L in 63 municipalities of eight SILAIS (regions), and by PROSILAIS (another project and funding mechanism) in an additional three SILAIS and their municipalities.

To reach these numbers of people, the M&L program built a facilitators network at all levels in the MOH including:

In addition to scaling up the Leadership Development program in the MOH, M&L completed the delivery of leadership development programs in the Ministry of the Family and the National Institute of Social Security in this reporting period.

Finally, close to 100 rural leaders completed a leadership development program in the municipality of Waslala, and an additional 120 rural community leaders are currently in a leadership development program. The rural leaders have produced a series of important community development actions that favorably impact health. For example, two leaders built school kitchens to improve the nutrition of community children. Other leaders built a community house where community members can have meetings and trainings and conduct health promotion and prevention activities, such as weighing and measuring children. Others improved a road to the school, while still others held community clean-up campaigns, and are negotiating with potential donors to help implement community-wide potable water systems.