Medical Research Council
World Health Organization
Health Systems Trust
2011-2012 Education Sector HIV and AIDS: Global Progress Survey- Progression, Regression or Stagnation?UNAIDS
How 'programmes' can support the development of districts
Defining the problem
At present many health workers complain that instead of supporting the process of district development, vertical programmes are confusing and overwhelming front line health workers and undermining the coordinated provision of services. Some people have even suggested that programme co-ordinators should not exist at district level. There are a number of reasons for these views:
- Management remains top-down in its approach. As a result, policies and plans for programmes usually originate in the National Department of Health and reach the district via the provincial and regional offices. This approach can result in the implementation of activities which do not reflect the priorities of the districts. For example, many districts are expected to implement a programme of  genetics services in circumstances where even the most basic maternal and child health services are unavailable.
- Programme co-ordinators have been appointed  in many districts with little consideration given to their role and responsibilities. Some co-ordinators lack the experience, and the management and technical skills to function effectively.
- Many districts lack the capacity or mechanisms for integrating programmes into a comprehensive district plan. The relative weakness of many district structures and management systems increases the danger that programmes operate in a vertical way. For example, in one district an STD co-ordinator trained all the nurses in the use of the syndromic approach for the treatment of STDs, but did not inform the district pharmacist about the drugs that would be needed to implement the approach. The intervention failed because the implications on other aspects of the district had not been considered.
- Programme co-ordinators are often regarded as line managers of facility staff e.g. the maternal and child health (MCH) co-ordinator is seen as being responsible for direct supervision of all clinic-based MCH services in the district. This results in fragmented management and confusion, particularly in districts with numerous programme co-ordinators.  Some clinic nurses end up being  supervised by several co-ordinators who each think that their programme is the most important!