At the end of the first year, eight of the 10 health teams had achieved 95% or more of their desired results and had selected a new challenge without prompting . Three districts--Aswan, Daraw and Kom Ombo--increased the number of new family planning visits by 36%, 68% and 20%, respectively, compared to the same period the year before. Three teams achieved notable increases in the average number of prenatal care visits per client. Gaafra Health Centre achieved an average of 3.6 postpartum visits per client as of the end of June 2003, up from 0.2 visits in June 2002 .
MSH conducted studies in 2003, 2004 and 2005 to evaluate the results and learn more about the expansion of the self-directed programme. In 2003, at the end of the one-year pilot, they found that:
All teams had changed from complaining about problems to identifying actionable challenges they could address.
All teams collected complete or partial data on their selected challenges and used the data to prepare written action plans with measurable outputs, time frames and defined human and financial resources. There had been a major change, from merely sending routine reports to the next level to analysing the data to monitor progress and understand their challenges.
All action plans used existing resources available to the teams; none required new human or financial resources.
Teams from the programme were eager to go to Cairo to present their success to the Ministry and demonstrate that by improving their own leadership they had improved service indicators. Nurses were among the proudest presenters.
Sustaining and scaling up the programme
When USAID funding ended after one year, in 2003, Dr Abdo El Swesy, an obstetrician/gynaecologist from Kom Ombo District Hospital, and Dr Mohamed Souror, the District Family Planning Director from Kom Ombo District, convened a group of participants to discuss how to continue without outside funding. They faced many challenges initially. In the donor-funded LDP pilot, participants had attended meetings in hotels and received allowances for food and transportation. In the second year, meetings were held at health facilities, and the costs of materials and transportation came out of facilitators' and participants' pockets. Nevertheless, participation remained high. Using a 10-page booklet of handouts and modules adapted from the original programme, facilitators from the three districts took the revised programme to 15 new health facilities.
In the second year, teams from Aswan District raised the number of prenatal visits per woman from 1.3 to 3.7, and child care visits increased from 1.1 to 3.5. These improvements helped to change clients' perceptions of the health facilities and workers and influenced other health practices positively. The second generation of the Kom Ombo team created a new medical information system, and teams continued to increase the use of contraceptives, including condoms, pills, injectables and IUDs . To achieve this, they implemented low-cost activities that could be accomplished by clinics using their own existing resources, including home visits, training for service providers and health education for women, men, and community leaders.
In the third year, the LDP scaled up to 100 health facilities and by 2005 it had reached all 184 primary health facilities--including more than 1000 health workers--in the governorate. Thirty-five local facilitators were developed over five 'generations'.
In 2004, an evaluation found that: "The LDP is perceived as a powerful tool to improve performance by all participants. The programme's participatory approach has enabled front line service providers to actively participate in discussions and... in the design and implementation of their own small-scale service delivery improvement projects, as opposed to conducting projects 'imposed' by higher levels of the health system. This has contributed substantially to participants' enthusiasm and ownership of their service delivery challenges" .
The LDP's role in decentralization
In 2005 an evaluation report found that: "Service providers who participated in this programme improved their commitment and love of their jobs...They act as partners to implement plans in their clinics rather than implementing plans put in place by somebody else. Trained health teams at the clinic level solve their own problems and don't wait for central level management to solve their problems" .
The evaluation also found that everyone who shared in the programme's implementation was motivated, the programme was easy to implement and it was adjustable, meaning that it was possible to add to it or to take things out as necessary .
The facilitators had problems that included:
advocating the programme to higher management at the governorate or central level;
finding time to expand the programme when the core team of facilitators became very busy (in new management positions);
addressing the turnover of doctors during the training. When this happened health workers in the facilities had to bring new doctors up to date to be able to work with the rest of the team.
Focusing on a governorate-wide challenge: reducing the maternal mortality rate
After training all health facilities in the governorate, in 2005 the Aswan LDP facilitators chose the governorate-wide challenge of reducing the MMR from 85 per 100 000 live births to 50. To accomplish this, LDP facilitators brought Safe Motherhood Committees to every district in the governorate. (These committees expanded on governorate-level committees initiated by the USAID Healthy Mother/Healthy Child Project.) District committees scanned to discover the factors contributing to maternal deaths in their areas. They focused on two factors that were within their control: (1) immediate transport of haemorrhaging women to a district hospital, and (2) a requirement that hospital physicians diagnose and treat in a team of three to prevent unnecessary haste and foster good decision-making under pressure. This requirement reduced unnecessary procedures and complications. 
Focusing on these two factors contributed to reducing the MMR for the entire governorate--a population of over two million. From 2006 to 2007, the Aswan Governorate reduced the MMR further, from 50.0 per 100,000 live births to 35.5. This figure continues to drop at a rate faster than in comparable governorates in Egypt. Qena is a governorate in Upper Egypt with similar economic and social conditions and similar amounts of MOHP and donor-funded programmes. In 2006 the MMR in Qena was 52.7 per 100,000, and in 2007 it was 52.0 per 100,000.
Developing a new generation of leaders for the health system
Since completing the programme, more than 20 LDP facilitators and participants have taken leadership roles in the Aswan health directorate. The commitment of the health workers in Aswan and the results they have achieved over six years have come to the attention of the central MOHP, and other governorates across Egypt are requesting the LDP for their health teams.
Scaling up to new areas and countries
Aswan facilitators have transferred LDP approaches to other governorates in Egypt. Through TAHSEEN, a USAID-funded project implemented in Egypt by the Catalyst Consortium, the Upper Egypt governorates of Minya, Bani Swaif and Fayoum were trained in LDP approaches and tools.
In 2005, Ministry of Public Health officials from Afghanistan went to Aswan to learn the LDP approach. They replicated the programme in five Afghan provinces that year. Now the LDP is used to improve service results in over 100 health facilities in 13 provinces across Afghanistan.
The LDP has been transferred to 35 developing countries around the world, and is used to scale up a variety of proven public health interventions. LDP tools and approaches are also being introduced into medical and public health curricula in Africa, Latin America and the Eastern Mediterranean.