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Employee Engagement
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Strategies used by facilities to improve iron and folate supplement availability for Antenatal Care in Kenya. What happens when national systems fail to meet client needs?
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Improvement Report
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Uganda| Palliative Care Collaborative
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Collaborative Profile
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Assessment of the Human Resources System in Niger
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Publications
Throughout Africa, a human resources crisis in the public health system has become one of the biggest challenges in the battle against HIV/AIDS, the improvement of maternal and child health and the management of chronic diseases. Health workers face a difficult daily workload in a challenging work environment with inadequate compensation and little recognition for their efforts. Human resource (HR) systems are generally weak and overall capacity in human resource management is low. As a result, health workers are often unprepared and unable to meet the high demands placed on them; they lose motivation, become disengaged, or vacate their posts altogether.
In response to this HR challenge and in an effort to improve the quality of health services, the Government of Niger requested the aid of the USAID-funded Health Care Improvement Project (HCI) in closing these HR gaps and in building the capacity of the MOPH to manage and support health care workers in the Region of Tahoua.A rapid assessment of current human resource systems at the national, regional, and district level was conducted, followed by an in-depth baseline assessment at 20 health facilities in three regions— in Tahoua, (15 sites) Maradi (3 sites) and Tillabery (2 sites). The rapid assessment of HR systems looked at the current recruitment, deployment, reward, supervision, evaluation, training and career advancement systems from the central to the district levels. The site-level assessments looked at the impact of those systems on health workers and at their overall engagement. Site-level assessments also included an in-depth look at productivity and client flow analysis.Several methods and tools were employed during the assessment: In-depth interviews with managerial staff from regional (34 individuals) and district (44 individuals) health teams and at referral facilities (eight individuals). Interviews were also conducted with 53 health workers. A time utilization tool measured the productivity of 33 health workers and a client flow tool measured how much time 565 patients spent at each stage of a clinical visit. To measure engagement of health workers, a confidential and anonymous instrument of 26 items was completed by 231 health workers, including 147 literate and 84 illiterate workers in 19 different health centers.The report details the findings from the assessment and includes English versions of the data collection instruments. The findings informed the design of a Human Resource Improvement Collaborative developed by HCI and the Ministry of Public Health of Niger to improve health worker productivity, engagement, and retention. -
Grace Children's Hospital - TB Screening
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Improvement Report
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Aligning and Clarifying Health Worker Tasks to Improve Maternal Care in Niger
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Publications
Throughout Africa, the human resources crisis in the public health system has become one of the biggest challenges in attaining the Millennium Development Goals (MDGs). In the face of difficult working environments and inadequate support, health workers are often unprepared and unable to meet the high demands placed on them; they lose motivation, become disengaged, or vacate their posts altogether. This report describes pioneering work in Niger by the USAID Health Care Improvement Project (HCI) to apply quality improvement methods to strengthen human resources management and performance at the facility- and district-management level to improve maternal care in the Tahoua Region.
Since May 2009, 15 health facility and 11 district management quality improvement (QI) teams have worked together with the support of the Ministry of Public Health (MOPH) in Niger and the USAID HCI Project. This work uses the QI Collaborative approach to develop, test, implement, and spread feasible strategies targeting specific human resources improvement objectives to improve maternal care services. As part of this strategic human resources management process to improve maternal care, teams aligned maternal health goals and objectives from the central to facility levels, and clarified and defined tasks and competencies for clinical staff in maternity units. Regional and district health teams continue to implement system changes while facility teams focus on improving performance and providing support to engage health workers.
These improvements resulted in significant clinical, performance and efficiency gains between May 2009 and December 2010: six out of the Tahoua region’s eight districts now meet the national target for the percentage of births (i.e., greater than 25%) delivered in a health facility; postpartum hemorrhage has been reduced by half in participating sites; adherence to essential newborn care standards has increased from 72% to 98%; and the average waiting time for pre-natal consultations has been reduced by 50-98%. When the collaborative started, none of the health workers had job descriptions, whereas now, almost all health workers have specific, written job descriptions and clear roles and responsibilities outlined for their work. Results from this program demonstrate that by building the capacity of health workers and district managers in teams to solve problems that affect their ability to provide maternal care, performance, productivity, efficiency, quality of care, and clinical indicators are sustainably improved over time. -
New online resource about Community Health Workers
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Publications
CHW Central (www.chwcentral.org) is a new interactive platform to facilitate information-sharing and dialogue about how to support and improve the effectiveness of community health workers, who serve in communities around the world providing health education and care. The website's features include:
- Online facilitated discussions with experts on current and critical issues facing CHW programs;
- A resource center of training materials, practical tools, and up-to-date guidelines; and
- A member exchange forum where registered users can post questions and solicit input.
Developed by the USAID Health Care Improvement Project, CHW Central draws on global resources and evidence from a number of organizations committed to improving and supporting community health workers, including USAID, The Global Health Workforce Alliance, CORE Group, CapacityPlus, and MCHIP.
CHW Central is managed by Initiatives Inc., in collaboration with University Research Co., LLC (URC) and Johns Hopkins Bloomberg School of Public Health Center for Communication Programs. -
Barriers to Advanced Education for Indigenous Australian Health Workers: An Exploratory Study
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Community Resource
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Improving Performance of Community-Level Health and Nutrition Functionaries: A Review of Evidence in India
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Community Resource
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Measuring engagement of community health workers to improve productivity, retention and quality of care
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Community Resource
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Coming soon: CHW CENTRAL, a new web-based resource for Community Health Worker Programs
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Daily diary analysis – An approach to strengthen information system at grass root level
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Improvement Report
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Reduction in length of stay of discharges from a Chilean Pediatric Unit.
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Improvement Report
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Strengthening Human Resources for Health to Improve Maternal Care in Niger’s Tahoua Region
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Publications
This short report describes the results of applying collaborative improvement to strengthen human resource management and improve the quality of maternal care in Tahoua Region of Niger.
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Baseline Assessment of HIV Service Provider Productivity and Efficiency in Tanzania
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Publications
Tanzania, like many other countries in Africa, is facing a severe shortage of qualified health professionals. Only 35% of positions in government health facilities have been filled, leaving Tanzania in the wake of burgeoning human resources for health crisis. According to the Annual Health Statistical Abstract from 2008, the national average of the population per medical officer was 64,000, 31,000 per assistant medical officer, and 7,000 per clinical officer. The shortage of health professionals has been exacerbated by the HIV/AIDS pandemic and other communicable diseases such as malaria and TB.
In an effort to improve the quality of care of HIV services delivered in Tanzania, the USAID Health Care Improvement Project (HCI) and the Ministry of Health and Social Welfare (MOHSW) began implementing a partner improvement collaborative in the Mtwara region in nine care and treatment centers in June of 2009. The aim of the collaborative is to apply QI methods to ART and PMTCT services in order to ensure a high quality of care is being delivered to clients. The collaborative is now looking to integrate HR interventions into its work in order to improve efficiency of service delivery, and strengthen health worker performance and engagement. Health worker productivity and engagement are integral to improving efficiency as they determine what tasks health workers perform and how engaged and motivated they are to perform at a high level.In collaboration with the Government of Tanzania, HCI designed a baseline assessment of HIV/AIDS service providers to gather information on productivity and engagement. The information gathered from this baseline assessment will be used to develop a set of HR improvement packages based on best practices that will be integrated into the ongoing ART collaborative. The baseline was conducted in six sites in the region of Mtwara from June 30th- July 6th, 2010.The assessment identified several areas where human resource management systems can be improved to strengthen provider efficiency and productivity and improve the quality of HIV/AIDS service delivery. All health workers should be provided with written job descriptions that clearly align their tasks and goals. Without written job descriptions, it is impossible to implement strong performance management. Recognition and reward systems can be improved to ensure that health workers get the acknowledgement and praise they deserve when they perform well. The process for performance evaluations needs to be communicated clearly with lower level facilities. Facility managers and providers should also learn how to set performance objectives. Promotion and career advancement opportunities are somewhat rare, which may affect worker motivation. The majority of employees are moderately engaged, regardless of the type of facility or the position they hold, but specific areas of engagement, such as recognition and materials, could be improved. Productivity appears to vary throughout the day with providers being very productive in the morning when patients arrive and productivity levels decreasing dramatically in the afternoon when client loads are low. Client flow does not appear to be a problem, but is something that should continue to be monitored since client loads can vary dramatically by day. -
Niger Human Resources Improvement Project Nominated for Two Awards at WHO Health Workforce Forum in Bangkok
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Publications
A Human Resources (HR) Improvement Collaborative in Niger’s Tahoua region and its key implementer, Dr. Saidou M. Ekoye, are finalists for two WHO Global Health Workforce Alliance Awards. Award winners will be announced during the Second Global Forum on Human Resources for Health held in Bangkok, Thailand from January 25-29. The HR improvement collaborative, supported by the USAID Health Care Improvement (HCI) Project, is a finalist for an Award for Excellence. Dr. Ekoye, general secretary at the Niger Ministry of Public Health, is shortlisted for the Special Recognition Award for his leadership in directing the HR improvement work, which will be presented among 36 finalists as a case study poster at the Forum.
Dr. Ekoye and HCI staff Dr. Maina Boucar, Ms. Lauren Crigler, Ms. Allison Wittcoff, and Dr. Tana Wuliji are participating in the Forum to share the approaches applied in Niger and the results. Since the collaborative began in April 2009, the 15 facility and 11 management improvement teams have achieved significant gains in both health worker performance and clinical care. Successes include: six of Tahoua’s eight districts have exceeded the national target for institutional delivery, the rate of postpartum hemorrhage has been reduced by half in sites engaged in collaborative improvement, and adherence to essential newborn care standards has increased from 72% to 98%. Best practices from the HR collaborative are now being adopted in other regions and incorporated in the Ministry of Public Health’s five-year action plan.” -
Measuring engagement of community health workers to improve productivity, retention and quality of care
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Publications
Context: The health workforce crisis most African countries are facing is enormous, and many countries rely heavily on community health workers to provide basic essential services. However, shortages of community workers also exist in rural areas as most of the population tends to be concentrated in urban areas.
Problem: Many CHWs are volunteers and receive little to no compensation, are often poorly trained and lack the materials and supplies necessary to perform basic services. CHWs are also overburdened by the number of households they must visit on a daily basis and the psychological impact of their work, which frequently leaves them feeling overwhelmed and sometimes unmotivated. As a result, the turnover rate for CHWs remains high.Assessment of problem and analysis of its causes: Improving motivation, productivity and retention of community health workers through incentives is challenging and many countries cannot sustain costly compensation plans for CHWs. Yet most community health workers perform well when they are engaged, feel respected by communities, and rewarded by the work improving the welfare of their clients. Addressing engagement of community workers by helping them solve the problems that discourage them can increase their standing in the community, improve their livelihood, and keep them more productive for longer periods.Strategy for change: To improve engagement with community workers in Ethiopia, HCI tested a new management approach, Employee Engagement, to increase worker motivation, self-efficacy and productivity at the community level. Through this engagement approach, community workers and their project officers/supervisors will develop and implement practicable and sustainable solutions to problems that discourage them.Measurement of improvement: HCI has adapted private sector employee engagement instruments and developed a short questionnaire for community workers to complete confidentially and anonymously every four to six months. Based on the results of the questionnaire, community workers and their project officers develop action plans to improve areas where engagement is low. The engagement tool was recently adapted for community workers providing care to OVCs in Ethiopia. It was administered to 30 community workers, including both volunteers and project staff, in two project sites in Ethiopia as part of a baseline assessment.Effects of changes: Project officers and community workers developed action plans based on results. For example, in Ethiopia staff realized that communication between the different levels of staff i.e. between community workers and project officers and leadership needed improvement and planned an orientation for all staff. Other action items included a workshop on team-building skills and training for staff on communication skills. The participants also found the questionnaire to be a useful tool to facilitate team-building and conflict management.Lessons learnt: The CHWs in Ethiopia were very enthusiastic about the tool and felt empowered to work in cooperation with their supervisors/project officers to find practical and sustainable solutions to the HR issues that affect them the most. CHWs found that another benefit of the tool was that it enabled them to look internally at their own performance, helping them to identify basic gaps in problem-solving skills.Message for others: Engaged workers are loyal to their organization, have a lower rate of absenteeism, have lower rates of accidents on the job and provide a higher quality of care than disengaged workers. The experience in Ethiopia proves that the employee engagement methodology can be successfully applied to CHWs working with OVCs. -
Health Workforce Competency and Facility Readiness for Safe Deliveries | Tanzania
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Publications
The maternal mortality ratio in Tanzania is estimated to be 578/100,000.1 A great majority of these deaths are due to obstetric complications, 90% of which can be avoided. Some obstetric complications can be predicted and most are treatable if women receive high quality care when needed.2 Care provided by a competent Skilled Birth Attendant (SBA) during labor, delivery and in the immediate postpartum period is a key component of quality obstetric care. The percentage of deliveries assisted by a SBA has become a proxy indicator for reducing maternal mortality.3
Despite the wide coverage of training service providers on Basic and Advanced Life Saving Skills in Tanzania since 2003, there is limited information on maternal and newborn care provider competency or the impact of these trainings. Therefore, the need to determine the competency levels of the service providers and functionality of the health systems was urgent.Research questions/objectivesThe research objectives of this study were three-fold:1.To determine the current competency levels of the workforce attending to women and newborn during labor, delivery and the immediate postpartum period (first 24 hours)2. To determine the facility readiness for provision of care during labour, delivery and immediate postpartum period.3. To provide recommendations for quality improvement in the delivery facilities.MethodologyThe study was conducted in eight districts within four regions of Tanzania Mainland, namely Kisarawe and Bagamoyo (Coast Region), Singida Rural and Manyoni (Singida Region), Njombe and Mufindi (Iringa Region), and Muheza and Korogwe (Tanga Region). The assessment comprised two parts: (1) a knowledge test consisting of 50 multiple choice and true/false questions covering several topics inlcuding infection prevention, uncomplicated labor and delivery, prevention and management of hemorrhage, immediate care of the newborn including newborn resuscitation and prevention and management of sepsis. The test was scored using a predetermined answer key. And (2) assessment of five skill areas - (i) active management of the third stage of labor (AMTSL), (ii) manual removal of placenta, (iii) bimanual uterine compression (iv) immediate newborn care, and v) neonatal resuscitation by observing participant performance of each procedure on an anatomical model. A total of 194 service providers from these facilities participated. Each participant was assessed in these five areas by trained observers.Health facilities were evaluated using a checklist for the existence of the essential and enabling factors. These included: human resource, medical waste management, availability of water and source of light, essential medicines, equipment and supplies, functionality of referral system, and availability and use of maternal and newborn guidelines standards.Results/FindingsThe average score for the knowledge test was 56%, with the scores progressively improving with ranking of facility category from 50% for dispensaries to 58% for district hospitals and also with increasing qualifications from 45% among medical attendants to 62% among Medical Officers and AMOs. The average score for active management of the third stage of labor and manual removal of the placenta were 55.3% and 54.5% respectively. Bimanual uterine compression, immediate newborn care (36%) and neonatal resuscitation (25%) were generally poorly performed compared to the others. There were no statistically significant differences between different facility and cadre levels.Regarding facility readiness, some key medicines such as antibiotics and haematenics were available in most health facilities. However, live-saving medicines such as oxytocin and magnesium sulphate were not in stock in more than 60% of the facilities. Organization and sustainability of referral/counter-referral systems and use of maternal and neonatal health standards were also poor.These findings indicate that gaps to provision of quality maternal and newborn services exist with regard to competency of health personnel, infrastructure and referral systems. There is also indication that minimal investment in training on specific approaches for prevention and management of life-threatening complications will significantly contribute to the reduction of maternal and neonatal mortality and morbidity.
1. World Health Organization 2006. Making a Difference in Countries: Strategic Approachto Improving Maternal and Newborn Survival and Health. Department of MakingPregnancy Safer. WHO: Geneva, Switzerland.http://www.who.int/making_pregnancy_safer/documents/wa3102006ma/en/index.html2. World Health Organization, 2004. Maternal Mortality in 2000: Estimates developed byWHO, UNICEF and UNFPA). WHO: Geneva, Switzerland.3. National Bureau of Statistics (NBS) [Tanzania] and ORC Macro. 2005. TanzaniaDemographic and Health Survey, 2004-5. Dar es Salaam, Tanzania. National Bureau ofStatistics and ORC Macro. -
Baseline Assessment of HIV Service Provider Productivity and Efficiency in Uganda
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Publications
In 2009, the USAID Health Care Improvement Project (HCI), in conjunction with the Ministry of Health, began implementing an improvement collaborative aimed at increasing the number of clients accessing HIV/AIDS care and antiretroviral therapy (ART), in addition to increasing the coverage of HIV/AIDS services. This “coverage collaborative” was implemented in 13 sites, and is linked with a series of improvement collaboratives that address different aspects of improving access to and retention of care and clinical outcomes for HIV-positive patients.
The primary goal of the coverage collaborative is to improve the efficiency of service delivery. Health worker productivity and engagement—the extent to which workers believe in their work, are motivated to do their job well, and feel valued for doing it—are integral to improving efficiency, since these criteria determine how much workers are able and willing to do and how motivated they are to perform well.
As part of the collaborative, HCI conducted a baseline assessment of HIV/AIDS provider productivity, efficiency, and engagement for the Ministry of Health. Five data collection tools were used for the assessment , which took place in November 2009, and included the following: a site manager interview, a time utilization tool, a productivity interview, a client flow assessment, and an engagement survey. The assessment included six health centers and hospitals.This report presents the key findings from the assessment and includes the data collection instruments in the appendix. To support the Ministry of Health in improving the productivity and engagement of providers delivering ART services in Uganda, the selected sites will use this information to make informed decisions about health worker allocation, time utilization, roles, efficiency, and management, which will result in improved HIV/AIDS service provider productivity and increased capacity to provide services to new patients. The successful interventions developed in the coverage collaborative will then be shared with other sites, in order to encourage learning and the replication of successful interventions. -
Counseling Cards
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Publications
Counseling Cards
The counseling cards are intended for health workers to use during sessions with HIV-positive prenatal and postpartum women. Published in English and Swahili, the cards are tools that health workers can use to explain: the risk of transmission of HIV from mother to child when no preventive actions are taken; infant feeding options for HIV-positive mothers; the concept of acceptable, feasible, affordable, sustainable and safe (AFASS) replacement feeding; and how to safely practice their chosen infant feeding method.Risk of Passing HIV from Mother to Baby
Using this counseling card as a guide, the health worker can show the client a graphic depiction of the risk of passing HIV from HIV-positive women to their babies when NO preventive actions are taken. The card shows that most babies are infected with HIV during pregnancy and birth (approximately 20%). It also depicts the rate of babies who become infected with HIV through breastfeeding (approximately 15%) The health worker can use the card to illustrate that the majority of babies (approximately 65%) are not infected with HIV, but should be protected through the use of ARVs and safer infant feeding.Infant Feeding Options
This counseling card is intended to assist healthcare providers counsel women who have tested HIV-positive. It offers graphic depictions of three of the most common methods being actively promoted for feeding infants of HIV-positive women in Tanzania so that the healthcare worker can guide the mother in determining the safest option for feeding her baby.Infant Formula or Modified Cow's Milk as a Safe Option
This counseling card is directed to women who have tested HIV-positive and who are exploring their infant feeding options.This graphic job aid enables counselors to discuss whether using infant formula or modified cow’s milk presents a safe and secure alternative to breastfeeding, following AFASS criteria.Risk of HIV passing from mother to baby if mother and baby take Nevirapine
Using this counseling card as a guide, the health worker can show the client that the risk of mother passing HIV to baby decreases the mother practices exclusive breastfeeding and mother and baby take Nevirapine.How to Breastfeed
This job aid is intended to assist the counselor to give clear instructions to pregnant women on how to breastfeed. Illustrated, step-by-step instructions are presented to promote good positioning of the baby to prevent breast problems which can increase the transition of HIV through breastfeeding.How to Hand Express Breast Milk
This counseling card graphically depicts the steps for the mother to follow to hand express breast milk, an important skill for all mothers to have, no matter what their status. It encourages the use of a cup rather than a bottle for feeding the baby.Many Ways to Position and Attach Baby
Using this counseling card as a guide, the healthcare worker can show the mother a range of ways to position and attach the baby.During the first 6 months, baby needs only breast milk
This card illustrates that during the first six months, the baby should be given only breast milk.The mother should avoid giving water, glucose water, and all other foods and drinks.Danger Signs
Danger signs indicating that the baby should be immediately taken to the nearest health facility are illustrated. -
Job Aids on HIV and Infant Feeding
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Publications
Health workers in many countries struggle with how to advise women on acceptable, feasible, affordable, sustainable, and safe (AFASS) options for infant feeding in the context of HIV. Making an informed decision about infant feeding is particularly critical for HIV-positive women to reduce the risk of HIV-transmission to their infants.
WHO, UNICEF, UNAIDS, and UNFPA recently updated their joint guidelines on infant feeding options for HIV-positive women, but such international reference materials often are not available in a form useable by frontline health workers. Tanzania is one of the first countries to develop—and now apply on a national scale—a comprehensive set of job aids on infant feeding and HIV/AIDS that feature high impact graphics and easy-to-follow instructions, reflecting the international guidelines aimed at reducing the risk of transmission of HIV from mother to child.
The need for counseling job aids reflecting the updated international guidelines was first identified during the development of the a global compilation of programme evidence by URC/QAP in 2003 and formative research conducted in Tanzania. The materials were adapted from several generic counseling tools designed by WHO, UNICEF, and USAID. Funded by USAID and the President’s Emergency Plan for AIDS Relief (PEPFAR), development took place under QAP-supported operations research conducted in 2004 in close collaboration with the Univerity of Bergen, Norway and the Kilimanjaro Christian Medical Centre (KCMC) in Moshi District, Kilimanjaro. The Ministry of Health and the Tanzania Food and Nutrition Centre (TFNC) were major contributors, as were a number of other organizations and national stakeholders An interactive and systematic process was followed to allow both international experts and national stakeholders to review, critique, provide inputs and guide decisions at strategic points throughout the development phase. Stakeholder consensus was an important consideration in the final design of the job aids.
Healthcare workers throughout Tanzania are currently being trained to effectively use the tools to counsel prenatal and postpartum women to make informed decisions about their infant feeding options and to help women safely practice their chosen infant feeding method. The materials use compelling graphics and easy-to-follow text to facilitate their use and understanding of key messages. To create the imagery, QAP’s team used a state-of-the-art process that employs digital photography, imagery scanning, and computer design graphics.
The Ministry of Health of Tanzania is providing substantial direction in the training of nurse counselors and the disseminating of the job aids in multiple regions of the country through government facilities. Reflecting growing interest in the adapatation of these job aids for other settings, QAP has worked with national authorities in Uganda and Zimbabwe to adapt the job aids for use by both their National Programmes for the Prevention of Mother to Child Transmission (PMTCT) and Infant and Young Child Feeding (IYCF).
Published in English and Swahili, the integrated set of materials include:
- • Question and Answer Guide: HIV & Infant Feeding – Answers to questions commonly asked by mothers, their families and communities
- • Counseling/Take Home Brochures: Exclusive Breastfeeding, Infant Formula, Cow’s Milk, Expression and Heat Treatment, Nutrition, and Feeding a Baby
- • Counseling Cards: Relative Risk of Transmission (100 babies), Infant Feeding Options, AFASS, Positioning and Attachment, and Expression and Heat Treatment of Breast Milk
Although the materials were developed for use with women in antenatal care clinics and postpartum clinics, the tools are also being used with women in other settings, as well as with fathers, elders, youth, local leaders and others in the community.
