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Performance management

  • The Human Resources Collaborative:Improving Maternal and Child Care in Niger. Final Report. | Publications

    Amid a worldwide health workforce crisis, health providers carry a burdensome workload, are inadequately paid, and often work in environments that preclude quality care giving. They become disengaged while the demand for health services grows and investments in health workforce development are flat or declining. Niger is one of 36 countries in sub-Saharan Africa experiencing a human resources crisis. It has one doctor per 35,000 population and one nurse or midwife per 5000. An impoverished, desert country, it has high rates of maternal and child mortality: more than 600 maternal deaths per 100,000.

    The U.S. Agency for International Development (USAID) is funding programs to implement its strategy for mothers and newborns. The strategy calls for the implementation of high-impact, cost-effective interventions during the child-bearing and postnatal periods. Among those programs is the USAID Health Care Improvement Project (HCI), managed by University Research Co., LLC (URC), which provides technical leadership and assistance for improving health care delivery and health workforce management to USAID-assisted countries. In addition to its emphasis on improving maternal and newborn care, USAID, through its Office of HIV/AIDS (OHA), is also concerned with expanding the evidence base for effective approaches to fortify human resources for health.

    In 2009, Niger’s Ministry of Public Health and its regional health management office in Tahoua requested assistance from HCI to implement a programto address the health workforce crisis. With too few staff and no prospects for additional staff, the Ministry sought to improve the management of human resources in selected facilities and management offices in Tahoua Region. The predecessor project to HCI had successfully implemented quality improvement (QI) interventions in the same region. The new project would build on that experience and the country’s National Health Development Plan, which targets maternal/child health and human resources.  

    Intervention:HCI proposed applying the collaborative improvement approach to improve human resources management in Tahoua. HCI had adapted for use in developing countries the collaborative improvement approach successfully implemented in the U.S., Europe, and Canada. The approach features QI teams that work at their own facilities with QI experts from HCI and the national health ministry. The teams work with the experts to learn the evidence-based interventions that will improve health outcomes. For the HR collaborative, in addition to the facility/clinical teams, teams also formed comprising managers. These management teams supported the facility teams by strengthening supervision and management. What distinguished the Niger HR collaborative from others HCI had helped implement was that no clinical interventions were proposed, only HR interventions.

    The Niger Human Resources (HR) Collaborative began with a baseline assessment in May 2009 and ended with an endline assessment in December 2011.  To guide improvement work in human resources management, HCI supported teams to work through the steps of the Human Resources Performance Cycle. Teams began with having each staff person develop a job description with his/her supervisor and continue with articulating tasks, determining training needs, performance evaluation, etc. Participating facilities moved through these steps, monitoring and reporting their success in achieving them, with many nearly completing the cycle.

    Throughout this process, health worker teams and their supervisors worked to implement the performance cycle within the context of the clinical areas they had selected. Job descriptions were developed as they relate to the maternity goals, feedback was provided within the context of the performance in question, and data was collected monthly on how well they were doing against the clinical indicators on which they focused. Health workers and their supervisors collected the indicator data, and managers reviewed and spot-checked those data. Embedding such data collection – and its related analysis and dissemination – in quality improvement processes is a key feature of HCI’s work, and it enabled the collaborative not only to adapt care processes at the point of delivery but also to show whether its impact was favorable and/or widespread.

    Results: The clinical results proved exciting and compelling: All major indicators showed clear improvement, and in each case, a distinct shift occurred during the early to mid-point of implementation, signifying that the improvement was statistically significant, not accidental. Deliveries by qualified health workers rose from 27% to 45% and contraceptive prevalence from 9.6% to 36%; post-partum hemorrhage fell from 2% to 0.06%, and mortality in children under five from severe malaria dropped from 15% to 4% at the pediatrics hospital. To achieve these results, the teams made major changes in how health workers managed themselves and were supervised: They instituted feedback mechanisms, developed checklists to analyze skill gaps based on redesigned tasks and jobs, shared results with clients and other teams, and became engaged with the results. Managers improved supervision practices and began developing performance checklists, observing health workers, and reviewing results.

    Conclusions and Recommendations: Overall both health workers and managers felt very positive about the human resources improvement work and that it had a positive impact on both working conditions and performance. Health workers felt that aligning their work with the Ministry’s objectives was essential. Moustapha Boukary, Head of Tsernaoua Health Post, commented, ‘’Before the HR Collaborative, we worked in unclear and cloudy conditions, but when we started aligning goals and objectives, we saw a clear direction.”

    This innovative approach offers countries a new way to address the many challenges they face in the health and HR sectors. The above-cited clinical results are unquestionable and promising for a much larger scale. The success of the Performance Cycle process – and the combination of HR management and QI – should be refined, adapted, and improved, so that HR professionals are not left to struggle with too few health workers, and health workers are not left without the HR processes common in developing countries. 

    The change package is documented and sufficiently flexible to be used in other regions in Niger and beyond. To implement this process again, either in Niger or elsewhere, the authors recommend that:
    1. A management change package should be developed that could be tested at the same time as the facility-level package. A change package similar to that implemented in Tahoua could be developed for implementation in the Ministry departments and regional management offices.
    2. Management and facility levels should work together on HR issues. Facility teams should test changes for their level, and management should scale solutions and revise policy. 
    3. Temporal relationships should be examined: What must be done stepwise and what can be done at once. 
    4. Some Performance Cycle sub-steps can be implemented by sites alone.
    In summary, the approach of focusing on improving the performance of health workers by better managing the elements of their performance and helping them manage themselves can improve any program and should be a part of any clinical intervention. The process and change package could be simplified and adapted for different contexts. Niger’s experience of having health workers become invested in outcomes, communities more aware of available services, and the process of work improved to better serve women and children should be replicated elsewhere.
  • Uganda | Application of quality improvement and performance management approaches to improve pharmaceutical process | Collaborative Profile
  • A Global Improvement Framework for Health Worker In-service Training: Guidance for Improved Effectiveness, Efficiency and Sustainability | Publications

    This short report describes how the USAID Health Care Improvement Project (HCI) is developing an improvement framework for in-service training programs in collaboration with key stakeholders. In-service training (IST) represents a significant proportion of investments made by Ministries of Health and development partners in building the capacity of health workers to competently, safely and efficiently provide quality health services.

  • Strengthening the Health Workforce in Tanzania | Publications

    Since 2008, the USAID Health Care Improvement Project (HCI) has supported the Ministry of Health and Social Welfare (MOHSW) and implementing partners in Tanzania to apply modern quality improvement (QI) methods to build the capacity of regional and district health management teams and providers to deliver high quality antiretroviral therapy (ART) and prevention of mother-to-child transmission (PMTCT) services in several mainland regions, including Mtwara. This short report describes the progress of interventions HCI is implementing together with the Tandahimba Council Health Management Team (CTMT) to improve health workforce performance management, employee engagement and clinical outcomes in Tandahimba.  

  • Improving CHW Program Functionality, Performance, and Engagement: Operations Research Results from Zambia | Publications


    The United Nations Millennium Project identified the large-scale training and deployment of community health workers (CHWs) as an important strategy to fill the human resources gap and achieve the Millennium Development Goals (MDGs). However, CHW programs are known to be fraught with significant human resources challenges. The USAID Health Care Improvement Project (HCI) developed the Community Health Worker Assessment and Improvement Matrix (CHW AIM) to help assess CHW program functionality and to provide benchmarks against which to measure program improvements. 
    Zambia’s large number and wide range of CHWs and the government’s openness to CHWs and recognition of their value made it an ideal country in which to conduct this operations research study to test whether the application of the CHW AIM tool contributes to CHW program functionality improvement. The CHW AIM operations research study was designed as a field intervention that applied the CHW AIM process twice over 13 months. It included a sample of six organizations (five intervention sites and one control site) and 156 CHWs. The CHW AIM process was applied at five organizations; engagement was assessed at all sites through an engagement survey, which was complemented with an in-depth engagement interview; CHW performance (task completion) in two HIV/AIDS service delivery areas that CHWs commonly provide, positive living and ART adherence counseling, was also assessed at all sites through analysis of service delivery audio recordings.  Data were collected between October 2010 and November 2011.
    The results indicate that the CHW AIM process contributed to program functionality improvement, but that improvement was neither linear nor consistent. Only two organizations improved their total program functionality scores, but every organization made gains in at least two program functionality elements that were direct results of plans made in response to findings of the first CHW AIM workshop. Important and positive changes were made in almost all of the CHW AIM elements.
    CHWs demonstrated “low performance” (<39%) in four of six sites at baseline and moderate performance (40-69%) in only two sites.  At endline, CHWs demonstrated moderate performance in four sites, for CHWs with matching baseline and endline data. There is a positive correlation between CHW AIM scores and performance, but a number of other factors also correlated positively with performance. These other factors included the time CHWs spent with clients (based on recording times), days of initial training (from CHW interviews), months worked as a CHW (from CHW interviews), average hours worked (as reported in CHW interviews), the type of incentive the CHW was provided (in-kind or cash), the value of CHW incentives, and three of the 15 CHW AIM elements.
    Organizations felt the CHW AIM process was useful and helped them take stock of their program and develop constructive actions to address issues. While measures of improvement captured through this study are inconclusive, the stories of improvement that come out of this study suggest that the tool can catalyze improvement.  It is worth noting that organizational investments in CHW programs varied greatly among sites that participated in the study. The CHW AIM process is fairly inexpensive to implement and should be feasible for most organizations to fund if it is incorporated in project plans and budgets.


  • Role Development of Community Health Workers | Community Resource

    This study reviews research on CHW programs and concludes there is an inconsistent reporting of selection and training processes for CHWs in the existing literature. It presents a conceptual model  for the role development of CHWs to guide future reporting of CHW programs in the intervention literature. 

  • Multidisciplinary Care Teams: Report of an IAPAC Consultation in Addis Ababa, Ethiopia | Community Resource

    A multidisciplinary care team can be defined as a partnership among health care workers of different disciplines inside and outside the health sector and the community with the goal of providing quality continuous, comprehensive and efficient health services. This report explores the potential of introducing multidisciplinary care teams into sub-Saharan health care settings in an effort to scale up access to antiretroviral therapy and to achieve efficiencies in the use of existing financial and human resources for health.

  • Effect of Implementation of Integrated Management of Neonatal and Childhood Illness (IMNCI) Programme on Neonatal and Infant Mortality: cluster randomised controlled trial | Community Resource

    This cluster randomized controlled trial assesses the effectiveness of the Integrated Management of Neonatal Childhood Illness (IMNCI) strategy in Haryana, India. The IMNCI model utilizes CHWs in the treatment of sick newborns and children and also incorporates home visits for early newborn care. The study concludes that the implementation of the IMNCI resulted in substantial improvement in infant survival and in neonatal survival in those born at home. The authors conclude the IMNCI should be a part of India's strategy to achieve the MDG on child survival. 

  • Tanzania Human Resources for Health Collaborative | Collaborative Profile
  • Community-Driven Tools for Data Collection and Decision Making: The PISA Action Guide | Community Resource

    The PARTICIPATORY INFORMATION SYSTEMS APPRAISAL (PISA) Action Guide systematically introduces and explains the concepts and strategies needed to make well informed, data-based decisions while empowering key stakeholders in the process. The action guide outlines team preparation activities, data collection methods, data analysis and action planning, and team learning & follow up activities. Local facilitators and key project stakeholders are actively involved in data instrument design, collection, reporting and analysis.

  • How to Mobilize Communities for Health and Social Change | Community Resource

    This field guide is designed for health program directors and managers of community-based programs who are considering using community mobilization to improve health at the individual, family, and community level. The field guide contains illustrative examples and lessons learned in community mobilization experiences from around the world, focusing on working with disadvantaged or marginalized groups in developing countries.

  • CHW Program Functionality Improvement, Performance and Engagement: Operations Research Results from Zambia | Publications

    The United Nations Millennium Project identified the large-scale training and deployment of community health workers (CHWs) as an important strategy for achieving the Millennium Development Goals (MDGs). However, programs involving CHWs are also known to be fraught with significant human resources challenges. The USAID Health Care Improvement Project (HCI) developed the Community Health Worker Assessment and Improvement Matrix (CHW AIM) to help assess CHW program functionality and to provide benchmarks against which to measure program improvements. 

    Zambia’s large number and wide range of CHWs and the government’s openness to CHWs and recognition of their value made Zambia an ideal country in which to conduct CHW AIM operations research. This research focused on CHWs supported by five different implementing partners in Zambia categorized as “community health volunteers” by the Zambian National CHW Strategy.
    This study focused on three research questions:
    1. 1) Does application of the CHW AIM tool contribute to CHW program functionality improvement?
    2. 2) What is the relationship among program functionality, CHW engagement and CHW performance?
    3. 3) What are the costs associated with implementing the CHW tool and what is the incremental cost effectiveness associated with its use?
    This study was designed as a field intervention study. The CHW AIM process twice was applied at the beginning and end of a thirteen month intervention period. The sample included six organizations, five of which applied the CHW AIM process, and 157 CHWs. Researchers collected data using an engagement survey complemented by in-depth interviews and other instruments to collect a variety of qualitative and quantitative data. Service delivery was assessed through audio recordings and the study team collected additional data on program design, results, and costs.


  • Rural Primary Health Care in Iran | Community Resource

    The South African Academy of Family Practice's Rural Health Initiative journal details their delegation's visit and observation of the rural primary health care network in Iran. They examined in particular the roles of different workers in the Iranian system and the health houses that are staffed by CHWs, known locally as, Behvarz. The health houses are responsible for: maternal and child health, TB, Malaria, mental health, chronic illnesses, symptomatic treatment, environmental health and occupational health.

  • Improving Programs through Training | Community Resource

    The Program Management Guide is a "how-to" guide created by Partners in Health. This unit outlines how PIH provides training for three broad groups who serve and are served by our healthcare programs: 1) community health workers, 2) clinicians, and 3) patients and the community . Specific guidelines—relevant to all three of these groups—are offered for developing healthcare-focused training programs in a resource-poor setting. 

  • Knowledge and communication needs assessment of community health workers in a developing country: a qualitative study | Community Resource

    This study documents the perceptions of CHWs on their knowledge and communication needs, image building through mass media and mechanisms for continued education. Focus group discussions were held with health workers and their supervisors in all four provinces in Pakistan. About four fifths of the respondents described their communication skills as moderately sufficient and wanted improvement. Knowledge on emerging health issues was insufficient and the respondents showed willingness to participate in their continued education.


  • Improving Pharmaceutical Service in the Primary Healthcare Sector Through the Training of Pharmacist Assistants | Improvement Report
  • Strengthening of Family Planning Service Delivery through 18 Urban Health Centers (UHCs) in 2 districts of Uttarakhand | Improvement Report
  • Championing Performance Standards to Increase Family Planning Use by Women after Postabortion Care at a Guinea Clinic | Improvement Report
  • Promising Practices in Supply Chain Management for Community-Based Distribution Programs: Global Survey of CBD Programs | Community Resource

    This global survey documents the preliminary research and findings that the JSI team compiled to inform the final project document, Supply Chain Models and Considerations for Community‐Based Distribution Programs: A Program Manager’s Guide. It can be used as a reference to any person or organization interested in CBD programs.

  • Assessment of the Human Resources System in Niger | 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.