Improve Health Worker Performance Research Articles

The integrated management of childhood illness (IMCI) and its potential to reduce the misuse of antibiotics.

BackgroundThe Strategy of the Integrated Management of Childhood Illness (IMCI) was introduced in Central Asia and Europe to address the absence of evidence-based guidelines, the misuse of antibiotics, polypharmacy and over-hospitalization of children. A study carried out in 16 countries analysed the status and strengths of as well as the barriers to IMCI implementation and investigated how different health systems affect the problems IMCI aims to address. Here we present findings in relation to IMCI’s effects on the rational use of drugs, particularly the improved rational use of antibiotics in children, the mechanisms through which these were achieved as well as counteracting system factors.Methods220 key informants were interviewed ranging from 5 to 37 per country (median 12). Data was analysed for arising themes and peer-reviewed.ResultsThe implementation of IMCI led to improved prescribing patterns immediately after training of health workers according to key informants. IMCI provides standard treatment guidelines and an algorithmic diagnostic- and treatment-decision-tool for consistent decision-making. Doctors reported feeling empowered by the training to counsel parents and address their expectations and desire for invasive treatments and the use of multiple drugs. Improved prescribing patterns were not sustained over time but counteracted by factors such as: doctors prescribing antibiotics to create additional revenues or other benefits; aggressive marketing by pharmaceutical companies; parents pressuring doctors to prescribe antibiotics; and access to drugs without prescriptions.ConclusionsFuture efforts to improve child health outcomes must include: (1) the continued support to improve health worker performance to enable them to adhere to evidence-based treatment guidelines, (2) patient and parent education, (3) improved reimbursement schemes and prescription regulations and their consistent enforcement and (4) the integration of point–of-care tests differentiating between viral and bacterial infection into standards of care. Pre-requisites will be sufficient remuneration of health workers, sound training, improved health literacy among parents, conducive laws and regulations and reimbursement systems with adequate checks and balances to ensure the best possible care.

A collaborative learning approach to improving health worker performance in adolescent sexual and reproductive health service provision: a descriptive feasibility study in six health zones in the Democratic Republic of the Congo

ABSTRACT Poor performance among health service providers is a key barrier to high quality, adolescent-responsive health services. Collaborative learning has been shown to strengthen health service provider performance, but few studies have examined its implementation in adolescent health services. In this paper, we describe a collaborative learning approach for adolescent health service providers implemented as part of a project aiming to prevent HIV in adolescent girls and young women in the Democratic Republic of the Congo (DRC) and explore its feasibility, acceptability, benefits and challenges. To do so, we reviewed plans, budgets and progress reports, as well as nested implementation research related to the project. We also carried out a quantitative analysis of the number, location, participants and topics of collaborative learning sessions conducted as part of this initiative, and thematic analysis to synthesise findings on perceived benefits and challenges. Under the project, 32 collaborative learning sessions of approximately two-hour duration were held with up to 15 participants, most of whom were nurses, between June 2018 and May 2019. The project cost was approximately USD 135,000 over three years. Reported benefits included improving health service provider attitudes, knowledge and skills; ensuring delivery of non-judgemental, empathic and confidential health services; and improving communication and collaboration between health services and adolescents together with their parents. While the novelty of the approach in this context presented challenges, our results suggest that collaborative learning in adolescent health services is feasible, acceptable, and inexpensive. It may help strengthen the knowledge and skills of health service providers, build positive attitudes and motivation, and improve their performance and thereby the adolescent-responsiveness of health services. Further research is needed to confirm these results in other settings and to examine the impact of collaborative learning on the acceptability and uptake of health services.

Effective strategies to improve health worker performance in delivering adolescent-friendly sexual and reproductive health services.

Despite recognition of the important role of health workers in providing adolescent-friendly sexual and reproductive health services (AFSRHS), evidence on strategies for improving performance is limited. This review sought to address: (1) which interventions are used to improve health worker performance in delivering AFSRHS? and (2) how effective are these interventions in improving AFSRHS health worker performance and client outcomes? Building on a 2015 review, a search for literature on 18 previously identified programs was conducted to identify updated literature and data relevant to this review. Data was systematically extracted and analyzed. Due to the parent review's eligibility criteria, all programs included health worker training. Otherwise, supervision was the most frequently reported intervention used (n=10). Components and methods related to quality of trainings and supervision varied considerably in program reports. Nearly half of programs described employing processes to ensure availability of basic medicines and supplies (n=7). Other interventions (policies, standards, and job descriptions [n=5]; refresher trainings [n=5]; job aids or other reference material [n=3]) were less commonly reported to have been employed. No discernible patterns emerged in the relationship between interventions and outcomes of interest. Multi-faceted complementary strategies are recommended to improve health worker performance to deliver AFSRHS; however, this was uncommonly reported in the programs that we reviewed. Effectiveness and cost-effectiveness evaluations of interventions and intervention packages are needed to guide efficient use of limited resources to enhance health worker capacity to deliver AFSRHS. In the interim, programs should be developed and implemented based on available existing evidence on improving health worker performance within and outside adolescent health. This review is the first to examine the interventions commonly used to improve health worker performance in delivering AFSRHS. The findings indicate a need for additional effectiveness and cost-effectiveness evaluations of such interventions. In the meantime, existing evidence on improving health worker performance within and outside adolescent health must be integrated more thoughtfully into program planning and implementation.

The Integrated Management of Childhood Illness (IMCI) – Beyond Mortality Reduction IMCI and Its Potential to Reduce the Misuse of Antibiotics

The Integrated Management of Childhood Illness (IMCI) was introduced in Central Asia and Europe to address the absence of evidence-based guidelines, antibiotics misuse, polypharmacy and over-hospitalization. The study carried out in 16 countries analysed status, strengths of and barriers to IMCI implementation and investigated how health systems affect the problems IMCI aims to address. Here we present findings in relation to implications on the rational use of drugs, particularly the improved rational use of antibiotics for children, the mechanisms through which these were achieved as well as counteracting system factors. Methods: 220 key informants were interviewed ranging from 5 to 37 per country (median 12). Data was analysed for arising themes and peer-reviewed. Findings: The use of IMCI as an algorithmic diagnostic- and treatment-decision-tool led to better prescribing patterns immediately after training according to key informants by - Providing a standard treatment guideline and job-aid for consistent decision-making - Counselling training for addressing parents´ expectations and desires for invasive treatments and use of multiple drugs Improved prescribing patterns were not sustained over time but counteracted by factors such as - Doctors prescribing antibiotics to create additional revenues or other benefits - Aggressive marketing by pharmaceutical companies - Parents pressuring doctors to prescribe antibiotics - Access to drugs without prescriptions. Interpretation: The revised IMCI strategy must include -Continued support to improve health worker performance enabling them to adhere to evidence-based treatment guidelines -Patient and parent education -Improved regulations and their consistent enforcement -The integration of point–of-care tests differentiating between viral and bacterial infection into the IMCI algorithm. Pre-requisites will be sufficient remuneration, sound training, improved health literacy among parents, conducive laws and regulations and reimbursement systems with adequate checks and balances to ensure the best possible care. Funding Statement: This work was commissioned by the WHO Regional office for Europe and funded by the Bill and Melinda Gates Foundation. Declaration of Interests: Most of the authors are or were WHO staff members and at some stage involved in the implementation of IMCI. No other competing interests declared. Ethics Approval Statement: This study was deemed exempt from ethical review by the WHO Ethics Review Committee (ERC.0002743003540/13).

Building Resilient Health Systems: Experimental Evidence from Sierra Leone and the 2014 Ebola Outbreak

Developing countries are characterized by high rates of mortality and morbidity. A potential contributing factor is the low utilization of health systems, stemming from the low perceived quality of care delivered by health personnel. This factor may be especially critical during crises, when individuals choose whether to cooperate with response efforts and frontline health personnel. We experimentally examine efforts aimed at improving health worker performance in the context of the 2014–15 West African Ebola crisis. Roughly two years before the outbreak in Sierra Leone, we randomly assigned two accountability interventions to government-run health clinics — one focused on community monitoring and the other gave status awards to clinic staff. We find that over the medium run, prior to the Ebola crisis, both interventions led to improvements in utilization of clinics and patient satisfaction with the health system. In addition, child health outcomes improved substantially in the catchment areas of community monitoring clinics. During the crisis, the interventions also led to higher reported Ebola cases, as well as lower mortality from Ebola — particularly in areas with community monitoring clinics. We explore three potential mechanisms: the interventions (1) increased the likelihood that patients reported Ebola symptoms and sought care; (2) unintentionally increased Ebola incidence; or (3) improved surveillance efforts. We find evidence consistent with the first: by building trust and confidence in health workers, and improving the perceived quality of care provided by clinics prior to the outbreak, the interventions encouraged patients to report and receive treatment. Our results suggest that accountability interventions not only have the power to improve health systems during normal times, but can additionally make health systems resilient to crises that may emerge over the longer run.

The feasibility and acceptability of collaborative learning in improving health worker performance on adolescent health: findings from implementation research in Moldova

BackgroundCollaborative learning has been shown to be effective in improving health worker performance, but relatively little is known about the feasibility or acceptability of collaborative learning in youth-friendly health services (YFHS). This paper describes the characteristics, feasibility and acceptability of a collaborative learning approach implemented in YFHS in Moldova as part of a national scaling up process.MethodsWe gathered and analysed data on the number, location, themes, and participants of sessions, as well as benefits and challenges of collaborative learning, using two information sources: 1) formal reports on collaborative learning sessions, and 2) two questionnaires conducted with participants and moderators.ResultsCollaborative learning sessions have been implemented in 30 out of 35 YFHS in Moldova. In 2016, 464 collaborative learning sessions were conducted. Sessions were conducted one to three times per month, had a mean of 15 participants and an average duration of two - three hours. 74.3% of participants (n = 6942) were from rural areas and 55.1% were health professionals. The most common topics in 2016 were adolescent health and YFHS (159 of 464 sessions), sexual and reproductive health (103 sessions), and violence (76 sessions).Reported benefits for participants of collaborative learning fell into three categories: 1) improved knowledge on adolescent health / development and use of evidence-based resources; 2) strengthened teamwork and cooperation; and 3) empowerment to provide high quality, youth-friendly care. Moderators identified benefits for the quality, youth-friendliness, and positioning of YFHS as centres of excellence on adolescent health. Challenges included the time and resources required to start and maintain the program, developing a constructive multi-disciplinary learning culture, and ensuring the involvement of stakeholders from outside YFHS.ConclusionThis study confirms that collaborative learning within YFHS is feasible and acceptable, and offers benefits to both participants and YFHS. Collaborative learning may be a valuable strategy to improve the quality and youth-friendliness of services. It may also be relevant to key challenges in scaling up YFHS such as increasing utilisation and achieving long-term sustainability. Further research is required to confirm our results in other settings and to examine the effects of collaborative learning at the outcome and impact level.

Maternal contributors to intergenerational nutrition, health, and well-being: revisiting the Tanjungsari Cohort Study for effective policy and action in Indonesia.

Perinatal and maternal mortalities in Java became of concern in the 1980s. Since some 90% of births took place at home, the Tanjungsari (TS) district of West Java was identfied as a locality where community-based risk management strategy might reduce this health burden. In 1987, traditional birth attendants (TBA) were trained to identify risk factors for unfavourable birth outcomes. From January 1st 1988 to December 1989, some 4,000 pregnant women in TS were followed and assigned either a trained or untrained TBA. In the first year, early neonatal, and maternal mortality rates (MMR) (32.9 per 1000 and 170 per 100,000 deliveries respectively) were reduced, but not sustained in the second year. Nationally, MMR was 446 in 2009 and 126 in 2015. Although possible to improve health worker performance, and community engagement, the most likely explanation for benefit attrition is that people and material resources 'downstream' of the TBA services were inadequate. Three decades later, Indonesian neonatal and maternal mortality rates of 14 per 1000 and 126 per 100,000 live births in 2015 (globally 16.2 in 2009 and 216 in 2015) according to UNICEF, still demanded improvement, despite more hospital-based births. The original 1988 cohort of women, their children and grandchildren, can now be interrogated for medium to long term health outcomes of nutritional, such as birth weight and growth, and other risk factors. The evolving TS cohort health and nutrition intermediates and endpoints are instructive. Maternal and early life factors predict adult energy metabolism and cognitive function.

Implementation research to assess a health workers performance-based management system in Nepal.

To test and refine a performance-based management system to improve health worker performance in Nepal. A mixed-methods implementation research in three districts. The study assessed health workers' job satisfaction at the start and end of the study. Qualitative techniques were used to document processes, and routine health service data were analysed to measure outcomes. Job satisfaction significantly increased in six of nine key areas, and the proportion of staff absenteeism significantly declined in the study districts. It demonstrated an increase in immunisation coverage, the proportion of women who had a first antenatal check-up also having a fourth check-up and the proportion of childbirth in a health facility. The greatest perceived strengths of the system were its robust approach to performance planning and evaluation, supportive supervision, outcome-based job descriptions and a transparent reward system. A functional health facility environment, leadership and community engagement support successful implementation. The performance-based management system has the potential to increase health workers' job satisfaction, and it offers a tool to link facility-wide human resource management. A collaborative approach, ownership and commitment of the health system are critical to success. Considering the Nepal context, a management system that demonstrates a positive improvement has potential for improved health care delivery.

Improving health worker performance through text messaging: A mixed-methods evaluation of a pilot intervention designed to increase coverage of intermittent preventive treatment of malaria in pregnancy in West Nile, Uganda.

Poor health worker performance is a well-documented obstacle to quality service provision. Due to the increasingly widespread availability of mobile devices, mobile health (mHealth) has received growing attention as a service improvement tool. This pilot study explored feasibility, acceptability and outcomes of an mHealth intervention designed to increase coverage of intermittent preventive treatment of malaria in pregnancy (IPTp) in two districts of West Nile, Uganda. In both districts, selected health workers (N = 48) received classroom training on malaria in pregnancy. All health workers in one district (N = 49) subsequently received 24 text messages reinforcing the training content. The intervention was evaluated using a mixed-methods approach, including four focus group discussions with health workers and three in-depth interviews with district health officials, health worker knowledge assessments one month (N = 90) and six months (N = 89) after the classroom training, and calculation of IPTp coverage from participating health facilities’ (N = 16) antenatal care registers covering six months pre- and post-intervention. Complementing classroom training with text messaging was found to be a feasible, acceptable and inexpensive approach to improving health worker performance. The messages served as reminders to those who had attended the classroom training and helped spread information to those who had not. Health workers in the district where text messages were sent had significantly better knowledge of IPTp, achieving an increased composite knowledge score of 6.00 points (maximum score: 40) compared with those in the district where only classroom training was provided. Average facility coverage of three doses of IPTp was also significantly higher where text messages were sent (85.8%) compared with the district where only classroom training was provided (54.1%). This intervention shows promise for the improvement of health worker performance for delivery of IPTp, and could have significant broader application.

Giving and promising gifts: Experimental evidence on reciprocity from the field

We test the value of unconditional non-monetary gifts as a way to improve health worker performance in a low income country health setting. We randomly assigned health workers to different gift treatments within a program that visited health workers, measured performance and encouraged them to provide high quality care for their patients. We show that unconditional non-monetary gifts improve performance by 20 percent over a six-week period, compared to the control group. We compare the impact of the unconditional gift to one in which a gift is offered conditional on meeting a performance target and show that only the unconditional gift results in a statistically significant improvement. This demonstrates that organizations can improve the performance of health workers in the medium term without using financial incentives.

Improving health worker performance of abortion services: an assessment of post-training support to providers in India, Nepal and Nigeria

BackgroundHealth worker performance has been the focus of numerous interventions and evaluation studies in low- and middle-income countries. Few have examined changes in individual provider performance with an intervention encompassing post-training support contacts to improve their clinical practice and resolve programmatic problems. This paper reports the results of an intervention with 3471 abortion providers in India, Nepal and Nigeria.MethodsFollowing abortion care training, providers received in-person visits and virtual contacts by a clinical and programmatic support team for a 12-month period, designed to address their individual practice issues. The intervention also included technical assistance to and upgrades in facilities where the providers worked. Quantitative measures to assess provider performance were established, including: 1) Increase in service provision; 2) Consistent service provision; 3) Provision of high quality of care through use of World Health Organization-recommended uterine evacuation technologies, management of pain and provision of post-abortion contraception; and 4) Post-abortion contraception method mix. Descriptive univariate analysis was conducted, followed by examination of the bivariate relationships between all independent variables and the four dependent performance outcome variables by calculating unadjusted odds ratios, by country and overall. Finally, multivariate logistic regression was performed for each outcome.ResultsProviders received an average of 5.7 contacts. Sixty-two percent and 46% of providers met measures for consistent service provision and quality of care, respectively. Fewer providers achieved an increased number of services (24%). Forty-six percent provided an appropriate postabortion contraceptive mix to clients. Most providers met the quality components for use of WHO-recommended abortion methods and provision of pain management. Factors significantly associated with achievement of all measures were providers working in sites offering community outreach and those trained in intervention year two. The number of in-person contacts was significantly associated with achievement of three of four measures.ConclusionPost-training support holds promise for strengthening health worker performance. Further research is needed to compare this intervention with other approaches and assess how post-training contacts could be incorporated into current health system supervision.

A cascade model of mentorship for frontline health workers in rural health facilities in Eastern Uganda: processes, achievements and lessons

ABSTRACTBackground: There is increasing demand for trainers to shift from traditional didactic training to innovative approaches that are more results-oriented. Mentorship is one such approach that could bridge the clinical knowledge gap among health workers.Objectives: This paper describes the experiences of an attempt to improve health-worker performance in maternal and newborn health in three rural districts through a mentoring process using the cascade model. The paper further highlights achievements and lessons learnt during implementation of the cascade model.Methods: The cascade model started with initial training of health workers from three districts of Pallisa, Kibuku and Kamuli from where potential local mentors were selected for further training and mentorship by central mentors. These local mentors then went on to conduct mentorship visits supported by the external mentors. The mentorship process concentrated on partograph use, newborn resuscitation, prevention and management of Post-Partum Haemorrhage (PPH), including active management of third stage of labour, preeclampsia management and management of the sick newborn. Data for this paper was obtained from key informant interviews with district-level managers and local mentors.Results: Mentorship improved several aspects of health-care delivery, ranging from improved competencies and responsiveness to emergencies and health-worker professionalism. In addition, due to better district leadership for Maternal and Newborn Health (MNH), there were improved supplies/medicine availability, team work and innovative local problem-solving approaches. Health workers were ultimately empowered to perform better.Conclusions: The study demonstrated that it is possible to improve the competencies of frontline health workers through performance enhancement for MNH services using locally built capacity in clinical mentorship for Emergency Obstetric and Newborn Care (EmONC). The cascade mentoring process needed strong external mentorship support at the start to ensure improved capacity among local mentors to provide mentorship among local district staff.

Impact of Contextual Factors on the Effect of Interventions to Improve Health Worker Performance in Sub-Saharan Africa: Review of Randomised Clinical Trials.

BackgroundAfrica bears 24% of the global burden of disease but has only 3% of the world’s health workers. Substantial variation in health worker performance adds to the negative impact of this significant shortfall. We therefore sought to identify interventions implemented in sub-Saharan African aiming to improve health worker performance and the contextual factors likely to influence local effectiveness.Methods and FindingsA systematic search for randomised controlled trials of interventions to improve health worker performance undertaken in sub-Saharan Africa identified 41 eligible trials. Data were extracted to define the interventions’ components, calculate the absolute improvement in performance achieved, and document the likelihood of bias. Within-study variability in effect was extracted where reported. Statements about contextual factors likely to have modified effect were subjected to thematic analysis. Interventions to improve health worker performance can be very effective. Two of the three trials assessing mortality impact showed significant reductions in death rates (age<5 case fatality 5% versus 10%, p<0.01; maternal in-hospital mortality 6.8/1000 versus 10.3/1000; p<0.05). Eight of twelve trials focusing on prescribing had a statistically significant positive effect, achieving an absolute improvement varying from 9% to 48%. However, reported range of improvement between centres within trials varied substantially, in many cases exceeding the mean effect. Nine contextual themes were identified as modifiers of intervention effect across studies; most frequently cited were supply-line failures, inadequate supervision or management, and failure to follow-up training interventions with ongoing support, in addition to staff turnover.ConclusionsInterventions to improve performance of existing staff and service quality have the potential to improve patient care in underserved settings. But in order to implement interventions effectively, policy makers need to understand and address the contextual factors which can contribute to differences in local effect. Researchers therefore must recognise the importance of reporting how context may modify effect size.

Improving health worker performance: The patient-perspective from a PBF program in Rwanda

The effect of performance-based financing (PBF) on patients' perception of primary health care services in developing countries in not well documented. Data from a randomized impact evaluation in Rwanda conducted between 2006 and 2008 in 157 primary level facilities is used to explore patients' satisfaction with clinical and non-clinical services and quantify the contribution of individual and facility characteristics to satisfaction including PBF. Improvements in productivity, availability and competences of the health workforce following the implementation of PBF have a positive effect on patients' satisfaction with clinical services even if patients' satisfaction is not tied to a reward. The positive effect of PBF on non-clinical dimensions of satisfaction also suggests that PBF incentivizes providers to raise patients' satisfaction with non-clinical services if it is associated with future financial gains. It is recommended that low and middle income countries build on the experience from high income countries to better listen to patients' voice in general and include an assessment of patients' satisfaction in incentive mechanisms as a way to increase the benefits of the strategy.

Health worker factors associated with prescribing of artemisinin combination therapy for uncomplicated malaria in rural Tanzania

BackgroundImproving malaria case management is partially dependent on health worker compliance with clinical guidelines. This study assessed health worker factors associated with correct anti-malarial prescribing practices at two sites in rural Tanzania.MethodsRepeated cross-sectional health facility surveys were conducted during high and low malaria transmission seasons in 2010 and collected information on patient consultations and health worker characteristics. Using logistic regression, the study assessed health worker factors associated with correct prescription for uncomplicated malaria defined as prescription of artemisinin-based combination therapy (ACT) for patients with fever and Plasmodium falciparum asexual infection based on blood slide or malaria rapid diagnostic test (RDT) according to national treatment guidelines.ResultsThe analysis included 685 patients with uncomplicated malaria who were seen in a health facility with ACT in stock, and 71 health workers practicing in 30 health facilities. Overall, 58% of malaria patients were correctly treated with ACT. Health workers with three or more years’ work experience were significantly more likely than others to prescribe correctly (adjusted odds ratio (aOR) 2.9; 95% confidence interval (CI) 1.2-7.1; p = 0.019). Clinical officers (aOR 2.2; 95% CI 1.1-4.5; p = 0.037), and nurse aide or lower cadre (aOR 3.1; 95% CI 1.3-7.1; p = 0.009) were more likely to correctly prescribe ACT than medical officers. Training on ACT use, supervision visits, and availability of job aids were not significantly associated with correct prescription.ConclusionsYears of working experience and health worker cadre were associated with correct ACT prescription for uncomplicated malaria. Targeted interventions to improve health worker performance are needed to improve overall malaria case management.

The effect of performance indicator category on estimates of intervention effectiveness

A challenge for systematic reviews on improving health worker performance is that included studies often use different performance indicators, and the validity of comparing interventions with different indicators is unclear. One potential solution is to adjust comparisons by indicator category, with categories based on steps of the case-management process that can be easily recognized (assessment of symptoms, treatment etc.) and that might require different levels of effort to bring about improvements. However, this approach would only be useful if intervention effect sizes varied by indicator category. To explore this approach, studies were analyzed that evaluated the Integrated Management of Childhood Illness (IMCI) strategy. Performance indicators were grouped into four categories: patient assessment, diagnosis, treatment and counseling. An effect size of IMCI was calculated for each indicator. Linear regression modeling was used to test for differences among the mean effect sizes of the indicator categories. Six studies were included, with data from 3136 ill child consultations. Mean effect sizes for 63 assessment indicators, 12 diagnosis indicators, 31 treatment indicators and 34 counseling indicators were 50.9 percentage-points (%-points), 44.7, 36.5 and 46.6%-points, respectively. After adjusting for baseline indicator value, compared with the assessment mean effect size, the diagnosis mean was 7.3%-points lower (P = 0.23), the treatment mean was 15.2%-points lower (P = 0.0004) and the counseling mean was 12.9%-points lower (P = 0.0027). Adjusting the results of systematic reviews for indicator category and baseline indicator value might be useful for improving the validity of intervention comparisons.

Supportive supervision: An effective intervention in achieving high quality malaria case management at primary health care level in Jos, Nigeria

Supportive supervision is a form of supervision that promotes quality at all levels of health system by strengthening relationships within the system through prompt identification and resolution of problems among others. It is an effective intervention in improving health worker performance in low resource settings. Malaria is responsible for majority of outpatient consultations in Nigeria at all levels of care. This was a facility-based interventional study with pre and post-intervention phases conducted among two groups.The study subjects were selected through a multistage sampling technique and data collection was done using both semistructured interviewer administered questionnaire and supervisory checklist. The mean knowledge scores of malaria within the intervention group showed an increase from 10.3 ± 1.4 at preintervention to 11.3 ± 1.5 at post-intervention (P < 0.0015). The proportion of respondents who correctly followed malaria management guidelines increased from 32.73% at first supervisory visit to 70.91% by the third supervisory visit (P < 0.001). An analysis of the supervisory checklist showed improvement in performance of healthcare workers with each supportive supervisory visit in most of the variables examined. This study has demonstrated that supportive supervision is a feasible and practicable tool in improving knowledge and practice of malaria case management among PHC workers.

Can performance-based financing be used to reform health systems in developing countries?

Over the past 15 years, performance-based financing has been implemented in an increasing number of developing countries, particularly in Africa, as a means of improving health worker performance. Scaling up to national implementation in Burundi and Rwanda has encouraged proponents of performance-based financing to view it as more than a financing mechanism, but increasingly as a strategic tool to reform the health sector. We resist such a notion on the grounds that results-based and economically driven interventions do not, on their own, adequately respond to patient and community needs, upon which health system reform should be based. We also think the debate surrounding performance-based financing is biased by insufficient and unsubstantiated evidence that does not adequately take account of context nor disentangle the various elements of the performance-based financing package.

Antenatal counseling in maternal and newborn care: use of job aids to improve health worker performance and maternal understanding in Benin

BackgroundAntenatal care provides an important opportunity to improve maternal understanding of care during and after pregnancy. Yet, studies suggest that communication is often insufficient. This research examined the effect of a job aids-focused intervention on quality of counseling and maternal understanding of care for mothers and newborns.MethodsCounseling job aids were developed to support provider communication to pregnant women. Fourteen health facilities were randomized to control or intervention, where providers were trained to use job aids and provided implementation support. Direct observation of antenatal counseling sessions and patient exit interviews were undertaken to assess quality of counseling and maternal knowledge. Providers were also interviewed regarding their perceptions of the tools. Data were collected before and after the job aids intervention and analyzed using a difference-in-differences analysis to quantify relative changes over time.ResultsMean percent of recommended messages provided to pregnant women significantly improved in the intervention arm as compared to the control arm in birth preparedness (difference-in-differences [ΔI-C] = +17.9, 95%CI: 6.7,29.1), danger sign recognition (ΔI-C = +26.0, 95%CI: 14.6,37.4), clean delivery (ΔI-C = +21.7, 95%CI: 10.9,32.6), and newborn care (ΔI-C = +26.2, 95%CI: 13.5,38.9). Significant gains were also observed in the mean percent of communication techniques applied (ΔI-C = +28.8, 95%CI: 22.5,35.2) and duration (minutes) of antenatal consultations (ΔI-C = +5.9, 95%CI: 3.0,8.8). No relative increase was found for messages relating to general prenatal care (ΔI-C = +8.2, 95%CI: -2.6,19.1). The proportion of pregnant women with correct knowledge also significantly improved for birth preparedness (ΔI-C = +23.6, 95%CI: 9.8,37.4), danger sign recognition (ΔI-C = +28.7, 95%CI: 14.2,43.2), and clean delivery (ΔI-C = +31.1, 95%CI: 19.4,42.9). There were no significant changes in maternal knowledge of general prenatal (ΔI-C = -6.4, 95%CI: -21.3,8.5) or newborn care (ΔI-C = +12.7, 95%CI: -6.1,31.5). Job aids were positively perceived by providers and pregnant women, although time constraints remained for health workers with other clinical responsibilities.ConclusionsThis study demonstrates that a job aids-focused intervention can be integrated into routine antenatal care with positive outcomes on provider communication and maternal knowledge. Efforts are needed to address time constraints and other communication barriers, including introduction of on-going quality assessment for long-term sustainability.

The rise and fall of supervision in a project designed to strengthen supervision of Integrated Management of Childhood Illness in Benin

In developing countries, supervision is a widely recognized strategy for improving health worker performance; and anecdotally, maintaining regular, high-quality supervision is difficult. However, remarkably little research has explored in depth why supervision is so challenging. In the context of a trial to improve health worker adherence to Integrated Management of Childhood Illness (IMCI) guidelines and strengthen supervision in southeastern Benin, we used record reviews, focus group discussions, key informant interviews, and cross-sectional surveys to examine the supervision process. Initially, little IMCI supervision occurred. The frequency increased substantially after implementing a series of workshops, but then deteriorated. Quantitative and qualitative data revealed obstacles to supervision at multiple levels of the health system. Based on supervisors' opinions, the main problems were: poor coordination; inadequate management skills and ineffective management teams; a lack of motivation; problems related to decentralization; health workers sometimes resisting IMCI implementation; and less priority given to IMCI supervision because of incentives for non-supervision activities, a lack of leadership, and an expectation of integrated supervision. To this list, based on our observations, we add: the increasing supervision workload, time required for non-supervision activities, project interventions not always being implemented as planned, and the loss of particularly effective supervisors. In terms of correctly completing steps of the supervision process, the quality of supervision was generally good. Managers should monitor supervision, understand the evolving influences on supervision, and use their resources and authority to both promote supervision and remove impediments to supervision. Support from leaders can be crucial, thus donors and politicians should help make supervision a true priority. As with front-line clinicians, supervisors are health workers who need support. We emphasize the importance of research to identify effective and affordable strategies for improving supervision frequency and quality. (ClinicalTrials.gov number NCT00510679).