optimizing health worker performance to improve health care … · day 2: foggy bottom, april 10,...

DAY 2: Foggy Bottom, April 10, 2019

HRH2030

Optimizing health worker performance to improve health care quality in low- and middle-income countries

PHOTO CREDIT GOES HERE 2

Wanda JaskiewiczProject DirectorHRH2030, Chemonics International

@HRHWanda @HRH2030Program@Chemonics


Lisa ManiscalcoHealth SpecialistOffice of Health SystemsUSAID Bureau for Global Health

@USAID @USAIDGH


Alex RoweChief of Strategic and Applied Science Unit, Malaria BranchCenter for Disease Control & Prevention (CDC)

@CDCgov @CDCglobal


Please click herefor Alex Rowe’s

HCPPR presentation

https://hrh2030program.org/wp-content/uploads/2019/04/HCPPR-phase-12-45-min-seminar-4x3-no-extra-slides-animated-v5-DC-policy.pdf

TeaBreak

Overview ofcurrent efforts onhealth workforce performance and HSS for quality

services

Brandina Kuyere, Malawi. Credit: Michelle Byamugisha


Rachel DeussomTechnical DirectorHRH2030, Chemonics International

@Rachel_deussom@HRH2030Program@Chemonics

Preliminary findings

HRH2030 Landscape Analysis on Enhanced

Supervision Approaches:

Best practices to improve health worker performance

and service quality

Chemonics International

10

The untapped potential of health worker supervision

• The supervision “status quo”• Limited accountability, supervisory capacity & resources• Fragmentation of private sector and community-based

workforce• Limited continuity & data integration within health

information flows

• Beyond other HSS interventions, enhanced supervision is estimated to have the highest potential impact (USAID 2017)

• How can enhanced supervision improve service quality?* Impact population health?

• What are supervision “enhancements”?

What is enhanced supervision?“A broad set of supervisory

interventions that improve provider performance through team-based,

learning approaches, including supportive supervision, the use of checklists, and in-person visits.”

– AOTC Report: USAID, 2017

* Building on evidence from: Kallander et al., 2015; Bailey et al., 2016; Webb, Bostock and Carpenter, 2016; Rowe et al., 2018.

11

Database search methodology

Databases: Popline, USAID DEC, WHO Global Health Library, Health Systems Evidence, Cochrane Database of systematic reviews, GlobalHealth & PubMed,ResearchGate, HRH Global Resource Center, mHealth compendium databases, Global Health Science & Practice, The Lancet, References from Bailey et al. 2015, Healthcare Management Information Consortium

Identification: Number of references identified through initial database search: 66,945

Search Terms: “enhanced supervision” OR “mentorship” OR “supportive” OR “team-based” OR “site-visit*” OR “coaching” OR “problem-solving” OR “check-list” OR “learn*” AND “health worker*”

• Duplicates: 298• Not related to health sector: 61,296• Not in English: 2• Intervention completed prior to 2010: 1,042• Applying further database filters: 2,608

Screening: Number of titles screened: 1,699

Eligibility: Number of titles and abstracts screened: 87

• Irrelevant to health worker supervision: 1,612

• Did not meet CASP Checklist criteria: 18• Did not demonstrate positive results: 24

Number of references excluded:

Included in landscape analysis: 45

12

HRH2030 Landscape Analysis Framework

1. Positive results? 2. Supervision enhancements? (e.g., inputs, processes)3. Scaled and/or sustained?

Source: HRH2030 2019. Adapted from GHWA 2014, Dieleman et al 2009, and informed by Campbell et al 2013.

CONTEXT INPUTS PROCESSES RESULTS

OUTPUTS OUTCOMES EFFECTS IMPACTMacro-level

Micro-level

Individual

Human resourcesTrainers, supervisor & supervisee profile(s)

Financial resourcesBudget source

Informational, technical & material resources

ModalityFrequencyLocation / FeedbackIn person, distanceService Delivery fociStructureAssessment type, # supervised, formalityData Use for Decision-MakingComplementary Intervention(s) “Enhancements”

HRH Outputs

HRH Outcomes

Population health

Maturity

Cost-effective-ness

HRH Effects Performance Productivity

HSS Outcomes

HSS Effects

Service Delivery

Type of study

Country

Health area(s)

Preliminary Findings

Tanjung Priok Health Center, Indonesia. Credit: Andi Gultom

14Source: HRH2030 2019. Adapted from GHWA 2014, Dieleman et al 2009, and informed by Campbell et al 2013.

Landscape analysis taxonomy for classifying enhanced supervision approaches


• 76% from Sub-Saharan Africa• Diverse methodologies used

• 24% case study/program report

• 22% RCT

• All focused on primary or community health care service delivery improvement

• Half dedicated to supervising CHWs

• Many disease- or program-specific

• District management team-led supervision

• Some policy-led approaches • PHC, CHWs, service equity, or task shifting

• Majority donor-funded (78% - additional

16% unspecified)

Characteristics of enhanced supervision approaches reviewed (n=45)

Cote d’Ivoire medical facility. Credit: Gildas Gbacada

16

Preliminary findings from inventory of enhanced supervision approaches (n=45)

Source: HRH2030 2019. Adapted from GHWA 2014, Dieleman et al 2009, andinformed by Campbell et al 2013.

17

Preliminary findings from inventory of enhanced supervision approaches (n=45)

Source: HRH2030 2019. Adapted from GHWA 2014, Dieleman et al 2009, andinformed by Campbell et al 2013.

PROCESSES Modality:• Quality improvement (QI) methodsFeedback:• Multi-level, timely feedback loops Data use for decision-making:• HMIS interoperabilityComplementary interventions:• Clinical mentoring • Community engagement

INPUTS Informational resource:• HMIS / health system performance data

RESULTS

Outputs, Outcomes or Effects:• Noteworthy achievements

Impact:• Scaled up and/or sustained over time

18

Supervision enhancement: Use HMIS to inform and prioritize sites and/or service areas

HMIS + clinical mentoring

Achieved task-shifting among mid-level providers for higher-quality HIV and TB services in Uganda

Naikoba et al. 2017

HMIS + mHealth app + weekly calls + job aid

Facilitated performance feedback for CHWs delivering nutrition services in India, who were more motivated, self-efficacious, and solved more technical problems

Kaphle, Matheke-Fischer and Lesh, 2016

HMIS + mHealth app + checklist + QI

Improved quality of care for private sector & CHW providers in malaria and FP services across Africa and Asia

Lussiana et al. 2016

HMIS + mHealth app + mentoring

Increased CHW data use, productivity, and accountability for adhering to iCCM / child health standards of care

Biemba et al. 2017

Potential for cost-effectiveness(Campbell et al., 2014; Biemba et al., 2017)

19

Supervision enhancements: Quality improvement (QI)

Of the 16 supervision approaches having QI as the primary modality:

Outputs • 63% [10] improved HRH skills, knowledge and attitudes

Outcomes • 69% [11] improved HRH competence• 50% [8] documented improved quality

standardsEffects • 81% [13] improved HRH performance

and/or productivity• 56% [9] improved the quality of care

Impact • 56% [9] improved population health … compared to 17% [3/18] of HR management as primary modality

20

Supervision enhancements:Digital data integration & multi-level feedback loops

District-level dashboards

• Promotes efficiency• Automates some

supervisory tasks

Manzi et al., 2012Agarwal et al., 2016

Interprofessional or network support

• Reinforces formal visits and promotes self-efficacy

Okuga et al., 2015Mkumbo et al., 2014

Data review meetings & facility improvement plans

• Improved health worker competencies in data-driven decision-making, including for CHWs

Aikins et al., 2013Manzi et al., 2018

21

Supervision enhancements:Complementary interventions

Clinical mentoring

• Addresses pre-service education and performance gaps

• Where continuing professional development is limited; for enhanced/new scopes of practice

Anatole et al., 2013 Manzi et al., 2014Som et al., 2014Ajeani et al., 2017

“Whole-of-system” approach

• Strengthens supervisor capacity• Strengthens health system enabling environment,

safety, equipment and supplies

Green et al., 2014Deussom et al., 2014 Battle et al., 2015 Gueye et al., 2016Kok et al., 2018

Community engagement

• Provide feedback on service quality / utilization, especially for CHWs

• Problem-solve; maintain or improve facility; advocate• Appropriate where there are issues of accessibility,

perceived quality, trust, and/or utilization

Okuga et al., 2015 Gueye et al., 2016

22

Discussion & next steps

• More country-led assessments of more advanced approaches; longer evaluation periods

• Limited detail of implementation approach, resource requirements• Limited ability to compare supervision enhancements in different

contexts, with different objectives

• Using the conceptual framework and taxonomy to review supervision enhancements (including the HCPPR) could help strengthen the evidence base & further define trends

Data-driven prioritization for supervision | QI methods | Digital data integration | Effective feedback loops | Community engagement | Clinical mentoring |

Strengthening supervisors and health system enabling environment

THANK YOU

Maliana Community Health Center staff, Timor-Leste. Photo credit: Rachel Deussom

Rachel Deussom [email protected]

Acknowledgements:Doris Mwarey, Katy Gorentz, Leah McManus, HRH2030 Core Team


Edson Araujo Senior EconomistHealth, Nutrition and Population Global PracticeWorld Bank

@araujoec @WBG_health

4/17/2019

Health Workforce Productivity and Performance

Optimizing health worker performance to improve health care quality LMICs April 9 2019

Edson C. AraujoSenior Economist, HNP GP

Overview •Health systems efficiency and the healthworkforce

• Health expenditures and health sector wagebill

• Health workforce performance andproductivity

Health Systems Efficiency • Improving health care systems,

while containing cost pressures, isa key policy challenge in mostcountries

- between 20% and 40% of all healthresources might be effectively lost dueto various forms of inefficiency

• IMF suggests that African countriescould raise life expectancy at birthby about five years on average ifthey used their health resourcesmore efficiently (Grigoli & Kapsoli2013)

Source: OECD, 2015.

In most of countries we observe the same trend(THE per capita growth > GDP per capita growth)

Source: Smith, 2012.

Health Spending => Outputs => Outcomes

The role of the health workforce in the health care system

Labor costs represent a significant portion of health expenditures

•making efficient use of health workforce has potential lead tosubstantial efficiency gains in the health sector

-The WHO (2010) estimates at 20% the level of health systems’inefficiency resulted from the health workforce

-based on the proportion of the health spending that is devotedto pay health workers, estimated that health workforceinefficiencies result in US$ 500 billion losses to the worldeconomy (WHO, 2010)

Source: WHO, 2010.

In Brazil, public sector wage bill increased faster the is a major driver of the increased in health care budgets…

0.00

50.00

100.00

150.00

200.00

250.00

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Pessoal UEM OCC UEM Total Consolidado UEM

Source: World Bank, 2017.

…however, productivity remains a challenge…Estimated number of consultations per doctor, OECD and Brasil, 2013

Source: OECD, 2015.

…and compensation is relatively high.


Multiple of health professional pay versus the average income per capita of the 10th richest decile of the population

Results from SDI surveys point to large variation acrosscountries...

Average number of consultations per professional per day Absenteeism - %

Source: World Bank

In Costa Rica, we observed a fall in productivity combined with a significant increase in compensation

3400

3600

3800

4000

4200

Ann

ual C

onsu

lts p

er H

ealth

Wor

ker

2005 2007 2009 2011year

Consults per Health Worker

Average Staff Cost per Consultation, selected cadres -2005-2011

050

0010

000

1500

020

000

Wag

e B

ill/C

onsu

lts

2005 2007 2009 2011year

Nurses GPsSpecialists Denists

Crude Productivity Ratio, Areas de Salud - 2005-2011

Increased the overall cost of delivering health services within the CCSS


In Latvia, large scope to increase the number of outpatient andhome visits…

Health Workers are important from a health financing perspective

0

10

20

30

40

50

60

70

EAP ECA LAC MENA SA SSA

Wage bill as share of Public Spending on Health %, By Region

SOURCE: Scheffler et al, 2013

In most countries, wage bill accounts for a large share of total health expenditure

SOURCE: Hernandez-Peña et a., 2013.

Health worker performance unpackedPerformance as a Function of Capacity and Effort

Source: Leonard et. al, 2015.

Evidence from Liberia (Leonard, 2017)

38%

26%

11%

21%

2%2%

47% 50%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2013 2015

Performance and the Three Gaps

Performance Can-Do Gap Know-Can Gap Knowledge Gap

Source: Leonard, 2017.

Uganda: What health workers know?Large difference between diagnosis and treatment knowledge

58%

50%

19%

Diagnostic Accuracy

Adherence to clinicalGuidelines

Management ofmaternal /neonatal

complications

45%

59%

62%

88%

28%

58%

26%

42%

53%

42%

9%

36%

AcuteDiarrhea

Pneumonia

Diabetes

Pulmonary TB

Malaria withAnemia

All

Full Treatment Correct Diagnosis

46% gap


Same provider

Quality of Care and Incentives

INPUTS

Health expenditure per capita, PPP

Hospital beds (per 1,000 people)

Nurses and midwives (per 1,000 people)

Physicians (per 1,000 people)

INPUTS (NON-DISCRETIONARY)

GINI

Adult literacy rate, population 15+ years, both sexes (%)

Prevalence of tuberculosis (per 100,000 population)

OUTPUTS

Life expectancy at birth, total (years)

Mortality rate, infant (per 1,000 live births)

Cause of death, by non-communicable diseases (% of total)

Assisted delivery

Measuring health workforce efficiency (DEA model)

Country coverageIncome Group n

High-income 37

Lower-middle-income 41

Low-income 26

Upper-middle-income 41

Total 145

Large variations in the HW density and composition

Summary • Labor costs represent a significant portion of health expenditures- making efficient use of health workforce has potential lead to substantial efficiency gains in

the health sector

- About 20% total inefficiencies (US$500bi)

• Available evidence, global and country specific, shows largescope to improve quantity and quality of services

- Productivity, absenteeism, and performance (know gap)

• Large variation across countries- In terms of HWs density and composition

- Payment systems and level of compensation (incentives structure)

[email protected]

mailto:[email protected]


Jeffrey MarkunsDeputy DirectorPrimary Health Care Performance Initiative (PHCPI)

@ImprovingPHC

• WHO Stakeholders PHCPI Briefing and Consultation

• July 21, 2015

PHCPI and Measuring the PHC Workforce

Presented by: Jeff Markuns, Deputy DirectorPrimary Health Care Performance Initiative

The Fundamentals

We are a partnership dedicated to transforming the global state of primary health care.

We were founded on the belief that strong PHC is the cornerstone of sustainable development in health and that

the future success of global PHC depends on better measurement.

We work withgovernments and development partners to strengthen PHC systems, and provide them with the

data, information, and support they need to drive evidence-based improvements.

Our partners arethe Bill and Melinda Gates Foundation, the World Health Organization, the World Bank, Results

for Development, and Ariadne Labs.

Led by: In partnership with:

Many countries have identified (PHC) as an urgent priority, but they lack comprehensive data to pinpoint specific weaknesses, understand their causes, and strategically direct resources to address them.

The Measurement Gap

“You can’t improve what you can’t measure.” – Dr. Margaret Chan

The processes and experiences that occur in the system, between inputs and outputs, are called the “black box” of PHC because influential stakeholders have not understood them and have not given them enough attention.

PHCPI Framework

E. Outcomes

A1. Governance & Leadership

A1.a Primary health care policiesA1.b Quality management infrastructureA1.c Social accountabilityA2. Health Financing

A2.a Payment systemsA2.b Spending on primary health careA2.c Financial coverageA3. Adjustment to Population Health Needs

A3.a SurveillanceA3.b Priority settingA3.c Innovation and learning

B1. Drugs & Supplies

B2. Facility Infrastructure

B3. Information Systems

B4. Workforce

B5. Funds

D1. Effective Service Coverage

D1.a Health promotionD1.b Disease preventionD1.c RMNCHD1.d Childhood illnessD1.e Infectious diseaseD1.f NCDs & mental healthD1.g Palliative care

E2. Responsiveness to People

E3. Equity

E4. Efficiency

E5. Resilience of Health Systems

E1. Health Status

C2. Facility Organization and Management

C2.a Team-based care organization

C2.b Facility management capability and leadership

C2.c Information systems

C2.d Performance measurement and management

C3. Access

C3.a Financial

C3.b Geographic

C3.c Timeliness

C4. Availability of Effective PHC Services

C4.a Provider availability

C4.b Provider competence

C4.c Provider motivation

C4.d Patient-provider respect and trust

C4.e Safety

C5. High-QualityPrimary Health Care

C5.a First Contact Accessibility

C5.b Continuity

C5.c Comprehensiveness

C5.d Coordination

C5.e Person-Centered

C1. PopulationHealth Management

C1.a Local priority Setting

C1.b Community engagement

C1.c Empanelment

C1.d Proactive population outreach

A. System Level Determinants D. OutputsC. Service DeliveryB. Inputs

Social Determinants & Context (Political, Social, Demographic, Socioeconomic)

PHC Core Indicators

57

Core Indicator mapping

• Composite Indicators– made up of some of the 38 Core Indicators –address the Inputs, Service Delivery, and Outputs domains. • The 38 Core Indicators map to only 11 of the 19 sub-domains within the PHCPI framework:

• The Progression Model addresses Capacity-related subdomains, thus filling measurement gaps to elucidate performance information across relevant areas of the PHCPI Conceptual Framework.

E. OutcomesA. System D. OutputsC. Service DeliveryB. Inputs

A1. Governance and Leadership0 indicators

A2. Health Finance4 indicators

A3. Adjustment to Population Health

Needs 0 indicators


4 indicators


1 indicator


0 indicators

B4. Workforce 4 indicators

B5. Funds0 indicators

C1. Population Health

Management0 indicators

C2. Facility Organization

and Management 0 indicators

C3. Access 2 indicators

C4. Availability of Effective PHC

4 indicators

C5. High Quality Primary Health

Care 4 indicators

D1. Service Coverage

11 indicators

E1. Health Status

4 indicators

E2. Responsiveness

to People0 indicators

E3. Equity 1 indicator

E4. Efficiency1 indicator

E5. Resilience of Health System

0 indicators

33% of subdomains in System have indicators

60% of subdomains in Inputs have indicators

60% of subdomains in Service Delivery have indicators

100% of subdomains in Outputs have indicators

60% of subdomains in Outcomes have indicators

PHC Vital Signs Profiles offer an entry point into driving PHC improvements through better measurement.

The profile will allow countries to:

Compare performance to in-country objectives

Form the foundation of additional in-depth analysis and more granular data gathering on PHC

PHCPI Vital SignsProfile

What does it mean to have a high performing PHC system?

Financing Capacity Performance Equity

✓ PHC is prioritized in the budget ✓ The system is

well-governed with good facility management and effective, proactive management ofpopulation health

✓ Adequate staff, facilities, supplies, drugs

✓ Good quality, access,and outcomes for themost vulnerable

✓ Better populationoutcomes

✓ Access: minimal financial barriers, travel distance

✓ Quality: accurate and appropriate diagnosis, treatment, coordinatedfollow-up

✓ Effective coverage of essential PHC services

✓ Low out-of-pocket expenditures

Launch of VSPs

12 “TrailBlazer” VSPs published!

• In the absence of strong quantitative indicators of PHC capacity, PHCPI has developed a mixed-methods assessment called the PHC Progression Model for measuring the foundational capacities of PHC.

• The PHC Progression Model enables the standardized, systematic assessment of foundational areas of PHC performance.

• The results of the PHC Progression Model assessment complete the Capacity pillar of the VSP.

Rationale for the PHC Progression Model

The PHC Progression Model is integral to the VSP

Completion of a PHC Progression Model assessment as part of the completion of a Vital Signs Profile gives countries a holistic understanding of PHC strengths and weaknesses, a critical first step in the measurement for improvement pathway.

Governance and leadership

Adjustment to Population Health Needs

Drugs and supplies

Facility infrastructure

Information systems

Workforce

Funds

Population Health Management

Facility Organization and Management

33 Capacity measures are summarized as 3 scores on the VSP

Measure 1: PHC Policies (1/2)Measure 2: PHC Policies (2/2)Measure 3: Quality management infrastructureMeasure 4: Social accountability (1/2)Measure 5: Social accountability (2/2)

Measure 6: SurveillanceMeasure 7: Priority settingMeasure 8: Innovation and learning

Measure 9: Availability of essential medicinesMeasure 10: Basic equipment availabilityMeasure 11: Diagnostic supplies

Measure 12: Facility densityMeasure 13: Facility amenitiesMeasure 14: Standard safety precautions and equipment

Measure 15: Civil registration and vital statisticsMeasure 16: Health management information systemsMeasure 17: Personal care records

Measure 18: Density and distributionMeasure 19: Quality assurance of PHC workforceMeasure 20: PHC workforce competenciesMeasure 21: CHWs

Measure 22: Facility budgetsMeasure 23: Financial management information systemMeasure 24: Remuneration

Measure 25: Local priority settingMeasure 26: Community engagementMeasure 27: EmpanelmentMeasure 28: Proactive population outreach

Measure 29: Team-based care organizationMeasure 30: Facility management capability and leadershipMeasure 31: Information system useMeasure 32: Performance measurement and management (1/2)Measure 33: Performance measurement and management (2/2)

Terms to be defined

Term Explanation Country DefinitionPrimary health care workforce

The primary health care workforce includes all health workforce engaged in delivering services specific to primary health care.

Progression Model Workforce Measures

• Measure 18: Workforce and distribution– Numbers of doctors, nurses and midwives

• Measure 19: Quality assurance of the primary health care workforce– Workforce training, qualifications and standards

• Measure 20: Primary health care workforce competencies– Competencies set and linked to access, continuity, comprehensiveness,

coordination and person-centered care• Measure 21: Community health workers

– Criteria for CHWs

PHCPI Framework

E. Outcomes

A1. Governance & Leadership

A1.a Primary health care policiesA1.b Quality management infrastructureA1.c Social accountabilityA2. Health Financing

A2.a Payment systemsA2.b Spending on primary health careA2.c Financial coverageA3. Adjustment to Population Health Needs

A3.a SurveillanceA3.b Priority settingA3.c Innovation and learning




B4. Workforce

B5. Funds

D1. Effective Service Coverage

D1.a Health promotionD1.b Disease preventionD1.c RMNCHD1.d Childhood illnessD1.e Infectious diseaseD1.f NCDs & mental healthD1.g Palliative care

E2. Responsiveness to People

E3. Equity

E4. Efficiency

E5. Resilience of Health Systems

E1. Health Status






C3. Access

C3.a Financial

C3.b Geographic

C3.c Timeliness






C4.e Safety



C5.b Continuity


C5.d Coordination





C1.c Empanelment


A. System Level Determinants D. OutputsC. Service DeliveryB. Inputs

Social Determinants & Context (Political, Social, Demographic, Socioeconomic)

PHCPI Quality Measures






C3. Access

C3.a Financial

C3.b Geographic

C3.c Timeliness






C4.e Safety



C5.b Continuity


C5.d Coordination





C1.c Empanelment


C. Service Delivery

Country 1

Country 2

Country 3

PHC Operational Framework: Vision for Action

• The state of PHC Data and Measurement needs improvement• The PHC Vital Signs Profile is a valuable first step in measuring PHC

systems and the workforce that drives them• Engage with countries and frontline workforce• More work is needed on measuring the PHC Workforce

– What are the competencies?– What is the right skill mix?– How do we measure performance?– What are the best measures for performance?– What other determinants are impacting workforce performance?

PHCPI Website

www.improvingPHC.orgFor more information, please contact Jeff Markuns, PHCPI Deputy Director, at

[email protected] Beth Tritter, PHCPI Executive Director, at [email protected]

http://www.improvingphc.org/


Kathleen HillTeam LeadUSAID Maternal Child Survival Program (MCSP) Jhpiego

@MCSPglobal @Jhpiego

Improving Health Worker Performance in multi-faceted QI Initiatives

Kathleen Hill, M.D., M.P.H. Maternal Health Team Lead, MCSP/Jhpiego

Optimizing Health Worker Performance for Improved Health Care QualityWashington D.C., April 2019

Donabedian Quality of Care Framework

* Skilled motivated health workers are one important health system input and contributor to care processes and outcomes

I

Inputs• Skilled, motivated

workers• Commodities• Policy, guidelines• Finances• Infrastructure

Care ProcessesCompetent People-

Centered Care

OutcomesPeople-

Centered and Health

Source: Donabedian Framework for Measuring quality of care

WHO Quality of Care Framework for Childbirth

Source: BJOG 2015

The MNCH QoC Network – launched in 2017Goals• Reduce maternal and newborn deaths and stillbirths in

participating health facilities by 50% over five years• Improve experience of care

10 First Wave Countries: Bangladesh, Côte d’Ivoire, Ethiopia, Ghana, India, Malawi, Nigeria, Sierra Leone, Tanzania, Uganda

12 “New” Countries participated in Addis Meeting: Botswana, Cameroon, Chad, DRC, Kenya, Liberia, Mozambique, Namibia, Niger, Senegal, South Sudan, Sudan

Health Worker QI/Health Systems Capabilities –historically neglected

Many managers and health workers lack QI skills and confidenceDiscrete QI competencies are needed by actors at distinct system levels to:

Develop national quality policy/strategyDesign RMNCH improvement work for scaleManage district/region-wide improvement (support to front-line teams)Improve care at the front-lines, including managing change and regularly measuring quality of care

Sierre Leone – QoC Network country: Conceptualizing clinical mentorship, QI coaching, Supervision

84

*Source: Sierre Leone Presentation QoC Network Meeting, Addis, 2019

MCSP Works at Global and Country Level in 30+ Countries…

To support global RMNCH efforts, including the WHO multi-country MNCH QoC NetworkTo support government and partners to improve quality of RMNCH care at scaleTo build country capacity across system levels to improve and sustain quality care - and to improve care continuously

Global leadership

Country implementation

National leadership

Regional and district

management

Service delivery

Systems Approach to Achieve Reliable Delivery of Quality Care for Every Person Every Time

System wide action: National – quality policy, strategy, governanceRegional/district – Management, leadership of qualityService delivery – facility, community

Leveraging of existing structures and processes; context mattersEngaging Community and civil society

Improving Quality of Maternal and Newborn Care in Nigeria –Ebonyi and Kogi States

Key Activities at National Level

Creation of first-ever National RMNCH QI Technical Working Group:National RMNCH QoC Policy & Strategy - building on WHO QoC frameworkParticipation as first-phase country in WHO QoC MNCH network

Development of operational roadmap, specifying national, state, LGA and facility-level activities

Improving RMNCH Care in Ebonyi & Kogi States: Key Approaches (sub-national level)

Facility level - 91 Primary Health Centers and Hospitals • QI team work – regular meetings• Change management targeting critical

quality gaps• Routine measurement & analysis of

prioritized quality measures• Strengthening facility readiness • Regular shared learning across sites

State / District Managers• State-wide RMNCH improvement strategy • Phased improvement aims, quality measures• Capacity-building for QI/measurement and

clinical skills – managers, facility teams• Refining of established state integrated

supportive supervision processes• Investments in pre-service education

89

KogiEbonyi

Improving Woman-centered Intrapartum CareMonitoring BP, fetal heart rate; partograph use; prophylactic uteronic(N=27,643 total deliveries in 91 facilities)

0

10

20

30

40

50

60

70

80

90

100%

of w

omen

Month

% of deliveries for which partograph was used% of women who delivered and uterotonic given within 1 min of delivery of last baby% of women with blood pressure measured during labour% of women with documented fetal heart rate (FHR) during labour

Data Source: MCSP quality of care dashboard (DHIS and additional data)

Illustrative changes:• Re-organizing care

pathways to be more woman-centered and to expedite timely care

• Drug-revolving scheme, buying essential medications from pharmacies to sell to patients at a fair price

• Changes to ensure privacy for women in high-volume facilities

• Targeting additional support to lower-performing facilities

Improving Early Postnatal Care for Newborns: Skin to Skin, early Breastfeeding, Chlorhexidine Gel to Umbilical Cord

(N=27,643 total deliveries in 91 facilities)

Data Source: MCSP quality of care dashboard (DHIS and additional data)

0

10

20

30

40

50

60

70

80

90

100%

of n

ewbo

rns

Month

% of newborn babies put in skin-to-skin contact with mother% of newborn babies put to mother's breast within 30 minutes of birth% of newborn babies with Chlorhexidine gel applied to cord

Illustrative changes:• Preparing for delivery

with all commodities ready in delivery room

• Creating & sustaining hand-washing corners

• Introduction of chlorhexidine

• Establishing protected, stocked corners for immediate care of small sick newborns

Improving Quality of Maternal and Newborn Care and Postpartum Family Planning Services in

Madagascar

National level – policy, pre- and in-service curricula16 regions, 80 districtsFacilities supported - 826

753 primary level facilities (CSBs)63 hospitals

Population served: 17,391,085

Multi-faceted quality improvement interventions across regional, district and facility levels to improve RMNCH care in 763 PHCs and 63 Hospitals

Support to regional/district managers, 250 clinician trainers/mentorsto build clinical skills of 1,450 providers in 822 health facilities

• Competency-based training in low, repeating doses (on- and off-site)

• Regular reinforcement of MNH and PPFP skills via mentoring and supportive supervision (blended in-person and mobile)

• Establishment of Skills labs in 55 districts• Donation of equipment and materials to

health facilities (including anatomic models for peer-supported simulated practice)

MOH district teams supported to supervise and mentor facility teams to implement QI interventions to improve RMNCH services

Facility teams supported to achieve common priority improvement aims by:

•Analyzing underlying contributors to critical quality gaps•Identifying and testing sustainable changes to overcome gaps•Calculating and analyzing trends in quality indicators using dashboard•Sharing learning across sites

-

10

20

30

40

50

60

70

80

90

100

Aug Dec Mar Jun Sep Dec Mar Jun Sep Dec Mar Jun

2015 2016 2017 2018

% o

f wom

en

Month

Improved Antenatal Care Processes in 513 PHCs: increased proportion of women screened for PE/E with a blood pressure check

(N = 1,002,989 total ANC visits in which women’s BP checked)

Illustrative improvements:• Reorganizing patient flow and care pathways• Measuring and documenting blood pressure

for every pregnant woman • Stocking and monitoring essential

commodities and medications in ANC area• Tracking BP measure on standardized

dashboard

Improved uptake of Postpartum Family Planning before discharge

(N = 203,213 total women delivering in 576 CSBs)

*does not include lactation amenorrhea methodIllustrative improvements:• Reorganizing postnatal care• Provision of PPFP

counselling in ANC, early labor and after delivery

• Improving counselling methods, patient materials, and provider skills

• Stocking FP methods in maternity postpartum area for easy access

8% 8%

16% 15%

20%

25%

22%

19% 20% 21%

T1 T2 T3 T4 T1 T2 T3 T4 T1 T2

2016 2017 2018Quarter

Improved outcomes in 513 PHCs: decreasing institutional maternal mortality ratio and fresh stillbirth rate (2015-2018)

0

50

100

150

200

250

T3 T4 T1 T2 T3 T4 T1 T2 T3 T4 T1 T2

2015 2016 2017 2018

MM

R (

per

100,

000

deliv

erie

s)Maternal mortality ratio in CSBs

(N = 183,483 total women delivered and 151 total maternal deaths)

0

2

4

6

8

10

12

14

16

18

T3 T4 T1 T2 T3 T4 T1 T2 T3 T4 T1 T2

2015 2016 2017 2018

Fres

hst

illbo

rnra

te (

per

1,00

0 bi

rths

)

Fresh stillbirth rate in CSBs (N = 183,483 total newborns [live and stillborn], including 2,035 total

fresh stillbirths)

Improved outcomes in 5 hospitals: decreasing hospital newborn mortality rate 2015-2017

(N = 9,321 live births; 211 pre-discharge newborn deaths in five regional hospitals)

Illustrative improvements:• Mapped and redesigned

patient care pathways • Enhanced coordination

across departments to accelerate provision of care

• Strengthened compliance and adherence to national guidelines

• Introduced and maintained resuscitation equipment where deliveries happen (operating / delivery room)

0

5

10

15

20

25

30

35

40

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2

Year 1 Year 2 Year 3

Pre-

disc

harg

e N

MR

Quarter

Reflections….recommendations

• Promote favorable policy, effective governance and partnerships across system levels

• Leverage local sustainable structures and processes to greatest extent possible

• Embed health worker capacity-building in broader QI efforts

• Build clinical and QI skills (and other skills per health worker cadre and need)

• Promote regular opportunities to share learning –motivates health workers and accelerates improvement across sites

• Invest in quality pre-service education and continuing professional development – “fit for purpose workforce”

Thank You

Learn more at: www.mcsprogram.org

Twitter.com/MCSPglobal

Facebook.com/MCSPglobal


Peter GravesVice President for New Business DevelopmentBroadReach

@pgraves @broadreachinfo

HRH Performance Management – APACE/South Africa

HRH2030 Day 2April 10, 2019

Peter GravesBroadReach

• South Africa & APACE Facts

• APACE Strategic priorities / Geographies

• Targets

• Standard Implementation Issues

Daily email to staff managersOverview

PLHIV: 7.5M

Target: 6.1M people on ART by December 2020 (90-90-90 target)

Current # People on ART: 4.5M

Gap: 1.6M

Current USAID Flagship Project: Accelerating Program Achievements to Control the

Epidemic (APACE) in South Africa

Years of implementation: 1 October 2018 to 30 September 2023

South Africa & APACE Facts

1. Focus on highest burden districts

2. Doubling of investments in supplemental

health worker staff

3. Fast-track HIV Treatment Surge

4. Expand community engagement through

comprehensive CHW program

5. Strengthen Management and Accountability,

including scale-up through evidence-driven

case finding / using data for better decision-

making

GoSA & PEPFAR Strategic Priorities

Limpopo

Mpumalanga

KwaZulu-Natal

Eastern CapeWestern Cape

Northern Cape

North West Province Gauteng

Free State

BroadReach High Burden Districts

High Burden Districts

Geographies

Ensuring executives, managers and field staff are able to learn and adapt?

Adaptive Management

Capabilities to drive a workforce consistently at scale?

Workforce ManagementExecutive oversight to drive program

performance?

Program Performance

Delivery of regular, on time to manage stakeholder expectations

Program Reporting

We focus on four critical implementation issues to maximize achievements across 90-90-90, our consultants and enabling technology help clients navigate pain points such as:

2

3 4

1

Target Implementation Issues

Capabilities to drive workforce consistently at scale?

Workforce Management

Field Staff Effectiveness Application

Daily Emails to Staff Members

Daily Emails to Staff Managers

Overall Staff Performance

Improved oversight of key indicators (Feb vs Nov)

Total remaining on ART

Headcount screened for TB

Presumptive TB identified

ART clients w/ missed appts

Improved submissions have created improved oversight and visibility of key weekly indicators

2

164%

209%244%

126%

DOH are now tracking 1M (Feb) vs 399K (Nov)

DOH are now tracking 398K (Feb) vs 128K (Nov)



Patient Value Delivered (Feb vs Nov)

• Viral Loads Done (%)

• Immunised < 1 year

Improved oversight is positively impacting performance and health outcomes

3

62% (Feb) vs 16% (Nov)

93% (Feb) vs 27% (Nov)

Submissions (Feb vs Nov)

97 77

49 34

52 38

52 27 29 28

14

Umkhanyakude

King Cetshwayo

Zululand

Ethekweni

Harry Gwala

uMgungundlovu

Umzinyathi

Ugu

Uthukela

iLembeAmajuba

The HIV Cascade Management Solution has made a significant positive impact on capturing data in weekly submissions

1

District Submissions increased from

5/11 (Nov) to 11/11 (Feb)

Increase in the number of facilities reporting

(Feb vs Nov)

Facility submissions have also increased

Case Study of a Scaled solution: Value added to Kwa-Zulu Natal DoH weekly data with BroadReach technology-enabled cascade management

USAID DisclaimerThe creation of this material was made possible by the support of the American People through the U.S. Agency for International Development (USAID) under Cooperative Agreement No. 72067418CA00024. The contents are the responsibility of BroadReach and do not necessarily reflect the views of USAID or the United States Government.

BroadReachBroadReach is a health solution company focused on improving the health and well-being of underserved populations. Using almost two decades of experience and foremost Vantage technology, we design and deliver effective solutions to healthcare problems in emerging markets, empowering stakeholders to make the right decisions and implement the right actions that improve health outcomes and change lives.

Founded in 2003, BroadReach is at the forefront of supporting African governments, donors and Ministries of Health in the implementation of Health Systems Strengthening programs. We have worked in over 20 countries worldwide.

Contact telephone numberCape Town: +27 21 514 8300Johannesburg: +27 11 727 9500

www.broadreachcorporation.com


Eric SarriotSenior Health Systems Strengthening AdvisorSave the Children, CORE Group

@COREGroupDC @SavetheChidren

DiscussionKey question: How can development partners collaborate and take action to develop strategies to sustain and scale effective health workforce performance approaches to improve health care quality in LMICs?

Optional Afternoon Workshop

Analyzing the HCPPR databases

Alex Rowe, CDC

THANK YOU

HRH2030

optimizing health worker performance to improve health care … · day 2: foggy bottom, april 10,...

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