Optimizing health worker performance to improve health care … · DAY 2: Foggy Bottom, April 10,...
Transcript of 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
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Wanda JaskiewiczProject DirectorHRH2030, Chemonics International
@HRHWanda @HRH2030Program@Chemonics
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Lisa ManiscalcoHealth SpecialistOffice of Health SystemsUSAID Bureau for Global Health
@USAID @USAIDGH
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Alex RoweChief of Strategic and Applied Science Unit, Malaria BranchCenter for Disease Control & Prevention (CDC)
@CDCgov @CDCglobal
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Please click herefor Alex Rowe’s
HCPPR presentation
TeaBreak
Overview ofcurrent efforts onhealth workforce performance and HSS for quality
services
Brandina Kuyere, Malawi. Credit: Michelle Byamugisha
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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
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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.
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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
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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
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• 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
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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.
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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
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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)
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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
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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
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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
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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
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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.
Source: World Bank, 2015.
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
Source: World Bank, 2013.
In Latvia, large scope to increase the number of outpatient andhome visits…
Overview •Health systems efficiency and the healthworkforce
• Health expenditures and health sector wagebill
• Health workforce performance andproductivity
Health Workers are important from a health financing perspective
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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.
Overview •Health systems efficiency and the healthworkforce
• Health expenditures and health sector wagebill
• Health workforce performance andproductivity
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
Source: World Bank, 2011.
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)
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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
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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
B1. Drugs & Supplies
4 indicators
B2. Facility Infrastructure
1 indicator
B3. Information Systems
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
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)
PHCPI Quality Measures
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
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]
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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
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*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
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KogiEbonyi
Improving Woman-centered Intrapartum CareMonitoring BP, fetal heart rate; partograph use; prophylactic uteronic(N=27,643 total deliveries in 91 facilities)
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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
PHOTO CREDIT GOES HERE 103
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)
DOH are now tracking 11K (Feb) vs 3K (Nov)
DOH are now tracking 27K (Feb) vs 12K (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
PHOTO CREDIT GOES HERE 119
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