Integrating views on support for mid-level health worker performance: a concept mapping study with regional health system actors in rural Guatemala

Abstract

IntroductionMid-level health workers are on the front-lines in underserved areas in many LMICs, and their performance is critical for improving the health of vulnerable populations. However, improving performance in low-resource settings is complex and highly dependent on the organizational context of local health systems. This study aims to examine the views of actors from different levels of a regional health system in Guatemala on actions to support the performance of auxiliary nurses, a cadre of mid-level health workers with a prominent role in public sector service delivery. A concept mapping study was carried out to develop an integrated view on organizational support and identify locally relevant strategies for strengthening performance.MethodsA total of 93 regional and district managers, and primary and secondary care health workers participated in generating ideas on actions needed to support auxiliary nurses’ performance. Ideas were consolidated into 30 action items, which were structured through sorting and rating exercises, involving a total of 135 of managers and health workers. Maps depicting participants’ integrated views on domains of action and dynamics in sub-groups’ interests were generated using a sequence of multivariate statistical analyses, and interpreted by regional managers.ResultsThe combined input of health system actors provided a multi-faceted view of actions needed to support performance, which were organized in six domains, including: Communication and coordination, Tools to orient work, Organizational climate of support, Motivation through recognition, Professional development and Skills development. The nature of relationships across hierarchical levels was identified as a cross-cutting theme. Pattern matching and go-zone maps indicated directions for action based on areas of consensus and difference across sub-groups of actors.ConclusionsThis study indicates that auxiliary nurses’ performance is interconnected with the performance of other health system actors who require support, including managers and community-level collaborators. Organizational climate is critical for making auxiliary nurses feel supported, and greater attention to improving the quality of hierarchical relationships is needed in LMIC settings. The participatory nature of the concept-mapping process enabled health system actors to collaborate in co-production of context-specific knowledge needed to guide efforts to strengthen performance in a vulnerable region.

Advancing the science behind human resources for health: highlights from the Health Policy and Systems Research Reader on Human Resources for Health

“…The Reader includes research articles that reflect on these power dynamics and the meaning of co-producing research in learning sites with district managers in South Africa [ 36 ], as well as how it better enables understanding of resilience among managers in Kenya [ 37 ] and supervision in Zimbabwe [ 13 ]. The Reader also highlights innovative examples of how to use participatory research methods with health workers such as the use of life histories in Uganda [ 38 ] and concept mapping in Guatemala [ 39 ]. Finally, Reader sections also highlight how collaborative approaches with health workers are key to supporting performance, whether through better role definition in Egypt [ 40 ] or improved problem-solving teamwork [ 41 ] that supports quality improvement over time [ 42 ].…”

“…With a keen eye on community level providers, the Reader reveals health worker worldviews on their constrained livelihoods and lived experience amid sustained poverty and hunger in Ethiopia [ 59 ]. It reveals the community embeddedness of midwives in Mali [ 62 ] and of rural health workers in Papua New Guinea [ 54 ], alongside other organisational factors that impact on community cadre performance in Ghana [ 45 ], Guatemala [ 39 ] and Papua New Guinea [ 43 ]. While informal providers are often discounted, they are included in the Reader through efforts to enumerate the total workforce in India [ 8 ] and in Bangladesh [ 9 ].…”

From knowing our needs to enacting change: findings from community consultations with indigenous communities in Bangladesh

“…Because there is very little access to state or NGO-provided health services in Bandarban, responsibility for health is placed on individuals and their families, who are left to fend for themselves. Attracting healthcare professionals to this area is difficult, because there is little infrastructure or incentives for establishing reliable bases for physicians or nurses [ 40 ]. As a result, communities have come to accept any care that is available to them, mostly in the form of traditional healers that live in their vicinity.…”

Identifying the Scope, Relevance and Integration Challenges for Mid-Level Health Providers in India: Perspectives on Advancing Primary Care

“…As seen in Guatemala, the biggest challenge in fully integrating CHOs into the primary care is a problematic managerial perception that adheres little to no importance to support community-level needs that prioritises the local issues. 24 This managerial bias against community integration is found to be one of the biggest challenges in the successful integration of MLHPs into mainstream healthcare systems and was aptly documented while studying the impact of ICT in augmenting primary care delivery by MLHPs in the South African context. The ndings suggest that the introduction of ICT based delivery would be futile if the community needs are not adequately incorporated.…”