Support and performance improvement for primary health care workers in low- and middle-income countries: a scoping review of intervention design and methods

Abstract

Primary health care workers (HCWs) in low- and middle-income settings (LMIC) often work in challenging conditions in remote, rural areas, in isolation from the rest of the health system and particularly specialist care. Much attention has been given to implementation of interventions to support quality and performance improvement for workers in such settings. However, little is known about the design of such initiatives and which approaches predominate, let alone those that are most effective. We aimed for a broad understanding of what distinguishes different approaches to primary HCW support and performance improvement and to clarify the existing evidence as well as gaps in evidence in order to inform decision-making and design of programs intended to support and improve the performance of health workers in these settings. We systematically searched the literature for articles addressing this topic, and undertook a comparative review to document the principal approaches to performance and quality improvement for primary HCWs in LMIC settings. We identified 40 eligible papers reporting on interventions that we categorized into five different approaches: (1) supervision and supportive supervision; (2) mentoring; (3) tools and aids; (4) quality improvement methods, and (5) coaching. The variety of study designs and quality/performance indicators precluded a formal quantitative data synthesis. The most extensive literature was on supervision, but there was little clarity on what defines the most effective approach to the supervision activities themselves, let alone the design and implementation of supervision programs. The mentoring literature was limited, and largely focused on clinical skills building and educational strategies. Further research on how best to incorporate mentorship into pre-service clinical training, while maintaining its function within the routine health system, is needed. There is insufficient evidence to draw conclusions about coaching in this setting, however a review of the corporate and the business school literature is warranted to identify transferrable approaches. A substantial literature exists on tools, but significant variation in approaches makes comparison challenging. We found examples of effective individual projects and designs in specific settings, but there was a lack of comparative research on tools across approaches or across settings, and no systematic analysis within specific approaches to provide evidence with clear generalizability. Future research should prioritize comparative intervention trials to establish clear global standards for performance and quality improvement initiatives. Such standards will be critical to creating and sustaining a well-functioning health workforce and for global initiatives such as universal health coverage.

Enhancing Workforce Capacity to Improve Vaccination Data Quality, Uganda

“…A similar package of interventions has been seen to improve the quality of supportive supervision for immunization in Georgia ( 13 ). Systematic literature reviews highlight the effectiveness of multifaceted approaches, which include audit, feedback, and supportive supervision, in building health workforce capacity ( 14 , 32 ). The capacity to understand the gaps and challenges faced and to tailor improvement strategies accordingly appears fundamental to improving immunization coverage ( 33 ).…”

“…Given the importance of an effective workforce, a central component of the Data Quality Improvement Plan was to enhance the capacity of existing healthcare workers to manage, analyze, and use vaccination data. The chosen approach was guided by growing evidence supporting on-the-job training of healthcare workers that includes feedback and follow-up ( 14 ), which had previously been used successfully in Uganda ( 15 , 16 ). This article describes the initial implementation (November 2014–September 2016) and outcomes of Uganda’s national strategy to improve administrative vaccination data quality, defined by the dimensions of management; collection; data produced (accuracy, timeliness, completeness); analysis; and use ( 17 ).…”

Health system strengthening—Reflections on its meaning, assessment, and our state of knowledge

“…Individual performance contracts can reduce absenteeism . Supervision can lead to improvements in quality and productivity . Workforce performance is more likely to improve when a coherent combination of strategies is used .…”

Development and validation of the ExPRESS instrument for primary health care providers’ evaluation of external supervision

“…supervision delivered by supervisors from outside the facility) of primary health care facilities appears to be common practice [6–9]. External supervision often focuses on management and administration more than on problem solving and feedback [6,7].…”

“…The external supportive supervision model [6–9,13] is described as unique to developing countries [15]. Numerous instruments have been developed in high-income settings to evaluate the quality of provider-centred supervision [16,17] and training [18] practices.…”