A community health worker conducts a follow-up visit with a child who had a fever in the preceding days in Kamalpur, Dhaka, Bangladesh. Photo by Anya Guyer, Initiatives Inc.

In response to the health workforce crisis in low resource settings, URC supports teams of health workers and managers to innovate and test solutions to address health workforce challenges and improve performance and productivity throughout the health system. The scope of this work is to inform policy, practice, and further research, mostly through the US Agency for International Development (USAID) Health Care Improvement Project (HCI).

URC conducts assessments and research to build understanding of health workforce challenges and evaluate the effectiveness of solutions. Additionally, we support the application of quality improvement methods and performance management strategies that engage and empower health workers and management to identify problems, develop and test their own solutions, and provide team-based support for performance.

Together with its partners, URC facilitates CHW Central, an online Community of Practice for shared learning, networking, and resources to support and strengthen community health workers. URC is a member of the Global Health Workforce Alliance and the Frontline Health Workers Coalition.

Merging Human Resources and Improvement Approaches for Better Care and Happier Providers

HCI is combining improvement and human resource approaches to improve the quality of service delivery and human resources management. The project partnered with the Ministry of Health in Tanzania to address problems in service delivery and human resources management. The partnership applied a unique combination of human resource and improvement approaches in 12 sites in Tandahimba District. The sites made (and continue to make) improvements to antiretroviral therapy (ART) and prevention of mother-to-child transmission of HIV (PMTCT) care and performance management by reorganizing and rationalizing processes of care and tasks. These improvements are reflected in modified job descriptions and models. Significant progress has been made in both human resources (as seen in the number of health care workers who have job descriptions) and clinical care (as seen in the percentage of women tested for HIV who enrolled in care). The figure shows an example of clinical care improvements relative to the percentage of HIV-exposed infants who received antibiotics to prevent morbidity and mortality due to opportunistic infections.

In Niger’s Tahoua Region, 11 management and 15 facility-based teams analyzed processes of care and then rationalized, shifted, and clarified tasks in order to achieve clinical objectives. They also developed mechanisms to improve competencies, share feedback on performance, and assess and recognize individual and team performance. Significant improvements were made in maternal care, while also increasing contraceptive prevalence rates and decreasing postpartum hemorrhage rates. In addition to clinical improvements, health workers became more productive and engaged in their work. The Ministry of Public Health has integrated this QI process to improve HR into its national five-year health plan, and implementation in the Maradi, Tillabery, and Zinder regions is underway.

Improving the Effectiveness, Efficiency, and Sustainability of In-service Training

Demonstration of postnatal examination using a checklist during an in-service training session in Uganda. Photo by Annie Clark, URC.

In-service training (IST) has been a major strategy for rapid scale-up of the provision of HIV, TB, and maternal and child health services. However, the need for more sustainable, effective, and efficient training for health workers continues. Through HCI, URC facilitated a global process that engaged over 100 experts from 26 countries representing training program providers, professional and regulatory bodies, Ministries of Health, development partners, donors, and experts to develop and reach consensus on an improvement framework for IST, the first global framework that focuses on practices to improve the effectiveness, efficiency, and sustainability of health worker IST. The framework will be officially launched in July 2012. URC is working with Ethiopia’s Ministry of Health and other key stakeholders to conduct a rapid assessment of IST and facilitate the development of a national IST strategy.

Community Health Worker Assessment and Improvement Matrix Toolkit

A key element of USAID’s strategic approach to maternal and child health is to significantly increase by 2013 the number of functional community health workers (CHWs) in USAID priority countries. To contribute to this, HCI and its partner Initiatives Inc. developed the CHW Program Assessment and Improvement Matrix (CHW AIM), a toolkit (manual) that defines 15 key elements needed for CHW programs to function effectively. It provides lists of high-impact, evidence-based interventions in maternal newborn care, HIV/AIDS services, TB services, water sanitation and health, and family planning to guide the assessment of current CHW services. The toolkit comprises of a participatory self-assessment and a performance improvement process to help organizations review current practices to identify program strengths and address gaps. It helps stakeholders assess the status of an intervention and determine the level of CHW program functionality. Additionally, it provides guidance for action planning to assist CHW program managers in strengthening their programs.

Assessing Community Health Volunteer Program Functionality in Madagascar

More than 13,000 community health volunteers (CHVs) in Madagascar are serving the needs of its predominately rural population. In late 2011, URC led the qualitative component of a mixed-methods assessment to determine the functionality of programs that support CHVs in Madagascar. Using the CHW AIM methodology, the method brought together CHVs, supervisors, program implementers, and other key stakeholders to build consensus on program functionality and identify areas for improvement. The assessment’s final report will be launched in late 2012.

Researching the Relationship between CHW Program Functionality and CHW Performance in Zambia

HCI and Initiatives Inc. conducted operations research in Zambia to test the CHW AIM toolkit as a quality improvement tool. The research also sought to determine whether any associations exist among CHW program functionality, CHW performance, and CHW engagement and to assess the costs of the CHW AIM process. The results indicate that CHW AIM can assist organizations to improve CHW program functionality, but that improvement may be neither linear nor continuous. Results also show a statistically significant correlation between CHW program functionality and CHW performance, suggesting that organizations with stronger CHW AIM program functionality scores will also have better performing CHWs.

Exploring Experiences and Perceptions of Task-shifting to Expert Patients in Uganda

Staff shortages in Uganda have led many health facilities to shift tasks to expert patients, HIV-positive clients who contribute to a health system’s effectiveness by providing services and support to others who have HIV/AIDS. Since limited documentation exists about the role of expert patients in 1) HIV/AIDS service delivery, 2) available organizational support, and 3) outside perceptions, 61 semi-structured interviews were conducted with various stakeholders at six health facilities participating in HCI’s HIV/AIDS improvement collaboratives. The study results indicate that shifting tasks has improved the quality of care and alleviated staff overload. The major remaining gap is the lack of a national policy or operational guidelines for recruiting, training, deploying, and supervising expert patients for integrating them into the health system.