Maximizing the return on investment in the health workforce: The role of quality improvement
(Midwives in Niger. Photo by Lauren Crigler.)
Health systems worldwide are challenged by a shortage of skilled health workers. A common theme among strategies to address the global human resources for health (HRH) crisis is how can we optimize the use of existing human resources to produce the best health care possible by reducing waste, inefficiency, and duplication. While in some settings providing more staff will go a long way to address poor outcomes, we know that simply adding personnel will not address the many problems rooted in inefficient and poorly designed service delivery systems.
Quality improvement (QI) approaches have a lot to offer in increasing the performance and productivity of human resources for HIV and other services. In QI, teams made up of frontline health workers, supervisors, and others involved in care analyze their own care processes and test ideas to determine if they lead to improvement in their local setting. While QI in clinical care is more familiar, QI methods readily lend themselves to issues of human resources management, to address gaps in performance, motivation, and competency.
With support from USAID and PEPFAR, the USAID ASSIST and predecessor USAID Health Care Improvement projects have applied QI methods to improve HIV program effectiveness by addressing underlying causes of weak health worker performance. Improvement strategies have helped to:
- Align health worker tasks and clinical care objectives
- Strengthen teamwork through applying principles of team-based performance management,
- Increase health worker job commitment and engagement through supervisor support and feedback,
- Strengthen health worker competencies through peer mentoring and coaching,
- Improve the quality of in-service training through coordination and rationalization of training activities, and
- Extend the reach of community health workers by engaging the larger network of community groups to support them.
Improvement interventions have also strengthened the capacity of government staff at the district and facility levels to support facility-level quality improvement and health worker performance, including strategies that increase the improvement skills of district managers.
What have we learned from applying QI to human resources for health?
Engaging health workers in making care more effective and efficient can be done in low-resource settings.
Building the capacity of health workers to manage their own performance and routinely monitor quality of care is a feasible, immediate intervention for addressing HRH performance gaps impacting service quality and coverage. Engaging health workers in clarifying their own work processes and in defining performance expectations makes health worker more accountable for results and leads to the identification of locally feasible ways to improve work processes, get “more bang for the buck,” and reach more patients with life-saving interventions like antiretroviral therapy. In Tanzania, task shifting and clarification of tasks instituted by health workers led to an increase in the proportion of HIV patients screened for TB, from 35% to 98% and an increase in the proportion of exposed children under 18 months who received daily Cotrimoxazole prophylaxis from 12% to 95%.
Addressing performance issues improves service delivery.
Significant improvements in service delivery can be attained alongside improvements in human resources management and health worker engagement when factors affecting performance are addressed as part of the improvement work. In Niger, clarifying tasks and job descriptions and streamlining work flow supported improving compliance with essential newborn care standards from 74% to 99%. Human resource performance issues that can be readily addressed with QI methods include unclear roles and tasks, ineffective or inefficient processes of work, lack of feedback, lack of competence to perform processes of work, and an inadequate working environment.
Leadership support is key.
The active involvement of health worker teams in improving their work is strengthened by supervisor support and perceived adequacy of health workers’ own competencies to perform their tasks. In addition to support from one’s supervisor, feedback and praise from colleagues and patients have also been found to increase engagement of health workers.
As we honor health workers around the world this week, let’s recognize that health workers themselves are the key to improving the quality and impact of health services. QI methods offer an often-underutilized strategy for mobilizing the health workforce for health system change, to maximize the return on investment in human resources for health.