Developing clear expectations and objectives for health workers focusing on MCH in Niger
In Niger’s Tahoua region, the challenge of finding enough human resources is severe. 2008 data compiled by the Ministry of Health show the ratio of doctors to patients is 1 per 100,000, there is 1 midwife per 9,000 women of child-bearing age, and 1 nurse per 8,000 people in the general population. These ratios are even higher in rural zones, where more than 80% of Tahoua’s population lives. This situation is aggravated by frequent reassignment of staff, as well as weak supervision of and in-service training for health workers. In response to this human resource challenge, the Government of Niger requested the assistance of the USAID Health Care Improvement Project to build the capacity of the Ministry of Health in managing and supporting health care workers in the Tahoua Region. For the first time, the collaborative approach was applied to managing health workers and linking improvements in performance management with impact on the quality of care for patients. The primary goal of the human resource improvement collaborative is to improve health worker performance (productivity and engagement) and the quality of maternal care by building the capacity of local management to sustain improvements in Niger’s Tahoua region. The pilot phase of the Niger Human Resource Collaborative includes 15 facilities from all eight Tahoua districts. The collaborative also uses15 clinical QI teams working on human resource and clinical indicators, as well as 11 management QI teams focusing on human resource indicators. At the facility level, the quality improvement team includes the facility manager, providers, a union member, and a district health team member. Seven improvement objectives were defined for the Human Resource Collaborative that will be introduced to teams in phases, beginning with work on the first objective. The seven objectives are: 1. Clear expectations and objectives for health workers 2. Competency development 3. Frequent feedback 4. Fair evaluation 5. Reward and consequence 6. Professional advancement 7. Safe and adequate environment
In May 2009, teams were introduced to Objective #1: defining objectives and clear expectations for all staff during the first learning session. Teams were shown how to articulate and align goals, design job descriptions with performance objectives, and develop action plans to define and align goals and objectives for all health workers within their facilities. At the second Learning Session, teams shared their work with respect to Improvement Objective #1, including the challenges and successes of aligning and rationalizing their jobs with Ministry priorities. They also prioritized goals that would measure their progress in key areas that would address the first objective. The 15 clinical quality improvement teams selected both human resource and clinical objectives to measure their results. Clinical objectives included increasing the rate for assisted deliveries, reducing rates and improving management of postpartum hemorrhaging, and increasing family planning coverage in health facilities.
A key to Objective #1’s outcome was having quality improvement teams develop written job descriptions with clearly defined tasks for health workers in their ward. The number of written job descriptions for health workers steadily increased at all 25 sites since teams began working on the first objective. As of January 2010, 65% of health workers have a written job description. Teams are now working on developing job descriptions for auxiliary workers. The human resource collaborative has also illustrated the link between human resource inputs and quality of care outcomes. Through improving human resource systems and processes, clinical indicators are positively impacted and the quality of care delivered is improved. For example, now that health workers have clearly defined tasks, they are able to concentrate their efforts on the key tasks and priorities of their position, which allows them to use their time more effectively. As of December 2009, the percentage of deliveries performed at facilities has increased since the start of the collaborative from 23% to 28%. As of November 2009, sites had reached a level of compliance with active management of the third stage of labor standards of 90%. There also has been an encouraging downward trend in postpartum hemorrhage rates sites are experiencing as a positive effect of the collaborative. The postpartum hemorrhage rate was 0% in December 2009. Teams measured the effect of their interventions by collecting data on both clinical and human resource indicators and documenting their work using the Standard Evaluation System database and journals. Examples of successful changes tested by teams relating to Objective #1 includes: 1. Maternity: Transferred prenatal consultation, which used to be done at the maternity, to the health center to reduce congestion and waiting time at the maternity. 2. District hospital: Transferred family planning activities to a midwife instead of the cashier. The team realized it was important to have a qualified person delivering these services. 3. District hospital: Reduced the number of antenatal care sessions held per week. The sessions were reduced to ensure that sessions are full when held.
Many human resource concepts such as goal alignment, objectives, tasks, etc. were completely new to QI teams at the facility level, and health workers had a hard time understanding the value-added of this work at the beginning of the process. However, as health workers have become more familiar with the concepts through coaching visits and learning sessions, they now are fully committed to the work and can see how changes in human resource positively affect their workload and the quality of care they deliver to patients. The human resource collaborative is an innovative approach because quality improvement teams are working on both human resource and clinical indicators simultaneously. This method has allowed them to clearly see the link between human resource inputs and clinical outcomes, and aligning their tasks with those of the district and the region helps them understand how they are directly contributing to improving health outcomes in Tahoua. Analyzing tasks also has allowed health workers and facilities to prioritize roles and responsibilities while improving the quality of care provided to patients. Another important lesson from this collaborative is the value of shared learning. Of the participating sites, there were five that had never done active management of the third state of labor and did not participate in a previous collaborative focused solely on essential obstetric and newborn care. However, through learning sessions and coaching, these health workers have now been trained in active management of the third stage of labor and are able to provide the essential part of obstetric care at their sites.