How can we achieve and maintain high-quality performance of health workers in low-resource settings?

Summary

In low and middle income countries, health workers are essential for the delivery of health interventions. However, inadequate health-worker performance is a very widespread problem. We present an overview of issues and evidence about the determinants of performance and strategies for improving it. Health-worker practices are complex behaviours that have many potential influences. Reviews of intervention studies in low and middle income countries suggest that the simple dissemination of written guidelines is often ineffective, that supervision and audit with feedback is generally effective, and that multifaceted interventions might be more effective than single interventions. Few interventions have been evaluated with rigorous cost-effectiveness trials, and such studies are urgently needed to guide policy. We propose an international collaborative research agenda to generate knowledge about the true determinants of performance and about the effectiveness of strategies to improve performance. Furthermore, we recommend that ministries of health and international organisations should actively help translate research findings into action to improve health-worker performance, and thereby improve health.

Introduction

The problem of inadequate health-worker performance in low and middle income countries is particularly urgent. Millions of children and adults die prematurely each year1, 2 even though many interventions exist that can prevent such deaths,³ and health workers (defined broadly to include public and private providers based in health facilities or communities) are essential for delivering these life-saving interventions. However performance (defined as adherence to an accepted standard or guideline) is very often inadequate, as documented in studies of child health, sexually transmitted diseases, family planning, obstetrics, mental disorders, injuries, and diabetes.4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 Governments and non-governmental organisations spend many resources on health workers and the systems that support them, and such investments could produce greater benefits to society than they currently do. Poor health-worker practices contribute to low use of health facilities by vulnerable populations, and improved performance might increase use of health services.19, 20, 21, 22 Additionally, health-worker practices can be harmful (eg, giving sedatives to children with pneumonia,¹⁶ or prescribing unnecessary antimicrobials23, 24, 25), and such errors of commission must be eliminated.

We aim to address the issue of achieving and maintaining high-quality performance of health workers in low-resource settings. We briefly outline the determinants of performance, discuss the effectiveness of strategies to improve performance, and describe knowledge gaps that, if filled, might lead to better interventions (or a better ability to select appropriate interventions) for achieving and maintaining high-quality performance. We acknowledge that the topic is vast, with many perspectives and actors. Because of limitations of space and, indeed, of the existing studies, this Review is an overview, based mainly on review articles of research undertaken in low and middle income countries and centred on public-sector workers in health facilities. In some cases, we refer to individual studies and research from industrialised countries.