Background
Methods
Study setting and design
Ghana | Mozambique | Rwanda | Tanzania | Zambia | |
---|---|---|---|---|---|
Intervention Catchment Population size | 500,000 | 1,999,000 | 480,000 | 857,000 | 450,000 |
Intervention setting | Rural | Urban/Rural | Rural | Rural | Peri-urban/Rural |
National population density (people per sq. km of land area) | 118 | 35 | 460 | 59 | 17 |
Intervention health worker density at baseline (nurses/1000) | 0.62 | 0.23 | 0.63 | 8.49 | 0.70 |
Number of intervention health facilities | 156 | 144 | 24 | 30 | 42 |
% of deliveries with skilled attendant at birth in intervention area at baseline | 54.03 | 65 | 64.6 | 67.9 | 67.9 |
Health system level of mentorship and coaching intervention | Province/District/Community | Province/District | District/health facility | Community | District/Health facility |
Country | Health Service Delivery | Human Resources | Health Information Systema
| Medicines/Vaccines/Technology | Leadership and Governance | Health Financing |
---|---|---|---|---|---|---|
Ghana | 1 | 2 | 2 | 2 | 1 | 2 |
Mozambique | 2 | 2 | 1 | 2 | 1 | 2 |
Rwanda | 1 | 1 | 2 | 2 | 2 | No |
Tanzania | 1 | 1 | No | 2 | 2 | No |
Zambia | 1 | 1 | 2 | 2 | 2 | 2 |
Evaluation framework and data collection
Data analysis
Results
Design phase of the PHIT mentoring and coaching interventions
Ghana | Mozambique | Rwanda | Tanzania | Zambia | |
---|---|---|---|---|---|
Priority areas | Emergency referral, perinatal intervention, IMCI, capacity building, management | Maternal, Newborn and Child Health (MNCH), malaria, pharmacy management | MNCH care, Integrated Management of Adult and Adolescent Illness (IMAI), HIV, Noncommunicable Diseases (NCD), QI, data utilization | Training and curriculum, supervision checklist | IMAI, IMCI, Emergency Obstetric and Neonatal Care (EmONC), HIV, mentorship, leadership |
Method of measuring performance | Mortality metrics, fertility rates, facility surveys | Standardized performance review matrices, observation, supervision guides | Observation checklist, Facility surveys | Case management observation tool, interviews | Chart reviews, observation tools, electronic medical record reports |
Indicators | Service utilization, QI indicators, leadership management | Service utilization for MNCH and malaria services, pharmacy management | Quality of MNCH, HIV, IMAI, NCD care compared to clinical guidelines, knowledge assessment | Quality of c-IMCI service provision compared to clinical guidelines, training evaluation | Service utilization and quality of IMAI, IMCI, HIV services compared to clinical guidelines |
Mentors/Coaches | Senior/experienced public health officials and clinical practitioners identified prior to intervention | Public health officials and nurses with 10 to over 25 years of experience working in, or supporting, provincial teams identified prior to intervention | Nurses and midwives with specialized skills hired at the district hospital as part of intervention | CHW supervisors in village, facility managers hired as part of intervention with at least 2 years of clinical training | Clinical officers, nurses/midwives, pharmacy technologists hired as part of intervention |
Mentor training | Used Ghana’s national Leadership Development Program (LDP) to build leadership capacity in budget management and resource allocation [43] | Iterative 2-day cycles, repeated on average every 6 months, with supervision visits in between meetings Data-driven identification of areas for improvement in service provision; development and implementation of action plans to address weaknesses | Initial workshop in clinical mentorship and QI, didactic training in area of focus, ongoing supervision by mentor supervisor and clinical supervisors | Week long session for training and curriculum, and field visits to WAJA in field practicum to test and finalize supervision checklists | Mentors were trained in basic clinical packages, and were coached by experts from the University of Alabama to enhance their clinical skills (such as physical examination, ordering and interpretation of lab tests, and differential diagnosis). |
Recipients of mentorship and/or coaching intervention | Community Health Officers (CHO) | Health system managers, principally at the district and facility levels | Health Center Nurses and Managers | Community Health Workers (WAJA) | Nurses, clinical officers, environmental health technologists, program officers, CHW, TBA, clinic support workers |
Didactic training for recipients of mentorship and coaching intervention | 18-month pre-service training and 6 months for Community Health Officers | In-service trainings based on MOH training, curriculum on using data for decision-making, linking service utilization patterns to resource planning, evaluating small-scale service delivery | Ensure mentees at the health center are trained in standard MOH packages (HIV care, EmONC, IMCI, NCDs, Essential Newborn Care) | Family planning education, supply chain management STI/HIV prevention education, safe motherhood and essential newborn care counseling and c-IMCI, | Month-long: Week 1 & 2: diagnosis and management of clinical presentations, clinical protocols Week 3: Patient registration and triage, clinical forms, data entry, medical record keeping Week 4: Same as 3 + antenatal care, postnatal care, danger signs assessment |
Preparation and implementation of mentorship and coaching interventions
Selection and orientation of mentors and coaches
Strategic deployment of mentorship and coaching teams
Ghana | Mozambique | Rwanda | Tanzania | Zambia | |
---|---|---|---|---|---|
Supervisory structure for mentoring intervention | Weekly field supportive supervision, visits from regional supervisors Peer mentoring exchanges, developed supervisory approaches [42] | District performance review and enhancement meetings where health facility and district staff are supported to collate and report key performance indicators. This includes 1–2 day one-on-one meetings with facility and district staff for coaching on synthesizing and interpreting secular trends in performance indicators. Ongoing post-performance review meeting coaching via quarterly supportive supervision visits from provincial and district health systems managers, including ongoing mentorship from PHIT teams embedded in provincial health department. | After mentee’s clinical training, mentors visit each health facility every 4–6 weeks to provide mentorship in each clinical domain. Mentors conduct coaching sessions with health facility staff as needed and work with health facility leadership to address systems-gaps. Quarterly debriefing meeting to discuss quality improvement indicators. | Comprehensive training for CHW that lasts 9 months, covering biology, clinical skills. Train CHWs, provide resources for facility/supply chain at district level. Mentoring occurs through facility supervision Travel to sites monthly during first 3 months, switch to quarterly supervision afterwards. | Comprehensive training (1 month intensive on-site), on-site mentoring (month 2), monthly supervision visits by QI team (month 3 onwards) to review medical records, assess accuracy of diagnosis |
Number of mentors | 17 | 14 | 10 | 30 facility managers 50 village supervisors | 18 |
Clinician/mentor ratioa
| 2.3 | NA | 12 | 4.8 | 9.3 |
Data use | Peer exchange, weekly clinical audit meetings [42] | Used in two-day performance meetings | Quarterly internal debriefing meetings, district data sharing meetings | Village supervisors track performance management. Used evaluation data from QoC study and 3-monthly longitudinal data system (Health and Demographic Surveillance Systems) on households | Shared through facility and national level meetings, QI team meetings |
Frequency of mentorship | Monthly | Biannual | Every 4–6 weeks | Facility managers: Biannual Village supervisors: Monthly | Monthly |
Data use for routine monitoring and supervision of the mentoring and coaching
On-site mentoring visits
Successes
Improvements in Knowledge | Improvements in Quality of Service Delivery | Improvements in M&E | Improved Motivation of Health Workforce | Challenges | |
---|---|---|---|---|---|
Ghana | Improved overall knowledge in tasks performed by Community Health Officers through observations and responses to questions | Emergency referral project - increases access to care, pushes services to community level [43] | Improved data literacy skills among health workers | Health workers invested in scaling up program [42] | Staff turnover, not strong M&E, difficult to stick to planned check-ins |
Mozambique | Median data concordance improved from 56% between 2009 and 2010 (baseline period) to 87% at the end of the intervention (2012–2013) [26]. | Better understanding of data, increased ownership, increased recognition of the importance of data sharing/feedback | Strong government involvement at all levels of the provincial health system, leads to more accountability and ownership, and better oversight by system managers | Low baseline computer and data analysis skills among front-line staff; conflicting priorities among limited number of provincial managers; difficulties in supporting (financially/logistically) facility and district action plans | |
Rwanda | Used pre/post-tests to assess knowledge changes and retention over time [district reports] | Better data literacy among providers and mentors. Improvement in data quality [55] | Coaching leads to interactive, collaborative capacity building, active listening and relationships, support (not policing), real-time feedback that lead to increased motivation [55]. | High demand for M&E support (data entry, analysis, reporting), difficult to stick to quarterly schedule, high turnover of health center staff, poor health facility infrastructure, logistical challenges (transport) limited mentoring time | |
Tanzania | Conducted evaluation of training program to identify processes that could be improved, found that correct IMCI diagnosis was satisfactory | Quality of care was ensured through measurements of correct diagnosis and treatment of under-5 illness by WAJA. 73% of 300 WAJA consultations were correctly diagnosed as measured against an IMCI-trained medical professional. 84% of 86 children diagnosed with malaria were treated correctly by WAJA. | Both clinical supervisors and WAJA cite their relationships as intrinsic motivators for better performance | Village CHW supervisors did not feel adequately compensated, tension because they were volunteers v. paid CHW. Challenges in ensuring visits to CHW from facilities. | |
Zambia | Improved patient-provider interaction, better outcomes, improved clinical judgement/case management, improvement in management of malaria according to protocols. | Increased use of Electronic Medical Record system, increases in data use and feedback [38]. | Local ownership and collaboration, increased trust from clinical workers of QI teams, increased support for work load [38]. | Shortage of qualified staff, MoH staff/volunteer attrition, poor health facility infrastructure, misunderstanding of mentor’s role by mentee, resistance to change |