Mentorship and coaching to support strengthening healthcare systems: lessons learned across the five Population Health Implementation and Training partnership projects in sub-Saharan Africa

The PHIT model was a ministry of health-academic partnership-driven intervention to implement and study health systems strengthening through multidimensional support across many of the World Health Organization (WHO)’s six health systems building blocks [23]. All five country sites were characterized by human resource constraints, particularly shortfalls in skilled workers and unmet needs in universal coverage for primary health care. The original intervention designs of the five PHIT projects differed in a number of areas, but all included mentoring and coaching [21, 31‐34]. Tables 1 and 2 describe the level of mentorship and coaching intervention, setting characteristics and targeted WHO health system building blocks.

We developed a framework for our analysis of the mentorship and coaching interventions reflecting the overall AHI evaluation framework [35] and the existing literature on mentorship and coaching and implementation science focusing on the implementation pathway as well as the outcomes (see Fig. 1). We used mixed methods to identify similarities and differences in the design and implementation of each project’s interventions, contextual factors influencing the design and implementation of the interventions, and explore improvements in targeted processes and shorter term outcomes. A questionnaire was designed to collect information in five categories, including: 1) mentorship and coaching goals, 2) selection and orientation of mentors and coaches, 3) integration with existing systems, 4) monitoring and evaluation, 5) challenges and successes, and 6) improvements and outcomes and contextual factors. The questionnaire was completed by key informants from each project and expanded through one-on-one semi-structured interviews. Data collected through the interviews were complemented by a review of publications from PHIT projects on mentorship and coaching and overall project qualitative and quantitative results. Follow-up telephone calls were done to augment information as needed.

Results from the interviews and document review were extracted and synthesized using the conceptual framework to identify and classify emerging themes. Quantitative results from the questionnaire and document review were also extracted to provide additional information on intervention design, implementation and associated results. Coaching/mentorship outcomes included changes in mentees’ knowledge and skills, data use for decision making, and where available, changes in quality of care and management practices.

Table 1 describes demographic characteristics and capacity of the intervention sites. The mentorship and coaching interventions reflected the individual country PHIT project designs, including targeted areas for improvement, local contextual factors identified through baseline needs assessment, and local challenges and culture. All of the projects focused on the subnational level (district or provincial), and four included on-site health facility work. Mozambique focused on improving management at the provincial level to ultimately improve care and health. Mentorship and coaching was designed to strengthen many of the WHO’s Health Systems Framework building blocks across all implementing sites (Table 2), although the targeted individuals and skills varied, reflecting baseline needs and intervention model.

In Rwanda and Zambia, mentorship was primarily used to strengthen quality of care delivery at health facilities and improve clinical systems of care, with a smaller focus on management and data use. In Rwanda, the Mentorship and Enhanced Supervision for Healthcare and Quality Improvement (MESH-QI) program was designed to strengthen clinical service delivery at health facilities through decentralized training of clinicians, regular supportive supervision incorporating clinical mentoring, and data collection to inform quality improvement work [27, 36, 37]. The MESH-QI program supported health center nurses in four key domains of clinical care and their supporting systems: women’s health, children under five, infectious diseases (HIV and TB), and non-communicable diseases (NCDs) (Table 3). At the district hospitals, MESH-QI targeted systems improvements [36]. Zambia implemented a facility-based supervisory intervention, in which QI teams provided clinical mentorship to health providers trained in various clinical domains [22, 38]. Community health agents were the main component of the overall PHIT intervention in Tanzania [39]. In addition to their initial training that covered key messages in maternal and child health related topics, including the community-based integrated management of childhood illness, they also received an intensive and ongoing mentorship to facilitate translation of the learned concepts into practice and improve performance.

Ghana and Mozambique focused more on improving management skills, leadership and governance at the community, facility, district or provincial level. In Ghana, coaching interventions focused on community and district leadership and governance as a strategy to build sustainable improvement in maternal and child health services, management and service capabilities at district-level [31]. The mentorship and coaching interventions were implemented using senior officers with expertise in clinical and health management from the public sector. The Mozambique PHIT project focused on improving management and leadership at the provincial and district level, strengthening existing health management units to strengthen systems and care designed to improve population health. Mentoring included management and improving use of health information systems and data [21]. PHIT project staff served as advisors with substantial experience working in, and supporting, the health system in the province. Provincial staff were composed primarily of physicians and nurses with over 5 years of experience leading provincial teams in their areas.

Despite differences in context and PHIT intervention design, there were a number of common features across sites. All sites focused on improving some of the same health service delivery areas, including maternal and child health and HIV (Table 3). While the level of intensity varied, all of the mentoring and coaching interventions included some work to increase management capacity and use of routine data to identify gaps and prioritize interventions [33, 37, 40]. Data review was also a component across the projects to guide the decision making of the mentors/coaches from the individual mentor-mentee level, to systems-wide levels [24].

The preparation and implementation of mentorship and coaching involved four core components: 1) mentor selection and orientation, 2) strategic deployment of mentorship and coaching teams, 3) data use for routine monitoring and supervision, and 4) on-site mentorship visits.

The choice of mentors or coaches reflected the areas and individuals targeted for support and improvement. All coaches and mentors were experienced in the targeted area and all received an orientation and training on mentoring and data-driven coaching techniques prior to starting. Coaches and mentors who focused on facility-based care were experienced providers, while management coaching was conducted by senior managers. For example, Ghana and Mozambique used provincial and district health managers as mentors and coaches. Tanzania, focusing on community-based care, used village health workers (VHW) and health facility managers [34] to serve as mentors. In all sites, PHIT project management teams served as technical advisors and master coaches for the field-based mentors (Table 3).

The deployment of mentors or coaches was informed by site specific priorities and overall intervention design. For example, in Rwanda and Zambia, mentorship occurred during on-the-job clinical consultations, while in Mozambique and Ghana, district level meetings were used to provide coaching to provincial and district managers. Supervision visits varied by site and context. For the provincial level intervention in Mozambique, in-person visits were limited to biannual meetings to discuss performance indicators, whereas the frequency of supervision visits in Rwanda and Zambia were monthly in order to facilitate quality improvement in provider care (Table 4).

In Tanzania, a curriculum was developed and used to train community health agents, or Wawezeshaji wa Afya ja Jamii (WAJA), in key areas of health promotion, reproductive health, Integrated Management of Childhood Illness (IMCI), community-based active case findings and management. Following this training, mentorship and coaching were integrated into regular supervision in the community by the VHW mentors and in the facility by the management mentors [34].

All PHIT projects established data review and feedback meetings that convened at least quarterly or annually. Routinely collected data were used to inform key decision making around coaching and mentoring priorities, and feedback to key stakeholders (Table 4). At the end of each meeting, quality improvement goals were reviewed and updated as needed by participants. Recommendations were shared with appropriate management groups, such as health management committees. Subsequent mentorship and coaching visits were planned to provide technical support and facilitate implementation of these recommendations.

In the PHIT projects that focused directly on facility-based care (Ghana, Rwanda, and Zambia), three main techniques were used to conduct facility-based mentoring: one-on-one mentorship, side-by-side teaching, and case reviews. The choice of techniques was informed by the mentee’s needs, workload, and the structure of clinical work. During the initial phase of the implementation where clinicians needed essential skills and competencies, side-by-side teaching was used more frequently. The more confident clinicians became, the more mentoring techniques transitioned to one-on-one mentoring. Case reviews were included to measure and improve knowledge on diagnosis and management of simpler and more complex cases. Real-time feedback between the mentor and mentee was consistently provided to reinforce best practices and identify areas for further improvement. In Mozambique, the mentoring and coaching intervention focused on improving capacity in management, leadership and accountability of health program managers at the district and provincial level [41].

A number of successes were seen in targeted short and mid-term outcomes (Table 5). In Mozambique, mentorship and coaching interventions supported the establishment of an evidence-based Maternal and Child Health (MCH) policy, improved malaria interventions, and strengthened pharmacy management across 13 districts with 133 health facilities [21, 23]. Work with healthcare management also led to improved data quality and use to evaluate and improve programs [40]. In Rwanda, quality of under-five care, including danger signs assessment, diagnosis, and treatment improved following mentorship visits as measured in both diagnosis and recognition of danger signs [27, 37]. In Zambia, adherence to adult clinical observation guidelines improved over a 12 month period following mentorship visits [38]. In Tanzania, mentoring of the VHWs was associated with high quality Integrated Management of Childhood Illness (greater than 70% for multiple domains). In Ghana, mentoring and coaching helped accelerate effective community-based health services coverage, leading to total community-based primary health care coverage in intervention areas and improvement in childhood survival, with a 35% reduction in the under-five mortality rate [42]. There was also clear growth in a strong and visible regional and district leadership for program management and political and social engagements, which resulted in successful implementation of community-based health planning and services [43]. Improved staff satisfaction and motivation were also reported across all intervention sites. In addition to improved quality in a number of health care areas, evidence from some of the PHIT projects showed satisfaction and general acceptability of the mentoring and coaching approach [22, 38, 42, 44].

A number of common challenges were encountered throughout the implementation of mentorship and coaching interventions. Turnover of both facility staff and mentors/coaches was high in the Zambia, Rwanda, and Ghana projects, resulting in needs for retraining of mentors, and difficulties in establishing critical mentor-mentee relationships, maintaining quality delivery by staff and building facility capacity to sustain improvements in systems and quality of care. Distance to health facilities, patient volume and the number of existing clinical personnel had direct impact on the design and implementation success of the clinical mentoring interventions. For example, many health facilities were located in remote geographic locations that required mentors to spend a long time travelling, resulting in transportation becoming a common barrier across PHIT projects. In many cases, mentors and coaches were required to share one vehicle with other teams of clinicians or supervisors visiting health facilities due to limited vehicle availability in order to decrease cost. Even though this was an effective strategy to efficiently use existing resources, it was a major cause of delays in mentoring activities and inhibited mentorship coverage for the full work day. Patient volume also was a challenge. A high volume of patients limited mentors’ time to provide real-time feedback and teaching moments, while low volumes, particularly in labor and delivery during mentor visit times, limited opportunities for side-by-side teaching. Competing priorities also served as a challenge, as in some cases mentors were called to work on other projects, particularly in cases where they were already embedded in Ministries of Health (MoH). This led to further decreased time for mentorship and challenges in meeting the recommended visit schedule. Finally, most projects did not have formal monitoring and evaluation (M&E) plans in place at the start to measure process and outcomes, specifically related to the mentorship and coaching components of the overall HSS intervention. Some looked mainly at outcomes (Ghana), while others had indicators more focused on facility performance (Mozambique, Zambia, and Rwanda). Low baseline data and low computer literacy among some of the mentors and coaches added a further challenge to routine data collection and effective use at the beginning and required additional training and support to ensure effective data collection, feedback and use. Table 5 summarizes the outcomes and implementation challenges.

Each PHIT project identified local contextual factors through strong engagement with local partners and a needs assessment prior to program implementation and modified their approach to reflect the needs and strengths of potential mentees. These included gaps identified in the existing skills and systems needed to achieve the projects’ HSS goals, anticipated challenges due to local environments (burden of disease, local geography), and targeted health service delivery areas. This was followed by adaption in the design of mentoring and coaching interventions and implementation strategies, and likely contributed to the success in implementation and progress in improving process and targeted outcomes. This adaption, combined with integrated monitoring and evaluation, helped overcome some of the challenges noted, including coordination of visits despite distance and transportation challenges, patient volume, and staff turnover (mentors and mentees). This integration of local context into the intervention while still maintaining the core components of effective coaching/mentoring versus simply replicating an existing model will be increasingly important as countries continue to further decentralize authority and responsibility for health system functioning and quality and outcomes of care.