Amid a worldwide health workforce crisis, health providers carry a burdensome workload, are inadequately paid, and often work in environments that preclude quality care giving. They become disengaged while the demand for health services grows and investments in health workforce development are flat or declining. Niger is one of 36 countries in sub-Saharan Africa experiencing a human resources crisis. It has one doctor per 35,000 population and one nurse or midwife per 5000. An impoverished, desert country, it has high rates of maternal and child mortality: more than 600 maternal deaths per 100,000.

The U.S. Agency for International Development (USAID) is funding programs to implement its strategy for mothers and newborns. The strategy calls for the implementation of high-impact, cost-effective interventions during the child-bearing and postnatal periods. Among those programs is the USAID Health Care Improvement Project (HCI), managed by University Research Co., LLC (URC), which provides technical leadership and assistance for improving health care delivery and health workforce management to USAID-assisted countries. In addition to its emphasis on improving maternal and newborn care, USAID, through its Office of HIV/AIDS (OHA), is also concerned with expanding the evidence base for effective approaches to fortify human resources for health.

In 2009, Niger’s Ministry of Public Health and its regional health management office in Tahoua requested assistance from HCI to implement a program to address the health workforce crisis. With too few staff and no prospects for additional staff, the Ministry sought to improve the management of human resources in selected facilities and management offices in Tahoua Region. The predecessor project to HCI had successfully implemented quality improvement (QI) interventions in the same region. The new project would build on that experience and the country’s National Health Development Plan, which targets maternal/child health and human resources.  

Intervention:HCI proposed applying the collaborative improvement approach to improve human resources management in Tahoua. HCI had adapted for use in developing countries the collaborative improvement approach successfully implemented in the U.S., Europe, and Canada. The approach features QI teams that work at their own facilities with QI experts from HCI and the national health ministry. The teams work with the experts to learn the evidence-based interventions that will improve health outcomes. For the HR collaborative, in addition to the facility/clinical teams, teams also formed comprising managers. These management teams supported the facility teams by strengthening supervision and management. What distinguished the Niger HR collaborative from others HCI had helped implement was that no clinical interventions were proposed, only HR interventions.

The Niger Human Resources (HR) Collaborative began with a baseline assessment in May 2009 and ended with an endline assessment in December 2011.  To guide improvement work in human resources management, HCI supported teams to work through the steps of the Human Resources Performance Cycle. Teams began with having each staff person develop a job description with his/her supervisor and continue with articulating tasks, determining training needs, performance evaluation, etc. Participating facilities moved through these steps, monitoring and reporting their success in achieving them, with many nearly completing the cycle.

Throughout this process, health worker teams and their supervisors worked to implement the performance cycle within the context of the clinical areas they had selected. Job descriptions were developed as they relate to the maternity goals, feedback was provided within the context of the performance in question, and data was collected monthly on how well they were doing against the clinical indicators on which they focused. Health workers and their supervisors collected the indicator data, and managers reviewed and spot-checked those data. Embedding such data collection – and its related analysis and dissemination – in quality improvement processes is a key feature of HCI’s work, and it enabled the collaborative not only to adapt care processes at the point of delivery but also to show whether its impact was favorable and/or widespread.

Results: The clinical results proved exciting and compelling: All major indicators showed clear improvement, and in each case, a distinct shift occurred during the early to mid-point of implementation, signifying that the improvement was statistically significant, not accidental. Deliveries by qualified health workers rose from 27% to 45% and contraceptive prevalence from 9.6% to 36%; post-partum hemorrhage fell from 2% to 0.06%, and mortality in children under five from severe malaria dropped from 15% to 4% at the pediatrics hospital. To achieve these results, the teams made major changes in how health workers managed themselves and were supervised: They instituted feedback mechanisms, developed checklists to analyze skill gaps based on redesigned tasks and jobs, shared results with clients and other teams, and became engaged with the results. Managers improved supervision practices and began developing performance checklists, observing health workers, and reviewing results.

Conclusions and Recommendations: Overall both health workers and managers felt very positive about the human resources improvement work and that it had a positive impact on both working conditions and performance. Health workers felt that aligning their work with the Ministry’s objectives was essential. Moustapha Boukary, Head of Tsernaoua Health Post, commented, ‘’Before the HR Collaborative, we worked in unclear and cloudy conditions, but when we started aligning goals and objectives, we saw a clear direction.”

This innovative approach offers countries a new way to address the many challenges they face in the health and HR sectors. The above-cited clinical results are unquestionable and promising for a much larger scale. The success of the Performance Cycle process – and the combination of HR management and QI – should be refined, adapted, and improved, so that HR professionals are not left to struggle with too few health workers, and health workers are not left without the HR processes common in developing countries. 

1. A management change package should be developed that could be tested at the same time as the facility-level package. A change package similar to that implemented in Tahoua could be developed for implementation in the Ministry departments and regional management offices.
2. Management and facility levels should work together on HR issues. Facility teams should test changes for their level, and management should scale solutions and revise policy. 
3. Temporal relationships should be examined: What must be done stepwise and what can be done at once. 
4. Some Performance Cycle sub-steps can be implemented by sites alone.