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.
CHW Central (www.chwcentral.org) is a new interactive platform to facilitate information-sharing and dialogue about how to support and improve the effectiveness of community health workers, who serve in communities around the world providing health education and care. The website's features include:
Developed by the USAID Health Care Improvement Project, CHW Central draws on global resources and evidence from a number of organizations committed to improving and supporting community health workers, including USAID, The Global Health Workforce Alliance, CORE Group, CapacityPlus, and MCHIP.
This short report describes the results of applying collaborative improvement to strengthen human resource management and improve the quality of maternal care in Tahoua Region of Niger.
A key element of USAID’s strategic approach to maternal and child health (MCH) is to increase by at least 100,000 the number of functional community health workers serving in USAID priority countries by 2013. At the request of the USAID MCH team, the Health Care Improvement (HCI) Project developed a tool that defines a set of key elements that are needed for community health worker programs to function effectively and measures how well programs meet these criteria. These elements were defined based on a review of recent literature on CHW programs (see link below) and suggestions from expert reviewers. The CHW Program Assessment and Improvement Matrix (CHW AIM) tool examines 15 programmatic components that CHW programs should consider as important to successfully supporting CHWs. These include: recruitment; the CHW role; initial training; continuing training; equipment and supplies; supervision; individual performance evaluation; incentives; community involvement; referral system; opportunity for advancement; documentation and information management; linkages to the health system; program performance evaluation: and community ownership.
In applying the tool, each component is rated with a four-point scale ranging from non-functional to highly functional. In addition to assessing whether CHWs are part of functional programs, the tool includes lists of high impact, evidence-based interventions for MCH and HIV/TB services to guide assessment of which services the CHWs are currently performing.
The instrument can be applied in a stakeholder meeting to assess the current status of a specific program and determine if the program as a whole is functional. Health workers within that program are then considered to be functional. In addition to helping determine whether a CHW program is functional, the tool also provides an action planning and resources guide to assist program managers in strengthening their community health worker programs.