IMPROVING HEALTH WORKER PRODUCTIVITY AND

PERFORMANCE IN THE CONTEXT OF UNIVERSAL HEALTH

COVERAGE: THE ROLES OF STANDARDS, QUALITY IMPROVEMENT,

AND REGULATION TECHNICAL WORKING GROUP (TWG) #7

This paper serves as a background report to inform the Global Strategy for Human Resources for Health.

The development of this paper has been coordinated through a thematic working group (TWG),

comprising of 2 co-chairs and a group of experts drawn from various Global Health Workforce Alliance

(GHWA) constituencies, operating under the oversight of the GHWA Board working group. The views

expressed in the paper, do not necessarily reflect the official position of GHWA. All reasonable

precautions have been taken by the co-chairs to verify the information presented in the papers.

- DRAFT FOR CONSULTATION -

Not to be quoted or referenced without prior permission from

the authors. Not for wider distribution.

Final Draft – August 29, 2014 1

IMPROVING HEALTH WORKER

PRODUCTIVITY AND PERFORMANCE IN

THE CONTEXT OF UNIVERSAL HEALTH

COVERAGE: THE ROLES OF STANDARDS,

QUALITY IMPROVEMENT, AND

REGULATION – FINAL DRAFT

BY TECHNICAL WORKING GROUP #7

CO-CHAIRS:

Frances Day-Stirk

President, International Confederation of Midwives (ICM)

The Hague, Netherlands

M. Rashad Massoud, MD, MPH, FACP

Director, USAID Applying Science to Strengthen and Improve Systems Project,

Senior Vice President, Quality & Performance Institute,

University Research Co. LLC. - Center for Human Services

Bethesda, Maryland, USA

Final Draft – August 29, 2014 2

INTRODUCTION

The Global Health Workforce Alliance (GHWA) has coordinated a global consultation, with the objective

to inform a future strategy on human resources for health (HRH) that will be relevant to the post-2015

development agenda (2015-2030) for all countries at all stages of socio-economic development. The

consultation builds on earlier work on the HRH implications of Universal Health Coverage (UHC), with

additional analyses of: future scenarios in the period 2015-2030; multi-sectoral government activities,

such as the International Labor Organization’s work with its Member States on strengthening social

protection systems, and; opportunities arising from the anticipated economic, demographic, and

epidemiologic transitions in many low- and middle-income countries. The consultation includes eight

themesi that can contribute to the overall development of a forward-looking strategy. The objective of

this paper by Working Group #7 is to examine the evidence and provide recommendations on the roles

of standards, quality improvement, and regulation for improving health worker productivity and

performance at all levels of the health system (see Table 1 for working definitions used in the paper).

We present a framework based on the review of selected evidence of factors promoting and impeding

productive and performance (Figure 1).

Table 1: Working Definitions

Human resources management

Interventions that aim for effective utilization of human resources in an organization1

Incentives All the rewards and punishments that providers face as a consequence of the organizations in which they work, the institutions under which they operate and the specific interventions they provide

2

Pay for performance The transfer for money or material goods conditional on taking a measurable health related action or achieving a predetermined performance target

3

Performance Performance of health workers includes the quality of their work, the technical skills they

use, the care they deliver, and the impact of their work on health outcomes.4

i Working group themes: 1)The drivers of change in health labor markets; 2) The role of transformative education;

3)Data and measurement of HRH availability, accessibility, acceptability and quality; 4) Accountability and

alignment for post-2015: the roles and responsibilities of state and non-state actors; 5) Leadership, governance

and policy alignment in public/private health systems; 6) The drivers of change in Fragile States; 7) Improving

productivity and performance: the roles of regulation, professional associations and standards; and 8) Building on

human capability beyond the health sector.

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Productivity Productivity of health workers is determined by the setting in which they work, their level of motivation, work organization, management capacity, the division of labor and other resources (e.g., equipment, drugs, examination rooms, and other characteristics of the setting) available.

5

Quality Quality of care is the function of the healthcare delivery system to deliver safe, effective, and patient-centered care in an efficient, timely and equitable manner. The Institute of Medicine (IoM) defines quality of care as the “degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”

6

Recognition systems A systematic approach or strategy to acknowledge, reward, and motivate the performance of health workers to provide quality health services through appropriate financial and non-financial incentives.

7

Regulation All those legitimate, appropriate and sustained means where order identify, consistency, control and accountability are brought to health systems through legally enforced and/or voluntary action.

8

Standards Explicit statements of expected quality in the performance of a healthcare activity – i.e., how a particular healthcare activity will be performed in order to produce the desired results. May take the form of procedures, clinical practice guidelines, treatment protocols, critical paths, algorithms, standard operating procedures, or statements of expected healthcare outcomes.

9

BACKGROUND

Improving health workers’ performance and productivity is vital to improving health care delivery, the

Millennium Development Goals, and commitments, policies, and actions beyond 2015. The evolving

momentum for Universal Health Coverage offers an important opportunity to look at HRH challenges in

the context of UHC.10 During the last decade, numerous intergovernmental resolutions as well as action

plans have highlighted the importance of HRH investments.11-16 However, policy makers and program

planers still struggle to determine the correct set of actions to improve worker performance and

productivity.

Critical human resources shortages, particularly in low-resource settings, require that we not only

develop long-term strategies for increased production and retention of health workers 17 but more

importantly that we strengthen the productivity and performance of the workforce we have so as to get

the best possible results and the highest impact with existing resources.

Health worker performance barriers such as unclear roles and expectations, unclear guidelines, poor

processes of work, inappropriate skills mix within the work setting, competency gaps, lack of feedback,

difficult work environments and unsuitable incentives mean that even where there are no critical

workforce shortages, health workers may still fail to provide quality care. While substantive evidence of

the effectiveness of different types of interventions to improve worker performance and productivity is

still limited, salient features are emerging from existing studies and country experiences that can help

inform a strategy for optimizing the performance and productivity of health workers and health worker

teams.18-19

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METHODS

This paper was developed by a group of experts comprised of representatives of professional

associations, non-governmental organizations, multi-lateral organizations and bilateral organizations

representing all regions of the world. The paper and its recommendations were informed by a targeted

desk study of published and grey material. In addition, detailed feedback from a group of expert

reviewers on the roles of quality improvement, regulation in HRH, and standards in addressing health

worker performance and productivity was obtained on drafts of the paper. An adaptation of the

Dieleman et al. framework formed the focus and direction of the paper (Figure 1).20

IMPROVING HEALTH WORKER PERFORMANCE AND PRODUCTIVITY

FRAMEWORK OVERVIEW

Figure 1 highlights that the determinants of health workers‘ performance and productivity are rooted in

factors related to: 1) the macro, or overall health systems, socio-economic/labor market, and political

level; 2) the micro level, such as the workplace itself or the communities in which health workers live;

and 3) the individual characteristics of health workers themselves.21 HRH interventions such as

standards of health care, quality improvement and regulation (inputs and processes) work in a dynamic

relationship with each other to improve health worker performance and productivity: Standards should

codify the evidence based interventions that should be incorporated into practice and the performance

expectations in the delivery or implementation of quality of health services. Standards drive the

improvement efforts needed to ensure their reliable implementation in everyday practice, yet at the

same time the experience of improving care can shed light on the realities of how to implement the

statndards and can consequently inform the revisions of these standards. Through regulatory

approaches, governments can establish expectations for the competence of healthcare providers and

the standards of the services.

Other inputs and processes such as strong human resource management and recognition systems to

support quality services and ongoing monitoring and evaluation of care processes are also needed to

improve the availability, responsiveness, and competence of the health workforce. As will be described

in the following sections, there is no clear linear relationship between inputs, processes and outcomes,

and between outcomes and effects. Instead, these issues are intricately related to each other and

interventions must be comprehensive and multifaceted, taking place simultaneously and at different

levels of the health system.22

KEY FINDINGS FROM EVIDENCE, RECOMMENDATIONS, AND AGENDA ITEMS THAT NEED TO

BE ADDRESSED IN THE FUTURE

STANDARDS

Global standards, or those adapted to a local situation, are explicit statements of expected quality in the

performance of a health care activity.23 They may take the form of procedures, clinical practice

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guidelines, treatment protocols, critical paths, algorithms, standard operating procedures, or statements

of expected health care outcomes, among other formats.

Standards communicate expectations for how a particular health care activity will be performed in order

that it achieve the desired results and define, for both health workers and clients, what is needed to

produce quality services. Standards are thus the cornerstone of most health care improvement

approaches, including accreditation of health facilities, external quality evaluation, continuous quality

improvement, and performance improvement. In fields like health care that are continuously evolving

with the development of new technologies, drugs, and procedures and that have an enormous body of

scientific evidence available to support clinical decision-making, ensuring that standards are regularly

updated, communicated to providers, and “evidence-based” is critical to assuring health care

effectiveness and outcomes.

Adherence to evidence-based standards has been shown to be associated with improved health

outcomes.24 Similarly/conversely failure to provide clinical care in accordance with evidence-based

standards has serious negative effects on patient outcomes.25 A substantial body of research on

guidelines implementation suggests many reasons why standards-based performance is often difficult to

achieve and sustain. At the most basic level, health workers may simply not be familiar with standards

because these have not been clearly communicated or disseminated from national to facility level. In

other cases, systemic factors such as lack of the necessary supplies or equipment to perform according

to standards; poor monitoring and evaluation of guideline implementation; and lack of human resources

can affect implementation of standards. Evidence has shown that combinations of interventions are

more effective than single interventions to induce and maintain health workers’ adherence to evidence

based-standards (e.g., graphic aids; clarity and repetition of messages; provision of opportunities to

discuss and try out new behaviors; making desired behaviors compatible with existing practices; and

approval and support of patients, peers, and supervisors).26

Proposed agenda:

1. Better tools and processes are needed that help health care providers know about evidence-based

standards in order to apply standards in their daily work. Further research is needed to test locally

appropriate and sustainable strategies for helping healthcare providers perform according to

standards in diverse and resource constrained conditions, including primary health care facilities

with non-physician health workers.

QUALITY IMPROVEMENT

The science of improvement aims at making systematic changes in the way healthcare is delivered to

increase the likelihood that those changes will result in better care. Despite an abundance of evidence-

based guidelines and consensus on what should be done, many simple, high-impact interventions

capable of saving lives and alleviating suffering are not reaching the people who most need them. Much

of this implementation gap is related to poorly designed processes of care delivery and weak health

systems. The fundamental concept of improvement science is that improvement requires change.

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Because not every change makes care better, changes must be tested to determine whether the change

improves care.27 Quality improvement approaches (e.g., implementation, execution, delivery, etc…) aim

to enable the health system, teams, and individuals to find ways in which to provide evidence based

interventions to performance expectations on a routine basis for every patient, every time in the most

safe, effective, patient-centered, timely, efficient, equitable way.28

Improving health worker engagement, performance, and productivity:

To achieve UHC so that all sectors of the population have access to quality care involves improving the

performance of the health workforce at every system level – sub-national management levels, local

facilities, and communities. To do so, we need to strengthen the capacity of managers, frontline

providers, community health workers, and volunteers to manage their own performance, identify

strategies for improving care, and monitor and evaluate best practices and health outcome results, so

that evidence will inform decisions and shape policies. This capacity, developed at all delivery levels,

results in strengthened systems and sustained quality of care.29

Much of the current focus of quality improvement has been on redesigning care delivery processes to

enable providers to follow evidence-based guidelines. These experiences in adapting improvement

methods to work across organizations levels are showing promising results.30 Employee involvement

through quality improvement teams has resulted in improved processes of care and patient outcomes.31

Bringing teams of health workers from across the levels of the health system to work together in

improvement teams allows the system to tap into their knowledge of the system’s inner workings and

develop potential solutions that can work. Engaging health workers in the design, testing and

implementation of changes enables clinical and non-clinical health workers at all levels of the system to

innovate and test practical ways that better utilize existing resources to improve health care.32-33

Educating health workers may only further magnify the “know-do” gap if health workers do not see

themselves as agents of change and are not empowered to make changes.34 Increased engagement

among nurses, for example, in high income countries has been associated with greater patient

satisfaction, nurse retention, and morale; lowered complications; and improved clinical measures such

as reduced infections and medication errors.35 Similarly, a recent unpublished study from Tanzania

found that health facilities with health workers with below average levels of engagement had three

times the proportion of HIV clients that were lost to follow-up.36 Since most providers who participate in

improvement activities carry out this work without compensation, suggests that non-material incentives

are at play. Research in this area is just beginning and we need to understand better what motivates

providers to participate in improvement activities and build these factors into their improvement

work.37

Improving health worker in-service training effectiveness, efficiency, and sustainability

A large portion of funding has been spent on in-service training (IST) to rapidly build health worker

competence to provide quality services. IST has gained prominence as a method to rapidly build health

worker competencies at scale. However challenges such as unnecessary duplication in training and

significant service disruptions have raised questions of the effectiveness, efficiency, and sustainability of

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training investments. Organizations such as the USAID Applying Science to Strengthen and Improve

Systems (ASSIST) Project have responded by developing and launching the Global Health Worker In-

service Training Improvement Framework, which codifies 40 training recommendations.38

Integrating improvement competencies into pre-service and in-service training

All health systems have some aspect of dysfunction, inefficiency, and ineffectiveness and continuous

improvement is a necessary part of day to day work for all health workers. While health worker

education and training systems have been doing increasingly better to build specific competencies to

practice in their profession, most health professions’ education and training systems are not equipping

health workers with the competencies to brainstorm, test, study, implement, and spread changes.

Consequently, improvement initiatives depend on ad hoc in-service training, while staff turnover and

rotations dilute the capacity of improvement teams.39

A key precondition to the sustainability of past and current investments in health care improvement is

the availability of a current and future workforce across the health system that has the competence to

lead and participate in improving care. Work is being conducted in the East Africa Region to define basic

core improvement competencies that can be integrated into health worker education and training, as

well as incorporating improvement competencies into pre-service training.40 There is currently a dearth

of literature and opportunities for shared learning to integrate improvement competencies into health

worker education and training. Going forward, a platform is needed to bring together key stakeholders

to share learning, curricula, evaluations, and adult learning methodologies.

Proposed agenda

1. Further research of improvement applications in worker productivity and performance is necessary

to determine how sustained results can be best achieved across time. Most experience in

developing and even in developed countries of improvement applications and health worker

productivity are based on time limited projects. There are very few examples where national spread

of quality improvement has worked over extended periods of time to ensure sustained results.41 42

2. Use innovative approaches such as best practices benchmarking or institution to institution

partnerships to share improvement approaches and results across thematic areas and sites with

policy makers and program implementers. Replicating results across type of settings, i.e. taking

improvement approaches usable in surgery and adapting them for safe childbirth, have rarely been

done successfully. In many cases, the approach is designed from scratch rather than sharing

approaches and results across sites.

3. Additional research is needed to address the role of improvement approaches to HRH interventions

such as task sharing, referral systems, pre-service training for quality improvement, motivation of

providers to carry out quality improvement work through non-material incentives, as well as

integrating quality improvement approaches into the private sector (i.e., large networks of NGOs).43

4. Improvement is top led, bottom fed. Priority-setting and empowerment for change is a leadership

function. Insightful testing and implementing of changes happen by the staff delivering the work

Final Draft – August 29, 2014 8

processes. This top-bottom relationship and how it can be enhanced is worthy of further

investigation.

5. There is limited research on the relationship between health worker engagement and healthcare

improvement in low resource settings. Further research is required to strengthening our

understanding of health worker engagement and interventions that can better engage health

workers to improve care.

REGULATION

The purpose of health professional regulation is to define and set rules regarding standards for

professional practice and education to ensure that health professionals are competent to practice at a

standard acceptable to the public who are recipients of that care.44 Regulators do so by holding

registers of individuals who meet their standards of education, training, professional skills, behavior and

health. There are four recognized elements: registration, standard setting, accreditation and

management of conduct, performance and impairment matters.45

The 2006 World Health Report identified major deficits in regulator systems while outlining three basic

models of regulatory systems: self-regulating professional associations; the command and control

approach of institutional regulators; and the advocacy of civil society. The report highlights that,

individually, none of these is sufficient to regulate the behavior of health workers and institutions and

concludes that “regulations resulting from the participation of all three bodies, as well as health care

institutions and the workforce, are more likely to generate trust and cooperation.” 46

As the scope of practice of existing practitioners has expanded, and the range of health workers has

increased, the issue of unique scopes of practice and overlapping responsibilities have presented task-

sharing as a challenge rather than a means of better meeting patient and population needs. 47

The evidence base on the whole focused on single profession or jurisdictional experience. With few

exceptions studies have been descriptive in nature and rarely examined aspects of the most efficient

and effective means of implementing regulatory systems and processes. Yet the aspects that need to be

addressed from multiple country case studies are consistent – regulation that protects the public yet

facilitates change; a register of the competent and practicing rather than those that have simply

completed a program; oversight or accreditation of pre-service education programs; mechanisms to

assure continuing competence; approaches that enable amendment of scopes of practice to meet

changing health needs; fair and transparent processes that support practitioner mobility and

simultaneously protect the public; and a range of conduct and competence approaches that are

proportionate to risk and efficient and effective to operate.

A consistent legal framework enables regulators to uphold their duty to protect the public yet,

dissonance between ministries of education, health, labor and others have contributed to fragmentation

and inefficiencies in planning.48 It has been argued that a systems based approach is needed to address

these and other performance gaps.49 Recently the African Health Professions Regulatory Collaborative

for Nurses and Midwives (ARC), a 17-country initiative, introduced a system-based approach for country

Final Draft – August 29, 2014 9

assessment regarding regulatory reform and a methodology to track and assess change. 50-52 Regulatory

reforms cannot be done in isolation or without regard to the cultural and legal traditions of the

jurisdictions concerned or other regulatory and quality assurance systems that interface and interact

with professional regulation.

Proposed agenda

1. Distil from available evidence a systems based approach to the development and

implementation of contemporary statutes and regulatory mechanisms and processes.

2. Undertake research to characterize/identify the impact of regulations and quality assurance

features that need to be addressed by any regulatory system so as to underpin the attainment

of UHC and improved population health.

3. Identify research gaps and propose a list of priorities for study that will focus on enhancing the

performance of regulatory systems.

OTHER FACTORS

This paper has focused specifically on the roles of standards, quality improvement, and regulation for

improving health worker productivity and performance at all levels of the health system. There are

many other factors that influence workforce performance and productivity. For example, there is a

growing body of research that shows that that job satisfaction, productivity and organizational

commitment – all “influencers” of quality and performance – are affected by management and

governance systems and leadership practices. Recent reviews of human resources management,

supervision and mentoring interventions identified key success factors to include: active involvement of

staff to identify and implement solutions to problems, active involvement of stakeholders in program

design, implementation and evaluation; organizational commitment and leadership; and networking and

supportive relationships.53 -54 Other important predictors of health worker performance and productivity

include:

Community involvement: The role of communities is significant for community health workers, whose

performance depends upon support from both the community and formal health system.55 Supervision

and management of communities’ health workers is historically provided by the health system yet often

reported as weak and ineffective. 56-66 It is necessary that level and scope of supervision is clearly

articulated to ensure that the supervisor and supervised understand what is expected of each in the

particular context. Experience with community involvement in supervision of community health

workers includes: provision of feedback on evaluations67 public recognition of performance and

contribution68 and provision of feedback and monitoring through village health committees.

Recognition systems: Research is showing that nonmonetary incentives (linked to health workers’ career

development, working environment – e.g., individualized mentoring, performance reviews with

feedback, continuing education, supportive career structures, non-monetary recognition of good

performance) are as important as financial incentives.69 There is mounting evidence that intrinsically

motivated public service providers (i.e. desire to perform an activity for no apparent reward other than

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the activity itself)70 “exert more effort and require fewer extrinsic incentives than self-interested

providers”71 -74and that the provision of financial incentives can undermine motivation, conflict with or

reduce intrinsic motivation, “worsen performance on complex cognitive tasks” and “reduce the desire to

perform an activity for its inherent rewards (e.g. pride in excellent work, empathy with patients)”.75-80

Even in cases where financial incentives have worked, they were “not the sole reason, and often not the

main reason, for motivation” but that other motivators such as recognition and esteem (i.e., from

public, peer, manager, community), appreciation (i.e. from managers, peers, patients, community),

conducive workplace norms and conditions, and opportunities for professional advancement and

development are also key. 81-83

CONCLUSION

This paper has highlighted the theme of the roles of standards, quality improvement, and regulation for

improving health worker productivity and performance in the context of UHC. As mentioned above, this

theme is not exhaustive in the factors influencing health worker productivity and performance, however

when addressed by a deliberate design can contribute to a forward looking strategy on HRH that will be

relevant to the post-2015 development agenda. Specific recommendations include:

Recommendation 1 (Standards): Conduct further research to test locally appropriate and sustainable

strategies for helping healthcare providers perform according to evidence-based standards in diverse

conditions; continually improve tools and processes to help health providers know about evidence-

based standards and apply them in their daily work.

Recommendation 2 (Quality improvement): Conduct further research and share results on the effect of

quality improvement approaches as a core strategy for better healthcare and health workforce

performance and productivity.

Recommendation 3 (Regulation): Adopt a systems based approach to develop and implement

contemporary regulatory structures and processes that align with changing health, education, and social

needs.

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Figure 1: Framework for improving health worker performance and productivity

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