The Performance of Health Workers

Washington DCsch_iihpub3186pu

Public-private delivery of insecticide-treated nets: a voucher scheme in Volta Region, Ghana.

BACKGROUND: Coverage of vulnerable groups with insecticide-treated nets (ITNs) in Ghana, as in the majority of countries of sub-Saharan Africa is currently low. A voucher scheme was introduced in Volta Region as a possible sustainable delivery system for increasing this coverage through scale-up to other regions. Successful scale-up of public health interventions depends upon optimal delivery processes but operational research for delivery processes in large-scale implementation has been inadequate. METHODS: A simple tool was developed to monitor numbers of vouchers given to each health facility, numbers issued to pregnant women by the health staff, and numbers redeemed by the distributors back to the management agent. Three rounds of interviews were undertaken with health facility staff, retailers and pregnant women who had attended antenatal clinic (ANC). RESULTS: During the one year pilot 25,926 vouchers were issued to eligible women from clinics, which equates to 50.7% of the 51,658 ANC registrants during this time period. Of the vouchers issued 66.7% were redeemed by distributors back to the management agent. Initially, non-issuing of vouchers to pregnant women was mainly due to eligibility criteria imposed by the midwives; later in the year it was due to decisions of the pregnant women, and supply constraints. These in turn were heavily influenced by factors external to the programme: current household ownership of nets, competing ITN delivery strategies, and competition for the limited number of ITNs available in the country from major urban areas of other regions. CONCLUSION: Both issuing and redemption of vouchers should be monitored as factors assumed to influence voucher redemption had an influence on issuing, and vice versa. More evidence is needed on how specific contextual factors influence the success of voucher schemes and other models of delivery of ITNs. Such an evidence base will facilitate optimal strategic decision making so that the delivery model with the best probability of success within a given context is implemented. Rigorous monitoring has an important role to play in the successful scaling-up of delivery of effective public health interventions

The Performance of Health Workers

Washington DCsch_iihpub3186pu

Turning around an ailing district hospital: a realist evaluation of strategic changes at Ho Municipal Hospital (Ghana)

<p>Abstract</p> <p>Background</p> <p>There is a growing consensus that linear approaches to improving the performance of health workers and health care organisations may only obtain short-term results. An alternative approach premised on the principle of human resource management described as a form of 'High commitment management', builds upon a bundles of balanced practices. This has been shown to contribute to better organisational performance. This paper illustrates an intervention and outcome of high commitment management (HiCom) at an urban hospital in Ghana. Few studies have shown how HiCom management might contribute to better performance of health services and in particular of hospitals in low and middle-income settings.</p> <p>Methods</p> <p>A realist case study design was used to analyse how specific management practices might contribute to improving the performance of an urban district hospital in Ho, Volta Region, in Ghana. Mixed methods were used to collect data, including document review, in-depth interviews, group discussions, observations and a review of routine health information.</p> <p>Results</p> <p>At Ho Municipal Hospital, the management team dealt with the crisis engulfing the ailing urban district hospital by building an alliance between hospital staff to generate a sense of ownership with a focus around participative problem analysis. The creation of an alliance led to improving staff morale and attitude, and contributed also to improvements in the infrastructure and equipment. This in turn had a positive impact on the revenue generating capacity of the hospital. The quick turn around in the state of this hospital showed that change was indeed possible, a factor that greatly motivated the staff.</p> <p>In a second step, the management team initiated the development of a strategic plan for the hospital to maintain the dynamics of change. This was undertaken through participative methods and sustained earlier staff involvement, empowerment and feelings of reciprocity. We found that these factors acted as the core mechanisms underlying the changes taking place at Ho Municipal Hospital.</p> <p>Conclusions</p> <p>This study shows how a hospital management team in Ghana succeeded in resuscitating an ailing hospital. Their high commitment management approach led to the active involvement and empowerment of staff. It also showed how a realist evaluation approach such as this, could be used in the research of the management of health care organisations to explain how management interventions may or may not work.</p

A realist evaluation of the management of a well- performing regional hospital in Ghana

<p>Abstract</p> <p>Background</p> <p>Realist evaluation offers an interesting approach to evaluation of interventions in complex settings, but has been little applied in health care. We report on a realist case study of a well performing hospital in Ghana and show how such a realist evaluation design can help to overcome the limited external validity of a traditional case study.</p> <p>Methods</p> <p>We developed a realist evaluation framework for hypothesis formulation, data collection, data analysis and synthesis of the findings. Focusing on the role of human resource management in hospital performance, we formulated our hypothesis around the high commitment management concept. Mixed methods were used in data collection, including individual and group interviews, observations and document reviews.</p> <p>Results</p> <p>We found that the human resource management approach (the actual intervention) included induction of new staff, training and personal development, good communication and information sharing, and decentralised decision-making. We identified 3 additional practices: ensuring optimal physical working conditions, access to top managers and managers' involvement on the work floor. Teamwork, recognition and trust emerged as key elements of the organisational climate. Interviewees reported high levels of organisational commitment. The analysis unearthed perceived organisational support and reciprocity as underlying mechanisms that link the management practices with commitment.</p> <p>Methodologically, we found that realist evaluation can be fruitfully used to develop detailed case studies that analyse how management interventions work and in which conditions. Analysing the links between intervention, mechanism and outcome increases the explaining power, while identification of essential context elements improves the usefulness of the findings for decision-makers in other settings (external validity). We also identified a number of practical difficulties and priorities for further methodological development.</p> <p>Conclusion</p> <p>This case suggests that a well-balanced HRM bundle can stimulate organisational commitment of health workers. Such practices can be implemented even with narrow decision spaces. Realist evaluation provides an appropriate approach to increase the usefulness of case studies to managers and policymakers.</p

Evaluating Delivery Systems: Complex Evaluations and Plausibility Inference

Delivery system evaluation is poorly defined and therefore a barrier to achieving increased coverage of interventions. We use a pre- and post-implementation cross-sectional observational study with assessment of the intermediate processes to evaluate a new delivery system for insecticide-treated nets (ITNs) in two regions of Ghana. In Volta Region, ownership of at least one net rose from 38.3% to 45.4% (P = 0.06), and 6.5% of respondents used a voucher in the purchase. In Eastern Region, ownership of a net rose from 13.7% to 26.0% (P < 0.001) and 0.5% of households used a voucher to purchase a net. Just 40.7% and 21.1% of eligible antenatal clinic (ANC) attendees were offered a voucher in Volta and Eastern Regions, respectively, and 36.0% and 30.7% used their voucher in the purchase of an ITN. Without attributing nets to the specific delivery system, in Eastern Region the success of the new system would be overestimated

Translating research findings into practice – the implementation of kangaroo mother care in Ghana

Abstract Background Kangaroo mother care (KMC) is a safe and effective method of caring for low birth weight infants and is promoted for its potential to improve newborn survival. Many countries find it difficult to take KMC to scale in healthcare facilities providing newborn care. KMC Ghana was an initiative to scale up KMC in four regions in Ghana. Research findings from two outreach trials in South Africa informed the design of the initiative. Two key points of departure were to equip healthcare facilities that conduct deliveries with the necessary skills for KMC practice and to single out KMC for special attention instead of embedding it in other newborn care initiatives. This paper describes the contextualisation and practical application of previous research findings and the results of monitoring the progress of the implementation of KMC in Ghana. Methods A three-phase outreach intervention was adapted from previous research findings to suit the local setting. A more structured system of KMC regional steering committees was introduced to drive the process and take the initiative forward. During Phase I, health workers in regions and districts were oriented in KMC and received basic support for the management of the outreach. Phase II entailed the strengthening of the regional steering committees. Phase III comprised a more formal assessment, utilising a previously validated KMC progress-monitoring instrument. Results Twenty-six out of 38 hospitals (68 %) scored over 10 out of 30 and had reached the level of ‘evidence of practice’ by the end of Phase III. Seven hospitals exceeded expected performance by scoring at the level of ‘evidence of routine and institutionalised practice.’ The collective mean score for all participating hospitals was 12.07. Hospitals that had attained baby-friendly status or had been re-accredited in the five years before the intervention scored significantly better than the rest, with a mean score of 14.64. Conclusion The KMC Ghana initiative demonstrated how research findings regarding successful outreach for the implementation of KMC could be transferred to a different context by making context-appropriate adaptations to the model.</p