Health worker performance, practice and improvement

Health worker performance is a complex and contested concept. The World Health Report defines health worker performance as a composite function of health worker availability, competence, productivity and responsiveness (World Health Organization (WHO), 2006). A well-performing health workforce is thus one that “works in ways that are responsive, fair and efficient to achieve the best health outcomes possible, given the available resources and circumstances” (WHO, 2006, p. 67). This inclusive definition factors in both technical and relational aspects of health worker performance and forms a touchstone for this chapter’s examination of different approaches to performance measurement and evaluation. Nonetheless, this chapter clearly distinguishes health worker performance from the related concept of quality, viewing quality of care as the product of concurrent and synergistic actions to ensure effective, efficient, equitable, patient-centred and timely care (Institute of Medicine, 2001). Health worker performance is thus a critical and necessary – but not sufficient or always dominant – component of overall quality of care

The Lancet global health commission on high quality health systems—where's the complexity?

[Extract] The Lancet Global Health Commission on High Quality Health Systems in the Sustainable Development Goals (SDG) Era (HQSS Commission).1 The launch draws attention to the fact that high quality health care, rather than just access to health care, will be necessary to meet the health-related SDGs. The Commission aims to address the lack of an “agreed upon single definition” of high quality health systems and produce “science-led, multidisciplinary, actionable work with […] measurable indicators”. But phrases like single definition and measurable indicators in the context of an exercise seeking to strengthen quality in highly variable health systems in low-income and middle-income countries (LMICs) should raise red flags

Power and politics: the case for linking resilience to health system governance

[Extract:] Since the watershed moment of the 2014 Ebola epidemic in West Africa and again in the midst of the current COVID-19 crisis, the concept of health system resilience has been a recurring theme in global health discussions.1 2 Although most frequently used in the context of epidemic response, resilience has also been framed as a ‘key pillar’ of health,3 and invoked in high-level calls for countries to ‘lead the work on building health system resilience’.4 Yet, as the authors of one of several recent reviews observed, the concept of health systems resilience remains ‘highly confusing’ and ‘still polysemic’.5 What it means ‘depends on one’s perception, one’s discipline, one’s function and what one wants to achieve’.5 In this editorial, I will, from the perspective of a health policy and systems researcher, draw out and reflect on some of these tensions, and make some suggestions about how we might achieve greater clarit

Translating, Contexting, and Institutionalising Knowledge Translation Practices in Northern Australia: Some Reflections; Comment on “Sustaining Knowledge Translation Practices: A Critical Interpretive Synthesis”

In this commentary, we reflect on how the three processes of translating, contexting, and institutionalising knowledge translation (KT) practices, as introduced in a critical interpretive synthesis on sustaining KT, might be drawn on to improve KT sustainability in the northern Australian health system, and some likely challenges. The synthesis provides a useful reminder that health systems are social systems and offers an analytical framework against which to map approaches that aim to align knowledge production and utilisation. By positioning “places” of knowledge utilisation and actor roles and networks as key to KT sustainability, the framework also offers the potential to draw attention to non-clinical settings, actors, and relationships that are central to improving health, but that may be historically neglected in KT research and scholarship

Call for papers-the Alma Ata Declaration at 40: reflections on primary healthcare in a new era

[Extract] The Declaration of AlmaAta was a watershed moment in global health. Indeed, in the four decades since its launch, there is a sense in which all declarations or communiques issued at global health conferences have been aiming for comparable historical impact. Launched in 1978 at the International Conference on Primary HealthCare, the declaration called for 'Health for All by the Year 2000 and promoted comprehen-sive primary healthcare as the preferred back-bone of national health systems alongside a number of other key elements including an emphasis on global cooperation and peace; a new economic order to underpin it; acknowledgement of the social determinants of health; involvement of all sectors in the promotion of health; community participation in planning, implementation and regulation of primary healthcare; and a focus on achieving equity in health status. In totality, these elements—which became known as the 'primary healthcare approach' —flagged a paradigm shift away from the medical model of health planning and service delivery and towards a 'social model' with an emphasis on addressing social determinants of health via intersectoral public health and preventive strategies based on local ownership and community participation

Adaptation with robustness: the case for clarity on the use of 'resilience' in health systems and global health

[Extract] In the last 3 years, the concept of resilience has received much attention in the health systems and global health literature, triggered by the Ebola outbreak in West Africa (which, in 2014, exposed a lack of health system and global health resilience) and followed in 2016 by the Global Symposium on Health Systems Research (with the theme ‘Resilient and responsive health systems in a changing world’). Resilience has been widely embraced in the literature,1–5 and also by the immediate past6 and current7 WHO Director General. BMJ Global Health has also published several reports applying the concept of resilience to how health systems respond to acute shocks and chronic stress

Challenges to managing quality of care in northern Queensland residential aged care facilities

Background: Senior management teams in residential aged care facilities (RACFs) face a range of challenges in providing quality health care services. With increasing attention directed at quality problems in Australian RACFs, there is an urgent need to better understand the experiences of this crucial cadre. This qualitative study sought to identify challenges from the perspective of current senior managers in residential aged care (RAC) organisations and map their influence on the quality of health care provided within. Methods: 20 semi-structured interviews were conducted with senior managers in 14 RACFs in northern Queensland, Australia. Thematic analysis was used, combining inductive identification of managerial challenges and a mapping exercise to locate these encounters against health system quality dimensions in the Australian National Health Performance Framework (NHPF). Results: Reported challenges to promoting and sustaining quality health care within RACFs included barriers to recruiting and retaining skilled staff, service constraints resulting from geographical isolation, limited access to quality fiscal resources, and a recent change to regulatory and administrative requirements. Identified challenges touch on all sub-dimensions of the NHPF. Conclusion: Several forces, many structural, currently challenge quality health care services in northern Queensland RACFs. Senior management teams come under substantial pressure and are developing short term solutions to protect quality in the face of often chronic and structural challenges. Alongside work to address macro-level issues, more work is needed to understand the personal and professional attributes of senior managers who are successful in positively influencing facility-level quality issues

A qualitative study of the role of workplace and interpersonal trust in shaping service quality and responsiveness in Zambian primary health centres

Background: Human decisions, actions and relationships that invoke trust are at the core of functional and productive health systems. Although widely studied in high-income settings, comparatively few studies have explored the influence of trust on health system performance in low- and middle-income countries. This study examines how workplace and inter-personal trust impact service quality and responsiveness in primary health services in Zambia. Methods: This multi-case study included four health centres selected for urban, peri-urban and rural characteristics. Case data included provider interviews (60); patient interviews (180); direct observation of facility operations (two weeks/centre) and key informant interviews (14) that were recorded and transcribed verbatim. Case-based thematic analysis incorporated inductive and deductive coding. Results: Findings demonstrated that providers had weak workplace trust influenced by a combination of poor working conditions, perceptions of low pay and experiences of inequitable or inefficient health centre management. Weak trust in health centre managers' organizational capacity and fairness contributed to resentment amongst many providers and promoted a culture of blame-shifting and one-upmanship that undermined teamwork and enabled disrespectful treatment of patients. Although patients expressed a high degree of trust in health workers' clinical capacity, repeated experiences of disrespectful or unresponsive care undermined patients' trust in health workers' service values and professionalism. Lack of patient–provider trust prompted some patients to circumvent clinic systems in an attempt to secure better or more timely care. Conclusion: Lack of resourcing and poor leadership were key factors leading to providers' weak workplace trust and contributed to often-poor quality services, driving a perverse cycle of negative patient–provider relations across the four sites. Findings highlight the importance of investing in both structural factors and organizational management to strengthen providers' trust in their employer(s) and colleagues, as an entry-point for developing both the capacity and a work culture oriented towards respectful and patient-centred care

Health inequality in the tropics and its costs: a Sustainable Development Goals alert

Background: It is known that health impacts economic performance. This article aims to assess the current state of health inequality in the tropics, defined as the countries located between the Tropic of Cancer and the Tropic of Capricorn, and estimate the impact of this inequality on gross domestic product (GDP). Methods: We constructed a series of concentration indices showing between-country inequalities in disability-adjusted life years (DALYs), taken from the Global Burden of Disease Study. We then utilized a non-linear least squares model to estimate the influence of health on GDP and counterfactual analysis to assess the GDP for each country had there been no between-country inequality. Results: The poorest 25% of the tropical population had 68% of the all-cause DALYs burden in 2015; 82% of the communicable, maternal, neonatal and nutritional DALYs burden; 55% of the non-communicable disease DALYs burden and 61% of the injury DALYs burden. An increase in the all-cause DALYs rate of 1/1000 resulted in a 0.05% decrease in GDP. If there were no inequality between countries in all-cause DALY rates, most high-income countries would see a modest increase in GDP, with low- and middle-income countries estimated to see larger increases. Conclusions: There are large and growing inequalities in health in the tropics and this has significant economic cost for lower-income countries

From favours to entitlements: community voice and action and health service quality in Zambia

Social accountability is increasingly invoked as a way of improving health services. This article presents a theory-driven qualitative study of the context, mechanisms and outcomes of a social accountability program, Citizen Voice and Action (CVA), implemented by World Vision (WV) in Zambia. Primary data were collected between November 2013 and January 2014. It included in-depth interviews and focus group discussions with program stakeholders. Secondary data were used iteratively—to inform the process for primary data collection, to guide primary data analysis and to contextualize findings from the primary data. CVA positively impacted the state, society, state–society relations and development coordination at the local level. Specifically, sustained improvements in some aspects of health system responsiveness, empowered citizens, the improved provision of public goods (health services) and increased consensus on development issues appeared to flow from CVA. The central challenge described by interviewees and FGD participants was the inability of CVA to address problems that required central level input. The mechanisms that generated these outcomes included productive state–society communication, enhanced trust, and state–society co-production of priorities and the provision of services. These mechanisms were activated in the context of existing structures for state–society interaction, willing political leaders, buy-in by traditional leaders, and WV’s strong reputation and access to resources. Prospective observational research in multiple contexts would shed more light on the context, mechanisms and outcomes of CVA programs. In addition to findings that are intuitive and well supported in the literature we identified new areas that are promising areas for future research. These include (1) the context of organizational reputation by the organization(s) spearheading social accountability efforts; (2) the potential relationship between social accountability efforts and making ambitious national programs operational at the frontlines of the health system and (3) the feasibility of scale up for certain types of local level responsiveness