Documenting Community Health Worker Compensation Schemes and Their Perceived Effectiveness in Seven sub-Saharan African Countries: A Qualitative Study.

INTRODUCTION: Community health worker (CHW) incentives and remuneration are core issues affecting the performance of CHWs and health programs. There is limited documentation on the implementation details of CHW financial compensation schemes used in sub-Saharan African countries, including their mechanisms of delivery and effectiveness. We aimed to document CHW financial compensation schemes and understand CHW, government, and other stakeholder perceptions of their effectiveness. METHODS: A total of 68 semistructured interviews were conducted with a range of purposefully selected key informants in 7 countries: Benin, Burkina Faso, Ghana, Malawi, Mali, Niger, and Zambia. Thematic analysis of coded interview data was conducted, and relevant country documentation was reviewed, including any documents referenced by key informants, to provide contextual background for qualitative interpretation. RESULTS: Key informants described compensation schemes as effective when payments are regular, distributions are consistent, and amounts are sufficient to support health worker performance and continuity of service delivery. CHW compensation schemes associated with an employed worker status and government payroll mechanisms were most often perceived as effective by stakeholders. Compensation schemes associated with a volunteer status were found to vary widely in their delivery mechanisms (e.g., cash or mobile phone distribution) and were perceived as less effective. Lessons learned in implementing CHW compensation schemes involved the need for government leadership, ministerial coordination, community engagement, partner harmonization, and realistic transitional financing plans. CONCLUSION: Policymakers should consider these findings in designing compensation schemes for CHWs engaged in routine, continuous health service delivery within the context of their country's health service delivery model. Systematic documentation of the tasks and time commitment of volunteer status CHWs could support more recognition of their health system contributions and better determination of commensurate compensation as recommended by the 2018 World Health Organization Guidelines on Health Policy and System Support to Optimize Community Health Worker Programs.

Use of Supervision Data to Improve Quality of Care for Malaria in Pregnancy: Experience in Six African Countries.

Malaria in pregnancy (MiP) intervention coverage, especially intermittent preventive treatment in pregnancy (IPTp), lags behind other global malaria indicators. In 2020, across Africa, only 32% of eligible pregnant women received at least three IPTp doses, despite high antenatal care attendance. We conducted a secondary analysis of data collected during Outreach Training and Supportive Supervision visits from 2019 to 2020 to assess quality of care and explore factors contributing to providers' competence in providing IPTp, insecticide-treated nets, malaria case management, and respectful maternity care. Data were collected during observations of provider-patient interactions in six countries (Cameroon, Cote d'Ivoire, Ghana, Kenya, Mali, and Niger). Competency scores (i.e., composite scores of supervisory checklist observations) were calculated across three domains: MiP prevention, MiP treatment, and respectful maternity care. Scores are used to understand drivers of competency, rather than to assess individual health worker performance. Country-specific multilinear regressions were used to assess how competency score was influenced by commodity availability, training, provider gender and cadre, job aid availability, and facility type. Average competency scores varied across countries: prevention (44-90%), treatment (78-90%), and respectful maternity care (53-93%). The relative association of each factor with competency score varied. Commodity availability, training, and access to job aids correlated positively with competency in multiple countries. To improve MiP service quality, equitable access to training opportunities for different cadres, targeted training, and access to job aids and guidelines should be available for providers. Collection and analysis of routine supervision data can support tailored actions to improve quality MiP services.

Improving Malaria Case Management and Referral Relationships at the Primary Care Level in Ghana: Evaluation of a Quality Assurance Internship.

In Ghana, Community-based Health Planning and Services (CHPS) compounds managed by trained nurses and midwives called community health officers (CHOs) play a major role in malaria service delivery. With heavy administrative burdens and minimal training in providing patient care, particularly for febrile illnesses, including malaria, CHOs struggle to comply with the World Health Organization's test, treat, and track initiative guidelines and appropriate referral practices. A clinical training and mentorship program was implemented for CHOs to prevent and manage uncomplicated malaria and offer appropriate pre-referral treatment and referrals to district hospitals. Medical officers, pharmacists, midwives, health information officers, and medical laboratory scientists at 52 district referral hospitals were trained as mentors; CHOs from 520 poorly performing CHPS compounds underwent a 5-day internship at their assigned district referral hospital to improve knowledge and clinical skills for malaria case management. Three months later, mentors conducted post-training mentoring visits to assess knowledge and skill retention and provide ongoing on-the-job guidance. Significant percentage-point increases were observed immediately post-internship for history taking (+12.0, 95% confidence interval [CI]=8.3, 15.1; P<.001); fever assessment (+24.9, 95% CI=20.9, 29.3; P<.001); severe malaria assessment and referral (+32.0, 95% CI=28.2, 35.8; P<.001); and knowledge assessment (+15.8, 95% CI=10.0, 21.3; P<.001). Three months later, a third assessment revealed these gains were largely maintained. Analysis of national health management information system data showed statistically significant improvements in testing, treatment, and referral indicators at intervention CHPS compounds after the intervention that were not observed in comparison CHPS compounds. This training and mentorship approach offers a replicable model to build primary care provider competencies in malaria prevention and management and demonstrates how developing relationships between primary care and first-level referral facilities benefits both providers and clients. More methodologically rigorous studies are needed to measure the impact of this approach.

"It builds your confidence you've done well": Healthcare workers' experiences of participating in a low-dose, high-frequency training to improve newborn survival on the day of birth in Ghana.

Background: The majority of newborn deaths occur during the first week of life, and 25‒45% occur within the first 24 hours. A low-dose, high-frequency (LDHF) training approach was introduced in 40 hospitals in Ghana to improve newborn survival. The aim of this qualitative study was to explore healthcare workers' experiences with the LDHF approach to in-service training. Methods: A total of 20 in-depth interviews and nine focus group discussions were conducted in 2016 in three regions of Ghana with healthcare workers who participated in implementation of the LDHF training approach. In-depth interviews were conducted with 20 master mentors and peer practice coordinators; 51 practicing doctors, midwives and nurses participated in focus group discussions. Data were analyzed using a thematic analysis approach. Results: Healthcare workers reflected on the differences between the LDHF approach and past learning experiences, highlighting how the skills-based team training approach, coupled with high-frequency practice and mobile mentoring, built their competency and confidence. As participants shared their experiences, they highlighted relationships established between Master Mentors and healthcare workers, and motivation stemming from pride in contributing to reductions in maternal and newborn deaths as critical factors in improving quality of care at participating health facilities. Conclusion: This nested qualitative study documents experiences of healthcare workers and mentors involved in implementation of a multi-faceted intervention that effectively improved maternal and newborn care at health facilities in Ghana. The way the intervention was implemented created an environment conducive to learning within the hospital setting, thus providing an opportunity for professional growth and quality improvement for all staff working in the maternity ward.

Accelerating newborn survival in Ghana through a low-dose, high-frequency health worker training approach: a cluster randomized trial.

BACKGROUND: Newborn deaths comprise nearly half of under-5 deaths in Ghana, despite the fact that skilled birth attendants (SBAs) are present at 68% of births, which implies that evidence-based care during labor, birth and the immediate postnatal period may be deficient. We assessed the effect of a low-dose, high-frequency (LDHF) training approach on long-term evidence-based skill retention among SBAs and impact on adverse birth outcomes. METHODS: From 2014 to 2017, we conducted a cluster-randomized trial in 40 hospitals in Ghana. Eligible hospitals were stratified by region and randomly assigned to one of four implementation waves. We assessed the relative risks (RRs) of institutional intrapartum stillbirths and 24-h newborn mortality in months 1-6 and 7-12 of implementation as compared to the historical control period, and in post-intervention facilities compared to pre-intervention facilities during the same period. All SBAs providing labor and delivery care were invited to enroll; their knowledge and skills were assessed pre- and post-training, and 1 year later. RESULTS: Adjusting for region and health facility type, the RR of 24-h newborn mortality in the 40 enrolled hospitals was 0·41 (95% CI 0·32-0·51; p < 0.001) in months 1-6 and 0·30 (95% CI 0·21-0·43; p < 0·001) in months 7-12 compared to baseline. The adjusted RR of intrapartum stillbirth was 0·64 (95% CI 0·53-0·77; p < 0·001) in months 1-6 and 0·48 (95% CI 0·36-0·63; p < 0·001) in months 7-12 compared to baseline. Four hundred three SBAs consented and enrolled. After 1 year, 200 SBAs assessed had 28% (95% CI 25-32; p < 0·001) and 31% (95% CI 27-36; p < 0·001) higher scores than baseline on low-dose 1 and 2 content skills, respectively. CONCLUSIONS: This training approach results in a sustained decrease in facility-based newborn mortality and intrapartum stillbirths, and retained knowledge and skills among SBAs after a year. We recommend use of this approach for future maternal and newborn health in-service training and programs. TRIAL REGISTRATION: Retrospectively registered on 25 September 2017 at Clinical Trials, identifier NCT03290924 .

Incremental cost and cost-effectiveness of low-dose, high-frequency training in basic emergency obstetric and newborn care as compared to status quo: part of a cluster-randomized training intervention evaluation in Ghana.

BACKGROUND: Low-dose, high-frequency (LDHF) training is a new approach best practices to improve clinical knowledge, build and retain competency, and transfer skills into practice after training. LDHF training in Ghana is an opportunity to build health workforce capacity in critical areas of maternal and newborn health and translate improved capacity into better health outcomes. METHODS: This study examined the costs of an LDHF training approach for basic emergency obstetric and newborn care and calculates the incremental cost-effectiveness of the LDHF training program for health outcomes of newborn survival, compared to the status quo alternative of no training. The costs of LDHF were compared to costs of traditional workshop-based training per provider trained. Retrospective program cost analysis with activity-based costing was used to measure all resources of the LDHF training program over a 3-year analytic time horizon. Economic costs were estimated from financial records, informant interviews, and regional market prices. Health effects from the program's impact evaluation were used to model lives saved and disability-adjusted life years (DALYs) averted. Uncertainty analysis included one-way and probabilistic sensitivity analysis to explore incremental cost-effectiveness results when fluctuating key parameters. RESULTS: For the 40 health facilities included in the evaluation, the total LDHF training cost was $823,134. During the follow-up period after the first LDHF training-1 year at each participating facility-approximately 544 lives were saved. With deterministic calculation, these findings translate to $1497.77 per life saved or $53.07 per DALY averted. Probabilistic sensitivity analysis, with mean incremental cost-effectiveness ratio of $54.79 per DALY averted ($24.42-$107.01), suggests the LDHF training program as compared to no training has 100% probability of being cost-effective above a willingness to pay threshold of $1480, Ghana's gross national income per capita in 2015. CONCLUSION: This study provides insight into the investment of LDHF training and value for money of this approach to training in-service providers on basic emergency obstetric and newborn care. The LDHF training approach should be considered for expansion in Ghana and integrated into existing in-service training programs and health system organizational structures for lower cost and more efficiency at scale.