We searched MEDLINE from 1966 to March, 2004. Search terms were (“quality assurance, health care” or “diffusion of innovation” or “quality of health care” or “preventive health services” or “inservice training” or “intervention studies” or “randomized controlled trials” or “health services misuse” or “clinical competence” or “guideline adherence” or “evaluation studies” or “outcome assessment [health care]” or “delivery of health care” or “medical staff, hospital” or “peer review” or
ReviewHow can we achieve and maintain high-quality performance of health workers in low-resource settings?
Introduction
The problem of inadequate health-worker performance in low and middle income countries is particularly urgent. Millions of children and adults die prematurely each year1, 2 even though many interventions exist that can prevent such deaths,3 and health workers (defined broadly to include public and private providers based in health facilities or communities) are essential for delivering these life-saving interventions. However performance (defined as adherence to an accepted standard or guideline) is very often inadequate, as documented in studies of child health, sexually transmitted diseases, family planning, obstetrics, mental disorders, injuries, and diabetes.4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 Governments and non-governmental organisations spend many resources on health workers and the systems that support them, and such investments could produce greater benefits to society than they currently do. Poor health-worker practices contribute to low use of health facilities by vulnerable populations, and improved performance might increase use of health services.19, 20, 21, 22 Additionally, health-worker practices can be harmful (eg, giving sedatives to children with pneumonia,16 or prescribing unnecessary antimicrobials23, 24, 25), and such errors of commission must be eliminated.
We aim to address the issue of achieving and maintaining high-quality performance of health workers in low-resource settings. We briefly outline the determinants of performance, discuss the effectiveness of strategies to improve performance, and describe knowledge gaps that, if filled, might lead to better interventions (or a better ability to select appropriate interventions) for achieving and maintaining high-quality performance. We acknowledge that the topic is vast, with many perspectives and actors. Because of limitations of space and, indeed, of the existing studies, this Review is an overview, based mainly on review articles of research undertaken in low and middle income countries and centred on public-sector workers in health facilities. In some cases, we refer to individual studies and research from industrialised countries.
Section snippets
Sources and quality of evidence
An essential first step towards improving performance is understanding the factors that influence it. Such factors fall into two categories: interventions (eg, training) and non-intervention determinants (eg, patient's age). Theoretically, the best source of evidence about the effect of interventions is a randomised-controlled trial; however these are rare in low and middle-income countries. Other study designs (eg, observational designs), although inherently more susceptible to some types of
Specific interventions
We examined two fundamental questions: which interventions are most effective (or cost effective); and, in what situations should a particular intervention be used? To answer the first question, we identified 11 literature reviews of studies about 15 strategies (table 2). Five were systematic reviews of studies from low and middle income countries,14, 25, 49, 52, 54 four were non-systematic reviews of studies from industrialised and low and middle income countries,45, 46, 47, 48 one was a
Knowledge gaps
We begin with the overarching goal that new knowledge should help achieve: a health system with high-quality performance that also can adapt rapidly to change while maintaining performance. We emphasise both aspects because standards change as new diseases and technologies emerge, and some existing technologies (especially antimicrobials) become less effective. For example, an evaluation of 17 clinical guidelines in the USA reported that the median time for a guideline to become outdated was
Recommendations
We make two recommendations. First, an international collaborative research agenda should be developed and financed to generate badly needed information about the cost and effectiveness of different strategies to improve performance, with special emphasis on which strategies are best adapted to different settings and health areas. Such an agenda might have three parts: (1) research on determinants of performance aimed at developing testable theories that explain health-worker practices; (2)
Search strategy and selection criteria
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