Findings, Recommendations & Lessons Learned
IDCAP Findings
In combination, classroom training and on-site support can improve individual clinician and facility performance. Though less than expected, our analysis indicates that a combination of IMID and OSS was associated with significant improvements in individual clinician and facility performance. The combined intervention resulted in statistically significant improvements in six of 22 facility performance indicators, the majority of which were related to emergency triage, assessment and treatment (ETAT) processes, and malaria care. Detailed results, including how individual areas of care were impacted by IDCAP’s interventions, are being written up in a series of peer-reviewed journals.
Classroom training and on-site support are complementary interventions. IMID and OSS augmented clinician performance in different ways. The high quality classroom training improved competence (but not individual practice) whereby a 25% relative increase in scores was observed. Conversely, on-site support improved individual clinical practice (but not competence). There was a statistically significant effect on history taking, physical exam and treatment, and patient education. OSS also had a statistically significant effect on one facility performance indicator, improving the estimated percent of emergency patients receiving treatment according to emergency triage, assessment and treatment (ETAT) standards.
A strong Data Surveillance System (DSS) may be an intervention in and of itself. As proposed, the DSS was an evaluation tool for measuring the facility performance indicators. Consequently, we minimized the role of the DSS in the CQI process and controlled for it in the evaluation. However, our analysis showed that the introduction of this comprehensive but simple system was itself correlated with significant improvement in two facility performance indicators. The DSS could have impacted performance in a number of ways. For example, with the DSS, health workers were able to complete routine reporting requirements more efficiently; and, some facility in-charges used data to track medication use. Future programs that give greater focus to the role of data collection and review may show broader impacts of a strong data surveillance system.
Recommendations & Lessons Learned
The design of IDCAP, development of IDCAP’s interventions, and the processes of implementing and evaluating IDCAP led to several lessons learned and recommendations that will be useful for other researchers and organizations attempting similar programs.
Pre-service medical education needs to “catch-up” to the realities of task-shifting. In the absence of sufficient quantities of doctors, mid-level practitioners are providing care to the vast majority of people in sub-Saharan Africa. As ministries of health are starting to permit MLP to initiate ART and provide other care traditionally outside their scope, pre-service training for MLP needs to be updated to reflect the clinical complexity of the care they are providing. While continuing medical education is certainly important, increasing attention and advocacy around strengthening pre-service education can help give MLP the skills they need before they enter the workforce.
Quality improvement is an on-going process, not a one-time fix. It is difficult to achieve lasting change in quality of care. Training, capacity-building, and quality improvement are all activities that require periodic refreshing. Many studies have shown that the impact of training deteriorates over time. Furthermore, treatment guidelines and medical technology are constantly changing. Across sectors, education is a continuous process. Educators, policymakers, and funders need to become more comfortable with investing in the ongoing cycle of training and re-training necessary to improve quality of care.
More research is needed to evaluate the impact of “in service” training programs. IDCAP’s OSS was designed as a low-dose, practical intervention that could ultimately be implemented by District Health Teams independently, and our modest results illustrate the potential impact of routine support and supervision by well-prepared MOH teams over a short period of time. Further research is needed to discern whether facility support approaches need to persist for longer durations, whether impact would grow over time, and whether the greater immediate impact of more intensive interventions persists over time. Health professionals impact care through complex systems, and training and continuous quality improvement initiatives are only two levers through which to improve quality of care. Other interventions might address:
- Healthcare worker motivation and support structures
- Human resources and supply chain management information systems
- Compensation packages or other incentives to ensure greater numbers of clinicians work full-time in rural, public clinics.
Further research is needed to understand what other interventions can strengthen human resources for health, and in turn, improve quality of care in Uganda and sub-Saharan Africa.
