Developing appropriate illustrations
Counseling for behavior change
Improving health provider skill
reminder materials

Improving health provider skills:
A behavioral approach

During the past few years, The Manoff Group has adapted its counseling approach (also used in TIPs) to improving the performance of health workers. Some recent examples include improving vaccinator performance in East Timorand injection safety in Zambia, and strengthening the disease surveillance system in the Dominican Republic.

Formative research in Zambia

As part of formative research in the injection safety project in Zambia (in partnership with Chemonics and JHPIEGO), Manoff managed TIPs with various types of health providers. Project staff observed providers interacting with clients (using a checklist to assess current practices related to injection safety), interviewed individual providers about current perceptions and practices, and finally negotiated specific improvements to try over a one-week trial period. After the trial period, the staff repeated the observation phase and conducted a follow-up interview for feedback on practices, feelings, influences and intention to continue. A similar process is being built into actual program implementation, so that supervisors can facilitate incremental improvements in health worker performance.

Performance improvement in the Dominican Republich

In the Dominican Republic, we used a similar approach and process as part of a performance improvement effort in the national epidemiological surveillance system. Responding to concerns about the system, the Dominican Republic's MOH, PAHO, and USAID's CHANGE Project (AED and The Manoff Group) undertook a rapid assessment of the national disease surveillance system in early 2004. The assessment found a system that was not functioning well due to poor understanding of job expectations and procedures, low motivation and lack of operational funds for forms, transporting samples, and supervision. Behavior-change strategies were prepared that included communication, training, supervision, supplies and logistics activities.

Supportive supervision received special attention. Fifteen experienced epidemiologists received three days of training as national supervisors. They mastered a simple, practical manual on disease surveillance tasks, other memory aids and communication materials, and how to train provincial epidemiologists and other local staff in their surveillance responsibilities. Guided by an assessment tool, national supervisors and provincial epidemiologists now jointly assess current practices, and causes of non- or partial performance, then reach agreements and discuss strategies for a feasible number of specific improvements between the current and next visits.

Six hundred seventy-five public and private-sector staff were trained in 2005. On average in their first self-evaluation, provincial epidemiologists were adequately performing 55% of their tasks, varying from 30% of evaluation tasks to 72% of tasks related to responding to information. If they are able to make improvements of less than 10% per quarter, they will be performing all key actions by September 2006.

Staff at all levels responded very positively to having a clear understanding of their job expectations, strategies to carry out their functions, opportunities to assess systematically how they were doing and specific areas needing improvement, and the ability to negotiate feasible change, with support from their supervisors. This behavior-centered approach has changed the image of supervision as policing to supervision as mutual problem solving.