1 Introduction

Since the early 2000s, there have been large increases in donor financing of human resources for health (HRH), -currently estimated at estimated at $4-6 bn per annum3 - yet much investment by external funders is not coordinated with national strategic plans and there has been little analysis of effects on performance. Too often training is a default reaction to a health system failure – popular because it is comparatively straightforward to deliver, with “numbers trained” an easy metric to report, good for satisfying short term delivery targets of funders.

Although there is little formal evidence there is a common view that a lot of money is wasted on ineffective training. Measurement tools for assessing the effectiveness of training are often weak, relying on tests which measure short term memory of knowledge, or self-reported learning translation. Knowledge has quite a weak correlation with performance (it is necessary but not sufficient). Another part of the problem is fragmentation – in Uganda, 22 different designated organisations responsible for training CHWs were counted.4

With advances in technology issues of proliferation, fragmentation and lack of alignment of solutions with national plans have come to the fore. Concurrently innovation has rocketed and the multitude of different players has thrown up some novel and excellent approaches, though even the most established are still struggling to find a truly sustainable funding model. The challenge now perhaps is to consolidate the best of these and look for ways to increase value from existing solutions and platforms that exist, leveraging the inherent economies of scale, rather than investing in developing yet more.

COVID-19 has brought about not only new imperatives but also opportunities to make use of new technologies to disrupt the way things are done and accelerate our engagement with technology. The need to limit face-to-face interaction, upskill large numbers quickly and cope with even more pronounced fiscal and economic pressures worldwide speak to the need for more efficient approaches. Many people have engaged more profoundly with new technologies for the first time.

Insights from learning theory and related disciplines like behavioural insights provide a muchenhanced evidence base of what works to improve learning and performance. From this, we understand that content-driven, one-size fits all approaches are only effective for specific situations and need to be complemented by more learner-centred, layered approaches in others.

This report provides a summary of the evidence base around innovative learning and performance management strategies relevant to frontline health workers. We provide an assessment of some notable examples of learning and performance strategies being used in lower- and middle-income countries (LMICs), considering their enabling features as well as the main constraints, keeping in mind a health systems lens. We examine examples of good practice and adaptations which have been made because of COVID-19, and the potential for promising approaches to be scaled up elsewhere.

Background to assignment

Gavi has contracted Mott MacDonald to undertake a mapping and assessment of learning and performance management approaches of frontline health workers. The purpose is to support Gavi’s efforts in transforming learning and performance approaches for frontline healthcare

3 Personal communication with Jim Campbell, WHO, 13 January 2020

4 O’Donovan J, O’Donovan C, Kuhn I, et al. Ongoing training of community health workers in low-income and middle-income countries: a systematic scoping review of the literature. BMJ Open 2018;8: e021467. doi:10.1136/bmjopen-2017-021467 workers in portfolio countries by mapping and assessing existing strategies, identifying gaps and highlighting innovations that can be scaled-up through Gavi’s support.

The output of this work will be applied for two main functions:

1) To inform Gavi’s support to countries during its new 5.0 strategy, in particular building health workforce capacity to address the problem of high unreached (zero dose) children and under-vaccinated populations.

2) By identifying ways to support routine immunisation and rollout of existing vaccines, to prepare health systems for COVAX and other vaccine introduction

This report presents the outcome from this work. We review the evidence-base on approaches which impact health provider performance, including learning/digital learning strategies, performance supporting strategies and wider health systems levers (Section 2). In Section 3, we discuss implementation experience and some enabling principles which support innovative performance strategies, highlighting some of the platforms and initiatives that apply best practice, including use of appropriate technology, and which could be rolled out at increased scale. Due to a plethora of interventions, there will be many that it is impossible to mention but which are nevertheless making important contributions. Section 4 looks at emerging technologies and future trends, and also reviews experience with adapting to virtual approaches from the education and agriculture sectors. In Section 5 we discuss the results from a deeper dive look at selected countries to illustrate some of the country level issues and explore what approaches have worked in various contexts as well as the path to sustainability. Given the need for better donor alignment and coordination, Section 6 presents a summary of how other funders are engaging with HRH workforce and performance. Sustainability is explored in more detail in Section 7, expanding on themes that emerged from review of interventions and key informant interviews. Finally, Section 8 summarises some of the key strategic opportunities where Gavi could act. A list of key informant interviews (KII) is at annex 1, and a bibliography of key references is at annex 2.

Through our literature and web review and KIIs, we identified prominent examples of innovative solutions to frontline health provider learning and performance. We sought examples which used blended and innovative approaches, including digital, and which had shown signs of adaptation during the COVID pandemic. Solutions were assessed against dimensions of effectiveness, scalability and sustainability. The results of this exercise – with 24 highly ranked solutions - are presented in annex 3 along with a note on scoring methodology at annex 4. An inventory of common global platforms for digital health interventions is an annex 5.

As this is a fast-moving space, and new evidence is emerging all the time, we strongly recommend that Gavi uses these results only indicatively and keeps under review promising solutions for which no data is yet available. Similarly, as interventions do not always translate well to different contexts, we also recommend that solutions being supported for scale up be required to demonstrate alignment to country strategies and plans and government buy-in.