Learning and Performance Management (LPM) is a term that includes any strategy to help health workers (HW) improve and maintain their performance. When HW perform well, they're providing high-quality services, which is crucial for increasing the likelihood of desired health outcomes.
LPM strategies could focus on the "micro" level (e.g. training or supervision for staff at service delivery points) or broader "macro" level systems issues (e.g. policy). Gavi, the Vaccine Alliance aims to support countries in implementing evidence-based LPM approaches that are tailored to their unique needs and context.
Globally, 1.5 million people lose their lives to vaccine-preventable diseases every year, and 25 million children are under-immunised. In Gavi-supported countries in 2021, there were 12.5 million "zero-dose" children who have not received even a single vaccine shot. Reaching these missed children and their communities is only possible if HW are skilled and well-supported.
The goal of putting HW needs at the centre of LPM is to reinforce their competence, and to improve their motivation, performance and retention.
Global health organisations’ current large investments in traditional lecture-style classroom training and supervision have not had the expected impact on HW performance. Better value for money is achieved through a combination of the more effective LPM approaches described below.
Conduct a needs assessment to identify areas of improvement regarding HW performance; examine existing data; and determine the root causes. Additionally, mobilise existing resources and partners that can support these areas. Based on this analysis, develop an LPM strategy, and select the most suitable approaches and solutions for the context to address the identified areas of improvement.
Multifaceted strategies that combine training with other interventions, such as supervision or group problem-solving, have greater effects on HW performance than these interventions in isolation. Providing the basics, such as equipment and supplies, is essential, but this should be complemented by interventions shown to improve HW performance. Training is most effective when conducted in the workplace, integrating clinical practice; but there are other effective delivery methods (e.g. self-paced digitally supported, peer-to-peer learning) . Supervision is more effective when supervisors themselves receive supervision; participate in problem-solving with HW; are trained in mentoring; and provide mentorship to their staff.
During the COVID-19 pandemic, the use of digital technology for LPM increased exponentially. However, the effects of digital interventions on HW performance have been mixed, often being small to modest. The decision on whether and how to use digital interventions should be based on evidence of effectiveness, suitability for the context and cost; and all interventions should be monitored.
For any LPM strategy, it is important to monitor HW performance and use the results to determine if the intervention needs further adaptation for greater impact. Conduct regular monitoring and evaluation to inform LPM priorities, and choose simple indicators that can be measured during routine supervision visits.
These five guiding principles serve as the foundation for impactful programmes to strengthen LPM and improve HW performance:
Use effective evidence-based approaches that are monitored and evaluated for impact on HW performance and evolve based on results.
Implement context-appropriate approaches that align with national priorities and are driven by national stakeholders.
Implement maintainable and adaptable LPM approaches; encourage country ownership and buy-in for better sustainability.
Put HW at the centre; select and adapt approaches that reinforce learners’ motivation, confidence and competence.
Carefully consider digital LPM approaches when they are contextually appropriate, based on needs and evidence; and do not burden HWs unnecessarily.
LPM is a term that includes any strategy to help health workers (HW) improve and maintain their performance. LPM strategies could focus on the “micro” level (e.g. training or supervision for staff at service delivery points) or broader “macro” level systems issues (e.g. policy). Gavi, the Vaccine Alliance aims to support countries in implementing evidence-based LPM approaches that are tailored to their unique needs and context. More strategic LPM will improve the quality of services and lead to better population health outcomes.
HW performance means how well vaccinators, other Expanded Programme on Immunization (EPI) staff and the staff of other health programmes adhere to national guidelines or otherwise work in ways that help achieve programmatic objectives. EPI examples include: how health workers (HWs) interact with patients (e.g. counseling that encourages caregivers to return for additional doses); safely administering vaccines; and broader programmatic actions (e.g. using data to identify zero-dose children; effective microplanning of vaccination outreach). More generally, when HWs perform well, they are providing high-quality services. Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes. High-quality care should be effective, safe, people-centred, timely, equitable, integrated and efficient.
We acknowledge that insufficient numbers of HW is a serious human resources challenge in many countries. However, LPM focuses on improving performance of current HW staff in your country.
LPM can be designed for any health workers (HW). The focus of LPM efforts to date has been on the professional and legally recognised frontline health workers (FHW) such as nurses, midwives, medical doctors and health workers responsible for the delivery of vaccines. There are differences when considering LPM strategies for this group compared to community health workers (CHW) or in-office personnel.
To reach national goals, keep health systems functioning efficiently and improve quality of care, it is critical that health workers receive continuous learning and enhance their skills amid ever-changing health challenges. With more effective LPM, it is possible to use money and time more effectively, keep health workers more motivated and reach better health outcomes.
LPM approaches are specific interventions to improve health worker performance (e.g. blended learning, group-based problem-solving, supportive supervision, mentorship).
LPM digital solutions are services, products or technology platforms that support learning and performance efforts; and are maintained by a specific solution provider (e.g. learning management system, decision-support mobile application, proprietary mobile application).
A working group comprising experts from Gavi, the Vaccine Alliance; its founding partners (WHO, UNICEF, Bill & Melinda Gates Foundation, World Bank); the US Centers for Disease Control and Prevention; and the Global Fund to Fight AIDS, Tuberculosis and Malaria provided inputs and contributions to the resulting vision, strategy and recommendations to improve HW performance.
2. How does LPM relate to other topics?
With the ever-changing health challenges, effective LPM is crucial in achieving Sustainable Development Goal (SDG) 3 of Ensure healthy lives and promote well-being for all at all ages. LPM is directly linked to SDG 3.8, Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all, and indirectly to many others.
LPM can support any programme by improving quality of care, motivating health workers, and providing better value for money. More effective LPM approaches means improved health worker immunisation practices (e.g., effective counselling of caregivers, and safe administration of immunisation doses), as well as improved data use, planning, and community engagement to reach zero-dose children and their communities.
LPM is directed towards frontline health workers, whereas Leadership, Management and Coordination (LMC) aims to strengthen national immunisation teams, coordination forums, and technical advisory groups. LPM approaches are focused on supporting improved health worker performance and may also be applied within LMC efforts aimed at a different set of skills focused on leadership and management.
Continuing professional development (CPD) is a nationally driven process to ensure health workers maintain and improve their professional skills. LPM efforts should link to health worker CPD goals and requirements. LPM focuses on how HW learning and performance will be delivered, and which evidence-based approaches and solutions to use in each context.
LPM is focused on improving health worker (HW) performance (e.g., better counselling, better microplanning for outreach activities). HRH includes HW performance, but also other health work force issues, such as HW production, deployment, and retention. LPM and HRH are linked, as HW performance can sometimes depend on having enough HWs. We acknowledge that insufficient HWs is a serious challenge in many countries. However, LPM focuses on improving performance of HWs that currently exist in your country. LPM approaches can be effective even with HW shortages. Moreover, some LPM approaches may strengthen HRH more broadly.
3. Country plans and action-oriented questions
We recommend that programmes apply the following five guiding principles.
Other approaches that have some degree of promising evidence related to learning outcomes include blended learning, mentorship (virtual or in-person), mobile-social learning, eLearning, and point-of-care decision-support tools.
The Quality Assessment Criteria and Tool can be used to guide a structured assessment of a specific LPM digital solution against the five guiding principles (impactful, country-driven, sustainable, learner-centric, digitally supported). Each principle has one to four standards, under which the level of assessment criteria will be evaluated. Based on the evaluation and final score of the solution, it will be easier to select appropriate LPM solutions. See more and access the tool here.
Health workers (HWs) ranked workplace-based learning, clinical practice rotations, and decision-support tools as the top three preferred learning approaches out of nine choices. They reported internal and external supportive supervision and pay for performance as acceptable. Health workers reported that older users prefer in-person training and audit-style supervision, and that younger users are more interested and willing to engage in technology-supported LPM. Self-study methods were the least preferred. Note that there is significant variation in country context for preferred LPM approaches, aligned with digital maturity, the maturity of decentralisation, and the health professions’ regulation maturity in the country for continuing professional development policies.