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Background A recent systematic review evaluated the effectiveness of strategies to improve healthcare provider (HCP) performance in low-income and middle-income countries. The review identified strategies with varying effects, including in-service training, supervision and group problem-solving. However, whether their effectiveness changed over time remained unclear. In particular, understanding whether effects decay over time is crucial to improve sustainability. Methods We conducted a secondary analysis of data from the aforementioned review to explore associations between time and effectiveness. We calculated effect sizes (defined as percentage-point (%-point) changes) for HCP practice outcomes (eg, percentage of patients correctly treated) at each follow-up time point after the strategy was implemented. We estimated the association between time and effectiveness using random-intercept linear regression models with time-specific effect sizes clustered within studies and adjusted for baseline performance. Results The primary analysis included 37 studies, and a sensitivity analysis included 77 additional studies. For training, every additional month of follow-up was associated with a 0.19 %-point decrease in effectiveness (95% CI: -0.36 to -0.03). For training combined with supervision, every additional month was associated with a 0.40 %-point decrease in effectiveness (95% CI: -0.68 to -0.12). Time trend results for supervision were inconclusive. For group problem-solving alone, time was positively associated with effectiveness, with a 0.50 %-point increase in effect per month (95% CI: 0.37 to 0.64). Group problem-solving combined with training was associated with large improvements, and its effect was not associated with time. Conclusions Time trends in the effectiveness of different strategies to improve HCP practices vary among strategies. Programmes relying solely on in-service training might need periodical refresher training or, better still, consider combining training with group problemsolving. Although more high-quality research is needed, these results, which are important for decision-makers as they choose which strategies to use, underscore the utility of studies with multiple post-implementation measurements so sustainability of the impact on HCP practices can be assessed. [ABSTRACT FROM AUTHOR]

Objectives: Recent studies have identified large and systematic deficits in clinical care in low-income countries that are likely to limit health gains. This has focused attention on effectiveness of pre-service education. One approach to assessing this is observation of clinical performance among recent graduates providing care. However, no studies have assessed performance in a standard manner across countries. We analysed clinical performance among recently graduated providers in nine low- or middle-income countries.Methods: Service Provision Assessments from Haiti, Kenya, Malawi, Namibia, Nepal, Rwanda, Senegal, Tanzania, and Uganda were used. We constructed a Good Medical Practice Index that assesses completion of essential clinical actions using direct observations of care (range 0-1), calculated index scores by country and clinical cadre, and assessed the role of facility and clinical characteristics using regression analysis.Results: Our sample consisted of 2223 clinicians with at least one observation of care. The Good Medical Practice score for the sample was 0.50 (SD = 0.20). Nurses and midwives had the highest score at 0.57 (SD = 0.20), followed by associate clinicians at 0.43 (SD = 0.18), and physicians at 0.42 (SD = 0.16). The average national performance varied from 0.63 (SD = 0.18) in Uganda to 0.39 (SD = 0.17) in Nepal, persisting after adjustment for facility and clinician characteristics.Conclusions: These results show substantial gaps in clinical performance among recently graduated clinicians, raising concerns about models of clinical education. Competency-based education should be considered to improve quality of care in LMICs. Observations of care offer important insight into the quality of clinical education. [ABSTRACT FROM AUTHOR]

Delivery in a health facility is a key strategy for reducing maternal and neonatal mortality, yet increasing use of facilities has not consistently translated into reduced mortality in low- and middle-income countries. In such countries, many deliveries occur at primary care facilities, where the quality of care is poor. We modeled the geographic feasibility of service delivery redesign that shifted deliveries from primary care clinics to hospitals in six countries: Haiti, Kenya, Malawi, Namibia, Nepal, and Tanzania. We estimated the proportion of women within two hours of the nearest delivery facility, both currently and under redesign. Today, 83-100 percent of pregnant women in the study countries have two-hour access to a delivery facility. A policy of redesign would reduce two-hour access by at most 10 percent, ranging from 0.6 percent in Malawi to 9.9 percent in Tanzania. Relocating delivery services to hospitals would not unduly impede geographic access to care in the study countries. This policy should be considered in low- and middle-income countries, as it may be an effective approach to reducing maternal and newborn deaths. [ABSTRACT FROM AUTHOR]