Performance Improvement • Volume 42 • Number 8 5

The Transition From Training toPerformance Improvement inLow-Resource Settingsby James L. Griffin

GUEST EDITORIAL

In this edition of Performance Improvement, you will read first-hand reports of howthe United States Agency for International Development (USAID) has used perfor-mance improvement models and adapted them for use in developing countries.

First is a description of USAID’s Office of Population and Reproductive Healthpolicies and practices. The second article talks about how the performanceimprovement process was implemented in two non-governmental organizations(NGO) in Haiti and Peru, and in a series of public-sector clinics in the EasternCape Province in South Africa. The third article describes the lessons and chal-lenges of developing and adapting tools to implement the performance improve-ment framework. Finally, you will read how performance improvement haschanged the way USAID’s activities and interventions are evaluated and fol-lowed by a discussion of the future of performance improvement in less-devel-oped countries.

USAID’s Office of Population and Reproductive Health seeks to increase the useof voluntary reproductive health services, reduce unintended pregnancies, andpromote maternal and child health. Since its inception in 1965, its populationand reproductive health programs have significantly increased the use of volun-tary family planning services in developing countries. Currently more than 50million couples in 60 countries use family planning as a result of USAID’s work.(For more information about USAID’s programs see the USAID website atwww.usaid.gov.)

Historically, USAID has sought to improve performance in the reproductivehealth sector through short- and long-term training. The latter usually consists ofproviding scholarships to public health professionals who work in less-devel-oped countries to study in the United States. Short-term training, which is muchmore frequent, focuses on improving the clinical knowledge and skills of doc-tors, nurses, and nurse-midwives.

USAID’s short-term training support has gone through three distinct phases. Anearly strategy was to take participants out of their own countries and into inter-national training centers in the United States or a third country for training. This

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had its merits: It developed a pool of competent health careprofessionals who could provide services and substantivetechnical leadership that would have otherwise beenunavailable. Despite its successes, this approach also hadlimitations: It was very expensive and in some cases failed toreflect the conditions that trainees faced when they returnedhome.

As a result, USAID reproductive health care programs beganto build in-country training capacity by developing a cadreof trainers within the existing health systems. They did thisthrough Training of Trainers courses; revising national, pre-service, and in-service training curricula and materials; andenhancing evaluation processes and skills. USAID typicallyworked with host country government training centers;national and regional NGOs; and schools of nursing, medi-cine, and midwifery.

This was effective in establishing local training capacity.The new trainers could reach and improve the skills of alarger number of health care providers throughout the coun-try. It also contributed to the development of customizedtraining materials and approaches that were better suited tothe local culture.

But the transfer of training from the classroom to the work-place had its limitations, too. This prompted a broader lookat the systems that support performance beyond training,such as supervision, worker motivation, clearer perfor-mance expectations for and feedback on performance, andhuman resource and worker deployment policies.

Consequently, in 1998, the Office of Population andReproductive Health developed a new training and perfor-mance improvement strategy. As part of this change, twotraining projects were retooled to include performanceimprovement, employing both training and nontraininginterventions. About a year later, the PerformanceImprovement Consultative Group (PICG) was formed. Thisis an informal gathering of people, mostly USAID partners,interested in performance improvement. Their goal was todevelop a common approach to help partners integrate per-formance improvement into their work, develop a simpleset of tools that would be appropriate for use in developingcountries, and provide a forum to discuss lessons learnedabout performance improvement.

One of PICG’s first achievements was to adapt the InternationalSociety for Performance Improvement Human PerformanceTechnology model and modify it for use as a shared frameworkfor developing country audiences (see Figure 1).

The performance improvement framework has proven veryuseful in less-developed countries and low-resource set-tings. It has been a key factor in introducing performanceimprovement and involving a variety of local stakeholders,such as local government officials and community and reli-gious groups. Using this framework also reinforces the con-cept that interventions should be directly aimed at the rootcause of the performance problem and should effect animmediate and positive change on worker performance.This further reinforces USAID’s drive to ensure that its pro-grams produce measurable results.

Figure 1. The Performance Improvement Framework.

A few things need to be considered when working in a less-developed country. First, many countries are undergoinghealth care reform. This process usually includes thedecentralization of management and financing, wherebyresponsibility for the delivery of health care services isshifted to local government authorities. Other componentsof health sector reform can include the development ofalternative financing mechanisms, the creation of essentialpackages of health services, and greater involvement of theprivate sector.

Health sector reform has had an impact on myriad of issuesconcerning the health care workforce, including workerretention and deployment, worker training, and supervisorysystems. Further, the HIV/AIDS epidemic has had a pro-found effect on health care systems in Africa, as well as onparts of Latin America and Asia. In addition to many healthcare workers being infected with HIV, overburdened healthcare providers and systems are faced with the additionalresponsibility of caring for people with the virus. Somehealth systems are having difficulty recruiting nurses anddoctors to work in high-prevalence areas or with certainhigh-risk groups. Finally, the impact of cultural influenceson how USAID’s partners do their work in developing coun-tries cannot be understated. If you look at the PICG’s

performance improvement model, you will see that theinstitutional context is prominent in this adapted process.

In closing, I would like to thank all of the people who tookthe time to contribute to this edition of PerformanceImprovement. More importantly, I would like to thank themfor the good work that they do.

Disclaimer: The opinions expressed are those of theauthor, and do not reflect the views of USAID.

Jim Griffin works for the CEDPA/TAACS programat the Untied States Agency for InternationalDevelopment’s Office of Population. Jim has morethan 15 years of training and performanceimprovement experience in less developed coun-tries. Prior to coming to USAID three years ago, Jimlived in Thailand and Bangladesh where he was theAsia Regional Training Advisor for Engenderhealth.

Jim has an undergraduate degree in Health Education and a master’s degreefrom the Columbia University School of Public Health. He was a Peace CorpsVolunteer in Sierra Leone in the late 70s and early 80s. Jim may be reached atJaGriffin@usaid.gov.

Performance Improvement • Volume 42 • Number 8 7

September 10-13Your Opportunity to Meet Face-to-Face

with More Than 600 Key HR ProfessionalsJoin IPMA-HR in the “Windy City” for the 2003 InternationalTraining Conference. The Conference will be held in the

heart of downtown at the Chicago Marriott Hotel.

If you would like more specific information about the Conferencecall IPMA-HR at (703) 549-7100 or go to http://www.ipma-hr.org online.

We look forward to seeing you in Chicago!

2003 IPMA-HR AnnualConference Chicago, IL

2003 IPMA-HR AnnualConference Chicago, IL