Learning from previous research: how to protect and train the healthcare workforce for pandemic response and effective vaccination rollout

This blog entry is in a series that highlights insights from research for development policies and practice, supported by the Knowledge for Change Program (KCP).

The COVID-19 pandemic tests the resilience of primary health care systems and raises questions of how to maintain healthcare quality in a time of crisis. The largest global vaccination roll-out in history has started, but many countries are not well prepared for fast and effective implementation. According to the World Bank's vaccine-readiness assessments of 128 low- and middle-income countries, while 85% of the countries have national vaccination plans, only 30% have developed processes to train a large number of front-line vaccinators who will be needed. At the same time, the second and third waves of COVID-19 are still throwing devastating blows to a number of countries, including India, where COVID-19 death toll has hit a record high.

The need to improve health care quality has never been more acute than it is now. What are the roles of informal healthcare workers in meeting critical health care needs in rural areas, especially in India? How can we effectively ensure patient safety to prevent intra-hospital disease transmission? What are the inspection and monitoring practices that should be put in place to accompany a regulatory framework on minimum patient safety protocols? We introduce a few pieces of research to shed light on these issues.

1. Tapping into the potential of informal healthcare workers

The pandemic calls for an all-hands-on-deck approach. This means that all forms of health care, including those provided by informal actors, could potentially be added to the suite of the solutions to respond to the pandemic and deploy vaccines. A KCP project on healthcare quality in India published in 2016 provides tips on how to solve the lack of access to healthcare in rural areas, which is now in dire need. Data collected in villages in Madhya Pradesh, India, show interesting results that challenge conventional wisdom. '. In Madhya Pradesh, 77% of rural primary care was provided by 'informal' doctors, who may lack formal medical qualifications but practice medicine in private clinics. When it comes to incorrect treatments, or overuse of incorrect medicines, there was no difference between informal private health care providers and their formal public counterparts. In fact, informal providers spent more time with patients and were more likely to adhere to a checklist of recommended case-specific questions and examinations than public providers. This raises the question of whether training informal providers, who have more incentives for making an effort, can improve healthcare quality more broadly, especially in places where the practice of seeing informal providers is more prevalent, such as in rural areas.

To test this hypothesis, researchers in a subsequent KCP study conducted a randomized evaluation of a nine-month training program for informal providers in West Bengal, India. The training included free lectures for informal providers on a variety of topics, including basic medical conditions, triage, and the avoidance of harmful practices. Informal providers who took the training significantly increased the likelihood of correct case management. In addition, the demand for informal providers' services increased, and so did their revenues. Informed by this study, the Government of West Bengal scaled up its training program to all providers in the state. Of course, structuring the training program for informal providers requires tremendous efforts, but leveraging both private and public health-care providers is crucial to meet the overwhelming demand. Moreover, regulating and engaging with the informal health sector to deliver quality care while simultaneously strengthening the public health system is also a long-term solution that can help build a resilient health care system for a future crisis.

2. Going back to the basics: following infection prevention and control protocols to improve patient safety

The ongoing COVID-19 pandemic has stretched hospital capacity at an unprecedented scale. A fundamental step to minimize the risk of intra-hospital disease transmission is to follow stringent infection-prevention and control protocols, but such practices are usually not followed thoroughly in many places. A recently completed KCP project revealed that compliance was very low for certain standard hygienic practices. The team traced 14,328 patients through 935 health facilities in three regions of Kenya in 2015, and observed that while most of the workers (87%) followed safety protocols for injection and blood-sampling safety, only 2.3% adhered to hand hygiene practices. These compliance rates were only weakly associated with the characteristics of health-care workers and facilities, such as knowledge and the availability of supplies, which suggest that perhaps a broader discussion on possibilities of behavioral changes are needed.

With observations of low compliance of infection prevention and control practices, how can governments effectively improve the safety of patients in practice? A group of DEC researchers conducted a large randomized control trial on accountability and compliance mechanisms of minimum patient safety standards in public and private clinics in Kenya, where the government had announced a new regulatory framework in 2016. To align incentives for compliance with minimum patient safety standards, the study introduced three broad components across the intervention: i) a regulatory framework accompanied by clear guidelines, ii) a monitoring system to track compliance, and enforce warnings and sanctions over time, and iii) a scoring and information scorecard system to disclose compliance status. The early findings showed that the intervention induced significant improvements in patient safety across the board, without increasing patients' out-of-pocket payments or reducing demand for health care. The average compliance level for the studied facilities increased from 'minimally compliant' to 'partially compliant.' These were exciting results, since prior to the trial, only 3% of facilities complied with minimum patient safety standards. This study highlights the importance of accountability mechanism and incentives in the design and implementation of a comprehensive regulatory framework. This pilot evaluation has influenced scaling-up of the implementation of the regulatory framework to all 47 counties in Kenya.

Since the early 2000s, KCP has supported multi-phase projects on health-care quality and produced research on the measurements and determinants of care quality. New methods and tools were developed to measure and assess the quality of health care. The tools have become widely accepted and quoted in key publications, including those by the National Academies of Medicine, and were replicated in multiple countries worldwide. Since the onset of the COVID-19 outbreak, teams were also mobilized to support emergency health operations by monitoring and tracking the pandemic's economic and health impacts closely. For instance, researchers in the Development Economics Vice Presidency of the World Bank, jointly with the Global Financing Facility for Women, Children, and Adolescents, provided supports to 36 low- and lower-middle-income countries to report monthly updates of health facilities data to health-management information systems. The data and their analytical assessments contribute to monitoring the continuity of essential health services in each country. With the launch of KCP Phase IV, more research, data, and analytical efforts will be devoted to analyzing effective emergency responses, vaccination rollouts, and the overall quality of health care.

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The authors would like to acknowledge contributions from the following projects under the guidance of task team leads (TTLs) and researchers: Kenya Patient Safety Impact Evaluation (TTLs: Guadalupe Bedoya and Jishnu Das); Quality of Care in Health Markets: Supply- and Demand-Side Perspectives (TTL: Jishnu Das); Quality of Care, Its Determinants, and How It Can Be Improved (TTL: Jishnu Das).

About the blog series: The Knowledge for Change Program (KCP) has launched a blog series to retrospectively highlight a selection of research projects conducted over the past 20 years, many of which still remain highly relevant and offer great lessons for development policies and practices today. Managed by the Development Economics Vice Presidency of the World Bank (DEC), the KCP promotes evidence-based policy making through research, data and analytics. To celebrate the KCP's fourth phase launched in November 2020, this blog series will look into the wealth of knowledge researchers have generated in KCP's previous phases, distill lessons learned, and inspire discussions on future research directions.

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