Can Coaching Health Workers Improve the Performance of Health Systems?
Co-Author: Shubhra Kumar, Research Associate at Columbia Global Center South Asia
In a 2011 article in the New Yorker, surgeon and writer Atul Gawande explored the idea of having coaches, such as in sports and singing, for other professionals including teachers and doctors. Different than managing or simply teaching, coaching combines judgment, guidance, and accompaniment to help people perform at their peak. Could applying the concept of coaching to health systems improve performance?
Many large-scale health systems already conduct routine supervision of health facilities and periodic training for health workers. These efforts, however, are not always effective. Across different states in India, our team from the Earth Institute and Columbia Global Center has noted that supervision is often conducted ad-hoc without clear or standard guidelines and frequently implemented as a faultfinding exercise that produces reprimands rather than corrective action. At the same time, trainings are carried out as sporadic, one-off events where health workers are pulled out of understaffed facilities to hear didactic lectures on very practical topics. Workers receive no individual attention and are given few opportunities for hands-on learning or to practice new techniques under the guidance of a trainer. Moreover, the centralized venue for the training usually differs substantially from the day-to-day practicalities amidst which workers ultimately apply these skills.
In an effort to apply Gawande’s idea of coaching to health systems, our team is working with the government of Mahbubnagar District in Andhra Pradesh (India) to pilot a model for ‘on-site coaching’ as an alternative approach to supervision and training. Andhra Pradesh is a state in southern India with a population of about 85 million. Mahbubnagar is one of the poorest districts in the state and, with over 4 million people, is comparable in population to many countries including Croatia, Oman, and Liberia.
In this ‘on-site coaching’ model, ‘coaches’ rotate through target facilities on a routine basis and spend up to three days at the facility during each visit. The ‘coaches’ observe the current performance of the facility as well as the skill level of each health worker. Based on this assessment, they then institute training customized to the unique needs of each worker. Skills are imparted through traditional classroom-based approaches, hands-on demonstrations with mannequins, and by seeing patients side-by-side with the health workers to reinforce their learning in actual practice. As the ‘coaches’ regularly cycle back through each facility, they develop rapport with each health worker and also begin recognizing how each person learns best and how to most effectively boost the facility’s overall performance.
At the heart of this ‘on-site coaching’ model is the idea that clinical staff need coaches, not supervisors or trainers. They need hands-on mentorship while executing their daily tasks rather than being called away from their facilities in order to attend lectures. They need approaches that provide tailored solutions to the challenges they face and incrementally strengthen their skills and knowledge month-by-month.
The pilot in Mahbubnagar was launched in December 2013 as a partnership between the district government; SVS Medical College, a private health education institution based within the district; the Earth Institute and Columbia Global Center. The initial pilot will include about fifty health workers and focus on improving the delivery of maternal and child healthcare. The model will be evaluated to improve the approach as well as determine how this type of coaching approach could be scaled up throughout the district and ultimately considered for wider state and national level rollout.