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.

For more information, click here for “Available resources”, and see Gavi Programme Funding Guidelines.

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.

1. The process of strengthening LPM should begin with a situation analysis/needs assessment to identify: a) areas of health worker (HW) performance (and broader programme performance) that need improvement; b) the causes of those areas of concern; c) existing resources, partnerships, data, and tools (including digital interventions) that could help address the areas of concern; and d) indicators of HW performance that could be monitored to assess how well improvement strategies have addressed the areas of concern (see the fourth sub-bullet, below). There are comprehensive approaches for conducting a situation analysis such as WHO’s methodology, however, a lighter approach that focuses on HW performance issues is also a reasonable option. 
    
2. Programme managers should not attempt to solve all problems at once. Begin with a few issues that are in the programme’s sphere of influence and programmatically important. When those problems are solved, move on to the next set of issues. Problems that transcend EPI (e.g. a country-wide shortage of HWs) should be addressed by engaging higher levels of the Ministry of Health hierarchy, and health and development partners.
    
3. When possible, strategies to improve HW performance should build on what currently exists (e.g. routine supervision, information systems, community networks, NGOs, and other partnerships).
    
4. The effects of any strategy should be monitored so that managers know how well it works. Monitoring data could be used to adapt strategies to local conditions and to facilitate learning as implementation proceeds, with the aim of increasing effectiveness.

We recommend that programmes apply the following five guiding principles. 

1. Use effective, evidence-based interventions (see evidence summary below) that are monitored for accountability and adaptation 
2. Have country-driven decision-making for interventions that are tailored to country contexts 
3. Pivot away from heavily donor-funded programmes and towards sustainable, country-resourced programmes 
4. Co-create interventions with health workers and other end users  
5. Consider carefully whether and how to use digital interventions

Learn more from Transforming Learning and Performance Management for Immunization Health Workers: A New Vision and Strategic Direction
 

• Providing printed information or job aids to health workers (HWs) as a sole strategy is unlikely to substantially change performance.
• Information and communication technology (i.e. digital interventions) might lead to moderately large improvements or no improvement, but typically has small to modest effects.
• Training only or supervision only (i.e. as a sole strategy) might produce large improvements or no improvement, but both strategies generally have moderate effects. An analysis of the highest quality studies of group (e.g. classroom-based) in-service training found only a modest effect. The effect of training tends to wane over time. It might be more effective to combine training with other strategies, such as supervision or group problem-solving.
• Training tends to be more effective when it is conducted at the site where HWs usually work and when it includes clinical practice.
• Supervision tends to be more effective when supervisors receive supervision and when supervisors participate in problem-solving with HWs. Supervision is likely to be more effective when supervisors provide mentorship to their supervisees (i.e. serve as teacher, role model, adviser, and sponsor). 
• Group problem-solving only (i.e. as a sole strategy) might bring about large or small improvements in HW performance, but moderate effects are more typical. The effects tend to increase over time.
• Multifaceted strategies that strengthen infrastructure (e.g. providing commodities), supervision, other management techniques (e.g. HW group meetings), and training; and the strategy of group problem-solving plus training might result in very large or only modest improvements, but such multifaceted strategies tend to have large effects. The large effects of group problem-solving plus training were stable over time (i.e. no discernable increase or decrease, on average). 
• Financial incentives for HWs, and health system financing strategies and other incentives (e.g. health insurance) might lead to large or small improvements, but these incentives typically have modest to moderate effects.
• The effects of regulation and governance strategies in isolation are unknown. When combined with other strategy components, they tended to have large effects; however, it is difficult to know how much these improvements were due to the effect of other strategy components.
• Programmes might want to consider the influence of context on strategy effectiveness. Certain strategies (e.g. group problem-solving, and training with either patient support or supervision) might be more effective in areas with higher levels of resources (e.g. urban areas). Other strategies (e.g. training only or supervision plus training) might be more effective in inpatient settings.

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.