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Health System Impact of the BHOMA Study: A Stepped-Wedge Cluster Randomised Trial

28 Pages Posted: 12 Mar 2019

See all articles by Wilbroad Mutale

Wilbroad Mutale

University of Zambia (UNZA) - Department of Health Policy and Systems

Samuel Bosomprah

Centre for Infectious Disease Research in Zambia

Jeff Stringer

University of North Carolina (UNC) at Charlotte

Helen Ayles

Zambia AIDS Related Tuberculosis (ZAMBART)

Ab Sharp

Zambia AIDS Related Tuberculosis (ZAMBART)

Namwinga Chintu

Centre for Infectious Disease Research in Zambia

James Lewis

London School of Hygiene and Tropical Medicine

Margaret Tembo

Zambia AIDS Related Tuberculosis (ZAMBART)

Roma Chilengi

Centre for Infectious Disease Research in Zambia

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Abstract

Introduction: Health system strengthening has become an important global agenda due to increased recognition that poor health systems result in poor health outcomes. However, strengthening health systems remains a challenging endeavour because of the complexity inherent in health systems. Health system interventions can result in unpredicted or unintended consequences. This paper explores the health system impact of the Better Health Outcomes through Mentoring and Assessments (BHOMA) which was implemented in three rural districts in Zambia over a period of four years.

Methods: Five Health system outcomes formed the basis of evaluating the intervention: Health worker skills, training and supervision, health worker motivation, quality of care (Health worker observation and patient exit interviews) in line with the the postulated theory of change. For each outcome, data collected through three cross-sectional facility surveys were combined in a single analysis to estimate the intervention effect. Intention-to-treat analysis was done according to the phase respective clinics were, at the time they provided outcome data. This allowed for comparision of clusters serving as self-controls when assessed prior to the intervention introduction which was staggered over time in stepped wedged design.

Findings: Overall there was improvement in three of the four intervention domains during the project period. After adjusting for sex and age, skills score showed increased by an average of 4.8 percentage points; training and supervision scores increased by 3.9%, while quality of care improved by 1.5 percentage points; all the three domain changes were statistically significant (p<0.05). However, overall health worker motivation score showed a non-significant reduction in motivation score of 0.2%.

Interpretation: The BHOMA intervention had a positive effect on three out of four major domains of the intervention. It remains to be seen whether these key system improvement changes translate into a measurable effect on the quality of care and whether they are sustained beyond the project life-span. Further qualitative work is needed to understand how motivation can be enhanced without unduly increasing the cost of health care delivery.

Funding Statement: The study was funded by Doris Duke Charitable Foundation (DDCF).

Declaration of Interests: The authors declare no conflict of Interest.

Ethics Approval Statement: The Study was approved by the University of Zambia Bioethics Committee (UNZA BREC).

Keywords: Health Systems, BHOMA, Health Worker Motivation, Human Resources

Suggested Citation

Mutale, Wilbroad and Bosomprah, Samuel and Stringer, Jeff and Ayles, Helen and Sharp, Ab and Chintu, Namwinga and Lewis, James and Tembo, Margaret and Chilengi, Roma, Health System Impact of the BHOMA Study: A Stepped-Wedge Cluster Randomised Trial (November 29, 2018). Available at SSRN: https://ssrn.com/abstract=3294759 or http://dx.doi.org/10.2139/ssrn.3294759

Wilbroad Mutale (Contact Author)

University of Zambia (UNZA) - Department of Health Policy and Systems ( email )

Lusaka
Zambia

Samuel Bosomprah

Centre for Infectious Disease Research in Zambia

P.O Box 34681
Plot 2374, Counting House Square, Thabo Mbeki Road
Lusaka
Zambia

Jeff Stringer

University of North Carolina (UNC) at Charlotte

9201 University City Boulevard
Charlotte, NC 28223
United States

Helen Ayles

Zambia AIDS Related Tuberculosis (ZAMBART)

Zambia

Ab Sharp

Zambia AIDS Related Tuberculosis (ZAMBART)

Zambia

Namwinga Chintu

Centre for Infectious Disease Research in Zambia

P.O Box 34681
Plot 2374, Counting House Square, Thabo Mbeki Road
Lusaka
Zambia

James Lewis

London School of Hygiene and Tropical Medicine

Keppel Street
London, WC1E 7HT
United Kingdom

Margaret Tembo

Zambia AIDS Related Tuberculosis (ZAMBART)

Zambia

Roma Chilengi

Centre for Infectious Disease Research in Zambia

P.O Box 34681
Plot 2374, Counting House Square, Thabo Mbeki Road
Lusaka
Zambia

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