Using the Performance Improvement methodology, PRIME II integrated solutions beyond training to address factors affecting provider performance. Approaches included:

• Supportive supervision and peer support networks
• Provider motivation and feedback
• Clear performance expectations.

• Kyrgyzstan: After an investigation revealed that providers had little motivation to counsel clients about sexually transmitted infections (STIs), PRIME II implemented a program at 28 family medicine centers and clinics in Bishkek in which provider performance data were collected through client exit interviews and posted monthly in areas of the facilities where only providers could see them. The percentage of clients reporting STI prevention counseling rose from 33% at the first posting to 56% for the sixth.
• Ghana: With a goal of reducing maternal mortality and morbidity, Ghana Health Services (GHS) has been scaling-up reproductive health care since the mid-1990s. Regional Resource Teams (RRTs) in safe motherhood were established to conduct life-saving skills and postabortion care training for midwives and supervise and support application of these new skills. After it became apparent that many RRT members were not performing to standard, PRIME II assisted GHS in conducting a performance needs assessment and implementing training along with non-training interventions in supportive supervision and ensuring adequate equipment and supplies. The percentage of RRT members performing their designated roles increased from 36% at baseline to 87.5% at final evaluation; improvements were also noted in the percentages of providers receiving supervisory visits (67% vs. 40%) and being told their job expectations (97% vs. 31%).
• Benin: Unmet need for family planning (FP) is high in Benin, where the average woman bears six children and only 7% of married women aged 15 to 49 are using modern contraception. In response, PRIME II applied the Performance Improvement approach in the private sector to assess and prepare a new cadre of 140 pharmacy agents to improve the quality of FP counseling and increase provision of oral contraceptives in the two largest cities, Cotonou and Porto-Novo. A year after training and non-training interventions, including better job definitions and development and use of job aids, an evaluation found prepared agents performing significantly better than unprepared agents in five areas of care (57% vs. 28% of all tasks carried out satisfactorily).
• Paraguay: Providers and their supervisors are often unaware of clients’ expectations and uninformed about clients’ perceptions of service quality. Dissatisfied clients simply fail to come back. At hospitals and health centers in Paraguay, PRIME II compared two strategies for client feedback: group meetings with clients and providers and feedback cards that clients can leave in an “opinion box.” Both approaches featured public display of client communication posters to summarize the good things clients said about services, their suggestions on ways to improve services, and the changes providers were making in response to the feedback. Observations of provider performance in components of prenatal care included in feedback showed significant improvement at the intervention facilities—from 21% to 57% for the group approach and 24.5% to 35% for the feedback card approach—as compared with an improvement of 23% to 23.5% for providers at a control facility.