Health Workforce and Quality: Understanding the Foundation of Effective Care Delivery

Abstract

Despite major advances in healthcare access worldwide, ensuring delivery of high-quality care remains a central challenge across all health system contexts. In both low- and middle-income and high-income settings, systemic challenges, ranging from inadequate resources and training support to time pressures, burnout, and fragmented care processes, undermine health workers’ ability to deliver timely, evidence-based care. These structural barriers contribute to gaps in delivering high quality care, care that is effective, safe, and people centered. Addressing these structural barriers and achieving better health outcomes requires strengthening the capacity, organization, and working conditions of the health workforce. This dissertation investigates how the characteristics and organization of the health workforce shape the quality of healthcare delivery across diverse contexts. The first two papers focus on maternal health in Kenya, a setting where facility-based deliveries have expanded rapidly but quality of care remains poor. Using a unique dataset combining direct clinical observations, provider interviews, and facility assessments, Paper 1 examines how factors such as facility resources, provider attributes, and workload affect the quality of labor and delivery care. Paper 2 then evaluates whether strengthening obstetric and newborn care skills through a large-scale nurse mentorship program can improve the quality of care. Leveraging data from a cluster-randomized trial, it provides evidence on how mentorship impacts provider knowledge, delivery care quality, and maternal and neonatal outcomes. Paper 3 shifts to a high-income setting, focusing on a different, yet pressing set of challenges. Although high patient volumes and limited time per encounter are challenges common to many health systems, primary care in the United States has undergone changes over recent decades such as increasing administrative demands and provider shortages that have substantially constrained the time available for each visit. These pressures potentially shape both the quality and comprehensiveness of care. Using electronic health record data and quasi-experimental variation in visit scheduling, this paper examines how reductions in visit time pressure influence the content and quality of primary care, including the delivery of preventive services. This dissertation provides evidence on how the organization, capacity, and environment of the health workforce shape the delivery of care. The findings contribute to a deeper understanding of how future initiatives might be designed to strengthen quality of care through the health workforce.