Despite the evolution of training approaches and technology, training initiatives for health workers continue to experience the same pitfalls, all at great cost and contributing to inadequate production and retention of the needed health workforce. Since the 1970s, training designs have progressed from information-based, classroom-oriented models to more interactive, competence-based approaches to performance-based training methodologies that emphasize effective transfer of skills and knowledge to the workplace. The trend toward more holistic and supportive training programmes has generally produced stronger on-the-job results among trained health workers. Still, training initiatives often fall into the same old traps that have beset the overall success and cost-effectiveness of these programmes for decades.
With the current crisis in human resources for health (HRH), these pitfalls have become more serious and are now seen as aggravating the situation and impeding the effective scale-up of training. On 9 January 2008, participants in a meeting with the World Health Organization (WHO), ministers of health, development partners, nongovernmental organizations (NGOs) and people living with HIV/AIDS embraced the Addis Ababa declaration, a call to action for the adoption of new WHO guidelines and recommendations on task-shifting as one of the strategies for bringing solutions to the HRH crisis. As described in the guidelines, task-shifting involves redistributing tasks, as appropriate, "from highly qualified health workers to health workers with shorter training and fewer qualifications in order to make more efficient use of the available human resources for health." [1
]. Successful implementation of these guidelines will require addressing the common pitfalls to training initiatives. Among the major traps are the following:
• Lack of country-level coordination of health training among donors, partners, ministries and other key actors: This manifests itself in many ways, among them mismatches between the skills and knowledge required by a country's health systems and the skills and knowledge produced by its educational systems. At its extreme, poor coordination and management of training can result in providers' spending more time in training than offering the services they are trained to deliver.
• Inequitable access to training: for reasons such as gender, type of cadre and location of the health worker.
• Interrupted services: The tendency to bring health workers to centralized locations for training too often causes serious disruptions in service delivery at facilities serving the most vulnerable populations.
• Failure to reinforce skills and knowledge training by addressing other performance factors: These factors include the work environment (equipment, supplies and other tools needed to provide services of good quality), organizational support, clear expectations and feedback, and motivation. Lack of attention to these factors hampers the effectiveness of training programmes, leads to poor application of newly-acquired learning in the workplace and can discourage retention of trained workers.
This commentary presents some key factors to consider for effective and accelerated scale-up of holistic training and performance-improvement programmes, drawing on IntraHealth International's lessons learned in designing reproductive health and HIV/AIDS training and performance improvement programmes over the last 28 years in countries around the world. Our work in human resources for health, especially through leading the USAID-funded Capacity Project, also informs this article.