Using management coaching techniques is feasible and can be benecial to strengthen health system in Western Kenya

To strengthen the health system in ve counties of Western Kenya, the System Enhancement for Transformative Health (SETH) Project provided training on coaching to its ocers and coordinators to build their capacity to support health management teams address the challenges they face in their daily work. Health management teams manage entire counties in kenya with limited management training and experience. Following 3 days of training, the project team provided coaching sessions to health management teams and was supervised by a professional coach over a 2-year period. This study aimed to evaluate the feasibility and acceptability of using professional coaching techniques to improve the capacity of project ocers to support HMTs in Kenya. sustainability


Abstract Background
To strengthen the health system in ve counties of Western Kenya, the System Enhancement for Transformative Health (SETH) Project provided training on coaching to its o cers and coordinators to build their capacity to support health management teams address the challenges they face in their daily work. Health management teams manage entire counties in kenya with limited management training and experience. Following 3 days of training, the project team provided coaching sessions to health management teams and was supervised by a professional coach over a 2-year period. This study aimed to evaluate the feasibility and acceptability of using professional coaching techniques to improve the capacity of project o cers to support HMTs in Kenya. (14) Key Informant Interviews (KII) and (5) Group interviews were conducted with all SETH project o cers and coordinators trained on coaching and the HMTs members they supported to collect their perceptions on the feasibility and bene ts of the intervention components. Respondents were also asked about the sustainability of the project.

Results
Results show that coaching improved the project o cers' self-reported skills and competencies to provide support to county HMTs. The project offers reported feeling better equipped to help HMTs identify lasting solutions to the challenges faced in their daily work. HMTs also reported having gained knowledge and skills to be used on their daily work thanks to the coaching sessions received.

Conclusions
The study indicates that integrating coaching in health system strengthening is feasible and appreciated by participants in the intervention. The potential impact of coaching on work performance and on health indicators remains to be evaluated.

Background
The System Enhancement for Transformative Health (SETH) Project was initiated in 2016 to improve provision of and demand for Maternal and Child Health and Nutrition (MCHN) services in the ve Kenyan counties of Kakamega, Siaya, Trans-Nzoia, Bungoma and West-Pokot.
Health management teams (HMT) are responsible for all aspects of the management of the health system in their county / sub county, among which to develop policies, guidelines and workplans, provide technical support to frontline health workers and coordinate and monitor provision of health services. The Kenya Health Policy 2014-2030 acknowledges that County and sub-County HMTs exhibit insu cient management skills that limit their capacity to support health workers to realize their full potential. (GoK, 2014). The SETH project's baseline survey also highlighted limited management skills among HMT. HMT leadership showed limited understanding of their responsibilities; provided minimal de nition of targets and goals; held only irregular staff meetings; displayed low self-con dence; and had weak data management practices. In addition, interpersonal communications were weak, which inhibited teamwork.
To address these gaps, in addition to providing technical and nancial support aimed at strengthening the health system (training, joint supervision, equipment, etc.), the SETH project tasked its Project O cers with helping HMT members identify and overcome challenges they faced in their daily work with the objective of helping them improve their performance. However, SETH Project O cers (SPO) were junior staff with limited experience and competencies in this domain. Supporting HMT that were more experienced and sometimes had greater technical competency was identi ed at the beginning of the project as a potential challenge for SPOs.
In response, SETH management identi ed coaching as a tool with the potential to enable SPOs to support HMTs in their routine management of the health system. It was anticipated that this approach would develop competencies such as listening, re ection, questioning and negotiation (Sonnino, 2016;Wolever et al., 2016;DiGirolamo, 2015;TLD Group, 2015). Olivero et al. (1997) found that management training led to a 22% improvement in employee productivity, and this increased to 88% when coaching supplemented training. Unfortunately, coaching is not commonly used alongside management training to increase worker performance (Utrilla et al., 2015).
Coaching has been applied to address capacity needs of managers in the health sector and was shown to enable workers realize full potential in work performance (Sonnino, 2016;Wolever et al., 2016).
Coaching improves workers' performance in healthcare service delivery. For example, CMI (2014) describes coaching as a non-directive intervention enabling recipients to acquire new approaches of solving problems for performance. Hammervoll (2011) postulates coaching as capable of improving human resource capabilities; while Kampa-Kolesch and Anderson (2001) asserts coaching as a systematic feedback intervention, designed to raise skills in solving problems. Coaching therefore makes workers independent in solving work-related gaps to improve performance and quality of output.
There exists a causal connection between coaching and performance of health workers. For instance, Muriithi (2016) indicated workers' performance as in uenced positively by environment, feedback and planning. On the other hand, Ellinger, Beattie and Hamlin (2014) a rmed coaching as having signi cant effects on workers' productivity and development. On the same vein, Batson and Yoder (2012) showed improvement in aspects of performance and relationships within health sector delivery. However, breadth of studies on impact of coaching on coaches and recipients relationships and performance remain scanty. A study conducted by McPherson et al., (2017) highlighted coaching as being useful in developing competencies of health managers in budgetary resources and time management skills. Relatedly, Fournies (2004) a rms that coaching can be integrated in health systems by training selected staff to cascade coaching skills for improved performance.
The ve SPOs were trained on coaching skills by Career Connections Limited -a professional coaching agency based in Kenya, in December 2017. Country director for Helen Keller and 2 coordinators of the SETH project, who supervise the SPOs, were also invited to participate in the training to enable them to provide support to SPOs over the course of the project. The SPOs were then required to practice their coaching skills in the course of their work on selected HMT members over a period of 2 years. They were each asked to identify at least 2 HMT recipients from either the county or sub-county level and organize between 3 and 6 coaching sessions with each of them with the aim of helping them address challenges they face in their daily work. During the 2 years, they were supported and supervised by the coaching agency though quarterly group meetings and individual monthly sessions designed to help them re ect on their practices. This supervision provided individualized support to SPOs. The objective of the coaching sessions by SPOs was to further develop their informal coaching skills but did not aim to make them professional coaches. These skills would then enhance their capacity to deal with their own work challenges, interact more effectively with senior and junior HMTs, and improve their facilitation of meetings and discussions.
During coaching sessions organized by SPOs, HMTs were counseled on how to critically analyze the challenges within the context of their current responsibilities, identify strengths and opportunities, and come up with their own solutions.
This study intended to examine the feasibility and impact of using management coaching techniques to strengthen performance of SETH project o cers in Western Kenya by examining how coaching practices could be integrated into the project activities, how coaching in uenced the self-reported work performance of SPOs and HMTs, and how it in uenced their working relationships.

Methods
Participants were sampled purposively to include those involved in all phases of the coaching intervention, including design, supervision, training, coaching and being coached. A total of 25 participants were involved in 14 key informant interviews (KII) 2 with national coordinators, 2 with professional coaches, 5 with SPO, and 14 with HMT members (table 1). 5 group interviews (GI) were also conducted using structured interview guides. The 5 GI were conducted with the SPOs, HMTs, and HMT colleagues and supervisors (Table 2). Primary data were collected between September and October 2019. All interviews were recorded and then transcribed verbatim for analysis. Interview transcripts were imported into Atlas.ti software (Atlas, 2018) for coding and thematic analysis. Analysis was conducted by a team of external researchers (non-a liated to SETH program). The choice of design, approaches and methods were drawn from a constructivist approach, which assumes that truths about reality are subjective, based on individual observer's cognitive perceptions (Wong, 2014;Sale, Lohfeld & Brazil, 2002). The analysis was informed by grounded theory, which consists in developing a theory of explanation grounded in and emerging from the data rather than from pre-existing categories and theoretical frameworks (Tie et al, 2019). Data were analyzed with open coding from which patterns were identi ed, then categories or themes, from which broader interpretation was developed. This was followed by validation of the report in a stakeholders' forum.

Results
The study applied qualitative methods to source data, as well as simple descriptive statistics, including quanti cation of multiple responses[1], where applicable.

Feasibility of Developing and Using Coaching Skills for Health System Strengthening
Coaching training: Out of 8 subjects having participated in the training, including 5 SPOs and 3 coordinators, 5 (63%) indicated that the training duration (3 days) was too short to grasp coaching skills su ciently to apply them effectively in their work. Consequently, most needed time to gain con dence before initiating coaching conversations with HMT, and did not begin coaching until three months after completing the training and after participating in a quarterly group meeting with the coaching agency where they could express their concerns and receive support. Chart 1 presents the reasons given for delaying application of the new skills (n=8).
Identi cation of HMT participants: Of the 5 SPOs and 3 coordinators trained in coaching skills, 5 (63%) identi ed HMT participants to coach at the sub-county level, 1 (13%) at the county level, while 2 coordinators (25%) did not identify any, citing work demands.
Consistency of formal coaching sessions: Competing responsibilities, particularly project implementation activities, and physical distance between SPOs' and HMTs work locations created barriers to regular coaching sessions. SPOs reported that work scheduled left little time for coaching sessions, as expressed by one SPO: "…I have been having a lot of competing activities, including meetings … they are like every other day. In some weeks I have three to four meetings in a day, and then I have to go to the eld to implement activities, and then I still have coaching to do… I have to postpone some activities in order to cope with the pressures." Supervision and continuous support: Coach supervision was provided off-site quarterly by an accredited coach supervisor. SPOs and coordinators were supervised both as a group and individually. Group supervision meetings provided opportunities for collaborative learning through re ection and sharing of experiences and for the practice and strengthening of coaching skills. These meeting also allowed participants to explore their coaching relationships and to build cohesiveness amongst themselves. In this regard, the coach supervisor observed that: "…from where I was sitting, I felt that the group session was creating a common thinking and I could see how they were connecting one experience to another. That provided a space for collective learning." Individual supervision sessions were more intense, providing each subject with time to examine in detail their personal experiences with coaching without fear of being judged by colleagues. The analysis revealed that the subjects found both individual and group supervision approaches bene cial and empowering as indicated in Chart 2 (n=9 -5 SPOs + 3 coordinators + 1 coaching supervisor).
Perceived e ciency of the approach: Six respondents (75%) suggested that the effectiveness of the coaching was enhanced by the combination of training and follow-on supervision, which allowed them to practice their coaching skills. Due to funding constraints, it was not possible to extend the training to HMTs at the county level. However, the 8 respondents felt that this training could have had a signi cant impact on strengthening health systems at the county level.
Sustainability of the coaching intervention: Questions on the perceived sustainability of the intervention were asked to the 8 SPOs and coordinators and to HMTs and their supervisors (n=20). Up to 80% of them indicated that extending the coaching intervention to county HMTs would make the intervention more sustainable. Fourteen (70%) opined that establishing forums to allow managers who have gone through coaching skills training to mentor and supervise colleagues and health workers would raise productivity. However, 11 (55%) were of the view that establishing appropriate measures for retaining HMTs coaching knowledge and skills would minimize losses that occur when skilled managers exit, as turnover among HMT is high.

Impact of Coaching on SETH Project O cers' Work Performance
Out of the 5 SPOs and 3 coordinators and their coaching supervisor (chart 4), 8 (89%) indicated that coaching training changed SPOs approaches to supporting health mangers. Seven (78%) suggested that the training enabled SPOs to change their approach from prescribing solutions to helping managers nd their own. Six (67%) indicated that coaching training improved SPOs skills in coaching, including: engagement, listening, re ecting, questioning and challenging, and ve (56%) indicated it improved SPOs' participation in meetings by enhancing their communication skills. As one SPO expressed it: "…initially I could sit in those meetings and feel like am not at that level, but coaching has really empowered me, I can have very candid discussions with whoever…a donor or a UNICEF representative… we can have very good engagement by asking them relevant questions and provoking their thinking." Chart 5 shows that out of 5 SPOs and 3 coordinators, 6 (75%) stated that coaching skills enabled them increase the number of interactions with HMTs and having gone together through a challenging new activity such as coaching improved teamwork and cohesion among them. Interestingly, most did not consider that the informal coaching improved their coaching skills, possibly as opposed to the formal coaching training and sessions, as informal coaching is de ned here as the use of coaching skills in daily work routine activities.

Impact of Coaching on HMTs Work Performance and Relationships
Although it was not the primary aim of the coaching training and supervision, the study looked at the perception of HMTs on the impact of coaching by SPOs. Chart 6 shows that out of 14 HMT subjects who participated in the KII, 9 (64%) asserted that the coaching they received improved their knowledge of contextual issues affecting delivery of services. Again, 7 (50%) felt that coaching by SPOs motivated HMTs participants to tackle problems that impeded work performance. In one instance, a SPO indicated that: "…when we started coaching sessions, I guided the HMT participant to identify and prioritize various issues constraining his work performance. We started tackling the challenges based on the order of severity. However, I came to realize that the HMT participant went ahead and used the new skills to tackle other challenges, which suggests that the HMT participant is motivated to address issues around his work." 7 (50%) hinted that the introduction of coaching skills, which entailed sensitization about coaching, purpose and potential bene ts strengthened the working relationships between SPO and HMT. However, 5 (36%) indicated that the coaching they received increased their apprehension, particularly around sharing information on personal challenges at work. Footnote: [1] Some open-ended questions required participants to provide more than one response (multiple responses). In such situations, the responses are quanti able and can be computed as percentages, based on number of respondents (sample size) or based on the total number of responses. In this study, the percentages have been computed based on the unique number of respondents.

Limitations
Although the main thrust of the study was qualitative analysis, some of the qualitative responses were quanti ed to generate frequency distributions. The small sample size limits the robustness of the descriptive statistics and any conclusions must be tentative.

Discussion
Feasibility of developing and using coaching for health system strengthening Integrating a coaching component in a health system strengthening proved to be feasible and SETH SPOs and coordinators reported that it improved their performance and con dence to perform their duty. HMTs also reported having gained from the coaching sessions they received. It however took several months after the initial training of SPOs for the coaching sessions with HMTs to take place, mainly because of apprehensions by SPOs who felt not well prepared. Eventually, both SPOs and HMTs understood and adhered to the approach and expressed signi cant bene ts from having participated to the sessions.
About two-thirds of the SPOs preferred applying their coaching techniques with Sub-County rather than County HMTs, since the latter were more likely to be more advanced in their careers than the SPOs. County HMTs were however integrated as mentors and followed closely the progress and impact of coaching sessions on the performance of sub-county managers.
Training and support for the application of coaching skills could be adopted at a wider scale but may need to be further adapted and should be considered from the design stage to ensure full participation of all actors in its design. The question of fully integrating HMTs in the intervention should be considered further as an important opportunity to strengthen management skills in the counties.
While the coaching Monitoring & Evaluation (M&E) process generated insights and in uenced implementation decisions, clear indicators for measuring impact were missing, which in turn, affected quality of information. Consequently, M&E frameworks with clear de nitions of success at the beginning and at the end, using SMART indicators, should be prioritized in developing coaching interventions that target effective outputs.

Impact of coaching on SETH Project O cers' work performance
Coaching skills training provided a valuable opportunity for SPOs to grasp coaching principles and skills, which empowered the employees to tackle issues affecting daily performance, as well as practice coaching skills on health managers. Concrete elements reported included an increased capacity to analyze the health environment and the health system they work in, increased capacity to brainstorm as a team and to nd practical solutions to the health challenges encountered, better organization of their work, and better understanding of their own management type. Training was linked to positive changes, however the training provided was a typical training for coaching diploma that is proposed in any domain of work, and some adjustments to the speci c needs and context of the SPOs may have enhanced the effectiveness of the training. The 2 years follow up and supervision that followed the training however compensated the initial di culties felt by the SPOs immediately after the training. It appeared also that impact of coaching was limited by the fact that organizing coaching sessions was not an initial priority in the project and suffered from competing tasks.
Coaching skills training enhanced SPOs communication skills and improved their constructive engagement with key stakeholders in in uencing decisions for delivery of MCHN services. For example, by applying both formal and informal coaching in their interactions with HMT colleagues, some SPOs in uenced members at the County level to allocate budgets for nutrition departments; while in another example, SPOs in uenced introduction of innovative community engagement forums using social media platforms.
In addition, informal coaching enabled SPOs to maintain interaction with HMT participants, to help HMT participants manage issues arising at the work place and enhanced teamwork and cohesion to improve productivity. The continuous interaction between SPOs and HMT participants was bene cial as SPOs got opportunity to improve on coaching skills, while HMTs improved problem-solving skills. Teamwork and cohesion improved among SPOs. In view of this, SPOs should be encouraged to apply informal coaching skills on both HMTs and other project staff to augment the intervention's impact on SPOs' performance.

Impact of coaching on HMT participants' work performance and relationships
The coaching they received enabled HMTs to re ect on work ethos, contextualize issues on performance and develop innovative solutions. With more knowledge HMTs reported being able to work more effectively in engaging with stakeholders and draw solutions to issues affecting delivery of MCHN services. Further, the intervention made HMTs more constructive and active in meetings. It improved their perceptions about MCHN services; enhanced their ability to cope with work-related pressure, motivated them to apply coaching skills to tackle issues arising outside work, and made them more in uential at workstations, which earned some of them more managerial responsibilities. Additional responsibilities for some HMTs suggests an increased exposure to challenges that would improve management competence; thereby, suggesting that coaching skills added value to HMTs career progression. In view of this, sensitizing health managers selected for coaching training about the need to seek own solutions to problems, helps improve their knowledge and motivation, as well as expedite change in perceptions, work practices and performance in delivering MCHN.
On the other hand, coaching training caused apprehension among some HMT participants to whom the intervention was a completely new way of engagement, while others indicated that coaching would increase workload. The success of coaching depends on the openness of HMT participants about issues that affect professional and personal life, which may be achieved in an environment of trust. This implies that building trust between SPOs and HMT participants is vital for bringing out real issues affecting health workers' performance for correct targeting. The process entails providing information to HMTs about coaching, roles and responsibilities in coaching relationships, boundaries of engagement and expected outcomes, among others for sustained productivity.

Conclusion
At the beginning of the SETH project, its o cers were trained on coaching and then asked to conduct coaching sessions with HMTs. They also received supervision on their coaching experience by a professional coach over a 2 years period. The o cers reported multiple bene ts to the training, the coaching of the HMTs and the supervision. They improved their capacity to re ect on the challenges affecting the health system, they improved their capacity to identify, individually and collectively, practical solutions, they improved their capacity to interact with others. HMTs also reported positive outcomes related to their capacity to re ect and analyze on their daily routine and on the ways to increase the performance of the health system.
This study suggested that the use of professional coaching techniques could increase the performance of personnel in charge of health system strengthening projects and of health management teams. A more rigorous operations research should be conducted to provide a more rigorous assessment of the impact of coaching on managers performance and on health outcomes. The initial coaching training should however be adapted to better t the context of health system managers. The training should be immediately followed by supervision by a professional coach.

Consent for publication
Each participant to the study signed a detailed consent form before participating to the study Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
PO collected and analyzed the data. DD was the main author of the manuscript. Other authors participated in the study and reviewed the manuscript  See image for caption

Supplementary Files
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