Coaching for quality improvement under performance-based contracting: a theory-of-change evaluation in Honduras
- 1George Washington University
Abstract
BackgroundPractice coaching is increasingly used to strengthen quality improvement (QI) capacity in primary healthcare (PHC) systems in low- and middle-income countries (LMICs), yet the causal pathways through which it shifts provider behaviour and the systemic conditions that enable or constrain them remain under-theorized. Using a theory-driven qualitative evaluation, we examined how and why a practice-coaching intervention influenced QI in cervical cancer screening (CCS) and antenatal care (ANC) within Hondurass decentralized PHC system during the third phase of the Salud Mesoamerica Initiative (SMI).
MethodsWe conducted a within-case explanatory case study. A programme theory was reconstructed before data collection and iteratively refined against evidence drawn from semi-structured interviews with 11 mid-level managers, 6 PHC team medical leads and 2 regional managers, complemented by direct observation and document review. Analysis combined deductive-inductive coding, thematic analysis and pattern matching, with reporting per COREQ.
ResultsWe identified four causal patterns that refined the initial programme theory. Three pathways were activated: novel professional identity among participating managers; data-driven learning and collective efficacy, triggered by verifiable progress on CCS but not for ANC, where outcomes were less attributable to teams actions and relational coordination, psychological safety and trust, which provided the interpersonal basis for the first two. A fourth unanticipated pattern showed structural misalignment between coachings enabling, learning-based logic and the directive, punitive logic of Hondurass performance-based contracting environment, limiting gains to localized enabling bubbles.
ConclusionsCoaching can activate meaningful QI pathways in LMIC primary care, but sustained, equitable impact requires purposive alignment between coachings learning-oriented principles and the institutional performance-management architecture, and matching of coaching investment to clinical processes with observable, attributable outcomes.
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BibTeX
@misc{munar2026coaching,
title = {{Coaching for quality improvement under performance-based contracting: a theory-of-change evaluation in Honduras}},
author = {W. J. Munar and L. E. Aranda and M. E. Lauria and P. Bernal Lara and C. Innocenti and M. Rodriguez},
howpublished = {medRxiv},
year = {2026},
month = may,
doi = {10.64898/2026.05.21.26353487},
url = {https://www.medrxiv.org/content/10.64898/2026.05.21.26353487v2},
note = {CC BY},
}
RIS
TY - UNPB
TI - Coaching for quality improvement under performance-based contracting: a theory-of-change evaluation in Honduras
AU - W. J. Munar
AU - L. E. Aranda
AU - M. E. Lauria
AU - P. Bernal Lara
AU - C. Innocenti
AU - M. Rodriguez
PY - 2026
DA - 2026/05/21
PB - medRxiv
DO - 10.64898/2026.05.21.26353487
UR - https://www.medrxiv.org/content/10.64898/2026.05.21.26353487v2
AB - BackgroundPractice coaching is increasingly used to strengthen quality improvement (QI) capacity in primary healthcare (PHC) systems in low- and middle-income countries (LMICs), yet the causal pathways through which it shifts provider behaviour and the systemic conditions that enable or constrain them remain under-theorized. Using a theory-driven qualitative evaluation, we examined how and why a practice-coaching intervention influenced QI in cervical cancer screening (CCS) and antenatal care (ANC) within Hondurass decentralized PHC system during the third phase of the Salud Mesoamerica Initiative (SMI). MethodsWe conducted a within-case explanatory case study. A programme theory was reconstructed before data collection and iteratively refined against evidence drawn from semi-structured interviews with 11 mid-level managers, 6 PHC team medical leads and 2 regional managers, complemented by direct observation and document review. Analysis combined deductive-inductive coding, thematic analysis and pattern matching, with reporting per COREQ. ResultsWe identified four causal patterns that refined the initial programme theory. Three pathways were activated: novel professional identity among participating managers; data-driven learning and collective efficacy, triggered by verifiable progress on CCS but not for ANC, where outcomes were less attributable to teams actions and relational coordination, psychological safety and trust, which provided the interpersonal basis for the first two. A fourth unanticipated pattern showed structural misalignment between coachings enabling, learning-based logic and the directive, punitive logic of Hondurass performance-based contracting environment, limiting gains to localized enabling bubbles. ConclusionsCoaching can activate meaningful QI pathways in LMIC primary care, but sustained, equitable impact requires purposive alignment between coachings learning-oriented principles and the institutional performance-management architecture, and matching of coaching investment to clinical processes with observable, attributable outcomes.
ER -