Coaching for quality improvement under performance-based contracting: a qualitative theory-of-change evaluation in Honduras
Year: 2026
Type: preprint
Abstract: ABSTRACT Background Practice 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 Honduras’s decentralized PHC system during the third phase of the Salud Mesoamerica Initiative (SMI). Methods We 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. Results We 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 coaching’s enabling, learning-based logic and the directive, punitive logic of Honduras’s performance-based contracting environment, limiting gains to localized ‘enabling bubbles.’ Conclusions Coaching can activate meaningful QI pathways in LMIC primary care, but sustained, equitable impact requires purposive alignment between coaching’s learning-oriented principles and the institutional performance-management architecture, and matching of coaching investment to clinical processes with observable, attributable outcomes.
Source: medRxiv
Institutions: George Washington University, Inter-American Development Bank
Language: English
Subfield: General Health Professions
Field: Health Professions
Domain: Health Sciences
Open Access status: green
OpenAlex ID: W7162854158