Hospital Quality Monitoring System and other existing national platforms to evaluate and improve performance, as well as generate new knowledge to inform clinical decisions and national policies.China faces the immediate need of addressing the rapidly growing population with cardiovascular disease (CVD) events and the increasing numbers who are living with CVD. Despite progress in increasing access to services, China faces the dual challenge of addressing gaps in quality of care and producing more evidence to support clinical practice. In this article, we address opportunities to strengthen performance measurement, programs to improve quality of care and national capacity to produce high impact knowledge for clinical practice. Moreover, we propose recommendations, with implications for other conditions, for how China can immediately leverage its  With the effects of changing lifestyles and an aging population, the growth in the numbers of individuals with CVD is predicted to continue at least till 2030. In this time period, the numbers of people with acute myocardial infarction (AMI) is estimated to increase from 8.1 to 22.6 million a year, and those with stroke from 8.2 to 31.8 million a year.4 Although preventive strategies are the ultimate solution to this epidemic of CVD, including attention to environment and behaviours,5 China faces the immediate need of caring for the rapidly growing population who are having and will have CVD events and the increasing number of individuals who are living with CVD. Moreover, these challenges are also relevant to many other non-communicable disease conditions.China is experiencing a rapid epidemiological transition, with particular implications for the growth of cardiovascular disease (CVD).6 hospital capacity,7 and the health care workforce,8 and has made much progress in expanding access to affordable care.9 However, even with these advances, China has additional work to do to ensure that these individuals have access to care that best enables them to achieve best possible health outcomes.China has recently been strengthening its health care system through far-reaching health care reform policies, focusing on insurance coverage,10 In particular, there are two areas that are vital to China's ability to meet the health needs of individuals who suffer from CVD (Panel 1). First, there is a need to improve the quality of care. Building health services capacity and fostering access are necessary, but not sufficient to ensure that individuals benefit from health care services. They must have access to the highest quality care. Second, there is a need to expand the evidence about the safety and efficacy of treatments for Chinese patients and how best to deliver the highest quality care. To achieve these goals, China needs to build a learning health care system, with the capacity to monitor performance, learn about what works best for whom, and evaluate what strategies support successful implementation of best practices and achieve optimal outcomes. In this way, China can be a model in showing how to make its health care system more accessible, but also configure it to deliver high quality care and to learn from the experience of every patient.As errors in medical care have caused numerous deaths and disabilities in low- and middle-income countries, which lack evidence about which strategies work best in resource poor settings.11 High quality care not only provides patients with the best opportunity to achieve the outcomes they seek, but avoids inefficiency and waste. Countries with limited resources particularly need to focus on what care is best and how it is provided,10 and strengthen healthcare delivery systems so they can produce high-level performance as efficiently as possible.In a health system with high quality of care, patients get the care they need, when they need it, without undergoing unnecessary or inappropriate treatments.12 We found evidence of progress in the care of people with coronary heart disease (CHD) and stroke, but also substantial opportunities for improving quality of CVD care (Appendix 3).Prior studies and government reports from China indicate large gaps in quality. We did a comprehensive literature search, focusing on quality of cardiovascular care, including the themes of healthcare quality noted by the US Institute of Medicine and World Health Organization .13 a period when many other countries experienced marked declines.15 The lack of improvement in China may be a result of no change in the underuse of reperfusion therapy, beta-blockers, and angiotensin converting enzyme (ACE) inhibitors. In particular, the reperfusion therapy rates were much lower than many other countries. For example, in a recent period China achieved 27% treated,13 compared with 94% in the United States (US),16 77% in the United Kingdom (UK),15 and 59% in India.17 Even among those patients who were ideal candidates for treatment, only half of them received the therapy. In addition, the effectiveness of treatment was compromised because of delays in treatment, with door-to-needle and door-to-balloon times for reperfusion much longer than the recommended standards.19 Similar findings have shown underuse and delay is common in administration of fibrinolytic therapy in patients with acute ischemic stroke (AIS).20One national representative study of patients with ST-segment elevation myocardial infarction (STEMI) found that in-hospital mortality rates, adjusted for demographic and clinical factors, have not improved from 2001 to 2011,21 Moreover, among Chinese hypertensive patients with history of ischaemic stroke, only 21% had their blood pressure controlled, as defined as lower than 140/90 mmHg for non-diabetic patients and 130/85 mmHg for diabetic patients.22 This underuse of secondary preventive medications is consistent across several studies. 30The issues with quality are not restricted only to acute treatment, as there are also gaps in secondary prevention, even as clopidogrel and statin treatment rates increased. According to the baseline characteristics of randomized participants of an international trial, HPS2-THRIVE, the use of statins among 10 932 Chinese participants was much lower than that among 14 741 European patients (48% vs 96%), who were similarly at high risk of vascular disease and had definite indicators for statins.31 and a warning incorporated into international guidelines.33Moreover, the studies show that not only do many people with strong indications for treatment not get treated, but there is also frequent treatment of people with contraindications. In AMI care, the use of beta blockers in patients at high risk for cardiogenic shock, which is considered a strong contraindication, was common, with 43.7%, 59.6%, and 53.6% of these patients receiving treatment in 2001, 2006, and 2011 respectively. Thus, there was no decline in the unsafe practice pattern of beta blocker use even after it was highlighted in the landmark trial in Chinese patients more than a decade ago,35Misuse of treatments has also been documented, undermining their benefit. For example, among patients with STEMI who were treated with fibrinolytic therapy, in addition to significant delays in administration. Also, based on guideline recommendations, it was commonly underdosed.36 Hospitals also varied in their use of guideline-recommended medications. Although 90% of eligible patients with AMI received early aspirin treatment in 2011 overall, many hospitals lagged in performance, with 15% treating fewer than 80% of their patients with aspirin.37The average quality performance across China obscures the fact that quality varies by hospitals and regions. In a study of a large network of hospitals that perform coronary artery bypass grafting (CABG) the in-hospital risk-standardized mortality rates in the years 2007 and 2008 ranged more than five-fold, from 0.7% to 5.8%. Regional differences in CABG mortality ranged from 1.6% in Eastern region to 2.5% in Central region.The reason that quality of care is not higher is not known. The substantial underuse of beneficial treatments cannot be explained easily as some strategies were adopted quickly and others were not. Moreover, the quality gaps not only exist in the expensive treatments that need advanced techniques and facilities , but also in the use of inexpensive treatments, which are accessible and simply administered .Adding to the complexity is the dual role of hospitals in China, as they typically act as the mainstay of both inpatient and outpatient care. Furthermore, data on the performance of other potential care settings such as primary care centres, is largely unavailable and hinders assessment and improvement in these areas, highlighting the need to identify strategies to collect and learn from the care provided in these settings.Continuous quality improvement is a cycle of identifying targets, intervening to improve, and assessing the effects. Only by measuring and reporting clinical practice measures, which are constructed with appropriate and standard criteria, can hospitals and health professionals clearly understand their opportunities for improvement. In the end, measurement is critically important, but it is also important to recognize that the objective is not measurement, but improvement leading to exemplary performance. Therefore, the measures need to be timely and actionable, so that health care organizations and individuals can respond quickly. Although China has made some achievements in developing a national system to collect clinical information, quality measurements have yet to be used as a catalyst to improvement.Hospital Quality Monitoring System (HQMS), an online data collection system launched in 2011, covers all tertiary hospitals over the country and can provide a platform for measurement and improvement. The system is designed to link hospital information systems and to upload a common dataset of information from all inpatients medical records ,38 seeks to standardize the treatment processes, enhance the management of cost and length of stay (LOS) and support the development of prospective payment systems in the future. For each inpatient case doctors are required to complete a detailed clinical pathway checklist (Appendix 5). The hospitals, however, are only required to provide the government with a brief summary of these reports every three months, rather than provide the patient-level data in a form that is amenable to detailed quality reporting. Therefore, these data have not yet been used for national quality reporting. Moreover, there is currently no auditing to assess the accuracy of the data.The Chinese government issued standard clinical pathways for each of 120 common admission diagnoses, including 11 CVD categories, and established an official monitoring system in 2009 for these pathways. This system, the 40 with a majority of the core criteria related to patient safety and care quality, also with indicators of readmission and reoperation after specific diseases like AMI and AIS embedded. However, without risk adjustment, the usefulness of the comparisons are limited because of the possibility that differences are the result of variation in case mix.As a consequence of not producing national information on performance, there is no mechanism to benchmark performance in a systematic way and to link incentives for performance with the interests of care providers in China . For hos41 The mainly fee-for-service payment provides an incentive for the pursuit of treatment volume, rather than quality, and can lead to prescribing profitable treatments and tests that may not be clinically needed,43 as has been noted in other countries.44 Thus, to align incentives with the best interests of patients is needed in China. Such incentives should promote prevention, evidence-based care and value. There is a particular need to reduce the waste of resources in a system that must serve more than a billion people.Despite some regional experiments and pilot projects, the payments to providers in China are still based on the number of care services provided, and not whether those services are appropriate or performed well – or whether good outcomes are achieved.46 Without measurement and quality accountability, patients may ask: how can I have faith in my doctor or hospital? With incentives that may be at cross-purposes to high-quality, high-value care for me, how can I trust the health care system to promote my interests? Attention to quality may be needed to address the growing tension between doctors and patients.46In summary, we identify a need to strengthen performance measurement, accountability mechanisms, and alignment of reward structures with the provision of high-quality, high-value care. Hospitals and doctors have little information about their performance and lack knowledge about what are the major gaps, how they can best improve, or how these interventions can be assessed and acknowledged, also the system lacks imperative motivation for delivering high quality service. Thus, there is an opportunity for the system to improve and respond to these needs. Moreover, transparent and accountable quality of care is crucial for the trust of patients in the performance of hospitals and doctors. This issue may be particularly important in China where the hospitals and doctors are experiencing an unprecedented crisis of confidence.Medical Quality Management Regulations,47 a program in which some tertiary hospitals will be appointed as the national or regional Medical Quality Control Centres (MQCC) in specific clinical fields. The intent for these Centres is to take the lead in formulating quality standards, collecting data, performing analyses, and disseminating findings for the purpose of quality control and improvement. With this effort, the professional communities in China then could become more engaged in the care quality management in addition to strong government leadership, which is considered critical according to experiences from the US and the UK, despite their different healthcare systems.Despite the challenges, there are formative efforts to improve the quality of care. To strengthen quality management and standardize clinical care, China has been drafting the 36 More importantly, these studies have developed collaborative and reusable platforms, which are poised for translating available evidence into optimal clinical care for CVD and continue in continuous data collection and evaluation. Such studies can produce interventions that can be tested in trials, such as the current ongoing cluster randomized trial, PEACE-2. In another example, the Clinical Pathways for Acute Coronary Syndromes (CPACS) group developed and evaluated specific clinical pathways and corresponding quality improvement strategies for ACS, including regular feedback and audit on key performance indicators.48 The studies found that despite the improvement in use of discharge medicines, there was no significant difference in early treatments, which need more coordination and have stronger effects on reducing early mortality. The CPACS group identified barriers to implementation of the clinical pathway,49 including lack of leadership support, variation in the capacity, healthcare funding constraints, are instructive for the future relevant efforts. Several other studies are in process and will provide further insight on quality improvement strategies for CVD care.51Clinical research focusing on quality and implementation science can provide valuable insights for quality improvement. For example, studies based on a national representative hospital network, China Patient-centred Evaluative Assessment of Cardiac Events (PEACE), and a national CABG registry, Chinese Cardiac Surgery Registry (CCSR), have identified clear targets for quality improvement.52 For example, the risk of myopathy in Chinese patients taking daily 40 mg simvastatin is ten times higher than in Caucasians.21 Moreover, the system is different, as is the use of traditional Chinese medicine, which may interact with certain medications or affect particular strategies.In addition to the need to better apply existing knowledge, China urgently needs to expand the evidence for what works best for whom. First, there is an overall deficit of information even in an evidence-rich area such as cardiovascular disease. As much as half of guideline recommendations are based on expert opinion. Beyond that, much of the medical evidence used in China is imported, with a paucity of local evidence about effectiveness and safety of treatments, even as clinical research in the country has grown rapidly during the past decades. There is evidence that Chinese patients may react to medications differently in effectiveness and safety from other populations.www.clinicaltrials.gov) of the US National Institutes of Health, China (5.9 thousand) lags far behind high-income countries, such as the US (83.4 thousand) and the UK (10.4 thousand). Moreover, despite having the world's largest population with over 1.3 billion, the number of studies per million people in China is disproportionally smaller than South Africa, Japan, Brazil, and Russia, as well as the global average level , or National Institute for Health and Care Excellence (13 CPGs vs 4 ECs). There are 216 recommendations with the evidence level A (highest) in Chinese CPGs,62 among which only less than 10% are based on studies that involved Chinese patients.Consequently, China's clinical practice recommendations are largely derived from expert opinions, low-level evidence, or imported knowledge. Professional societies in China have released 14 Clinical Practice Guidelines (CPGs) for CVD management in China, while there are 186 Expert Consensuses (ECs). The ratio (14 CPGs vs 186 ECs) is much lower than the current ones from American Heart Association (55 CPGs vs 16 ECs)64 Second, there are human capital issues. Training of clinical research design and implementation is weak in China. Most clinical research largely relies on individual or small groups of practicing doctors with limited time for investigation, which affects the development of studies in China, let alone the requirements for cooperation across scientific fields of statistics, information techniques, sociology, economics and others. Third, without continuous funding support, clinical research networks for multicentre studies are often organized for single projects in China, leading to one time use and wasting the opportunity to reuse them. Moreover, they lack components that would provide the necessary training and mutual communication in implementation. Finally, the regulatory system needs to be more proactive in identifying identify opportunities to promote conducting clinical trials in China.65An overall strategic plan for clinical research in China has yet to be established for several reasons. First, despite the increasing investments for medical research from the Chinese government, funding for clinical research was only one fourth of that for basic biomedical research ($250 million versus $1 billion).66 At this point, 19 NCRC were accredited, covering 9 clinical disciplines, including all major non-communicable diseases. The government supports NCRC to establish sustainable collaborative networks, to take leading roles in multicentre clinical studies on knowledge generation, translation and application, and more importantly, to participate in the formulation of national clinical research roadmap and strategies. The vision for the NCRCs is to promote clinical research that can be translated into practice, to strengthen development, improvement and use of high value health care services, to reduce inefficiency and wasteful practices, and to improve population health and clinical outcomes. From the government, staged investments have underscored the missions of the NCRC – the first round funding of CNY81 million (about US$13 million) in 2014, has supported 13 clinical studies, one of which was to assess the quality improvement interventions focusing on gaps recently identified in China PEACE study and CCSR; the second round of CNY320 million (about US$52 million) in 2015, is about to support 27 studies on “assessments of management strategies for major diseases”. These efforts are expected to lay a foundation for future clinical evidence generation in China.The Chinese government has initiated long-term investments in clinical research that will strengthen the country's ability to generate evidence for clinical practice and policy formulation. In 2013, the Chinese Ministry of Science and Technology and National Commission for Health and Family Planning officially announced the funding of Chinese National Clinical Research Centres (NCRC).To improve the care and outcomes of patients with CVD, it is essential for China to further extend previous efforts to generate the knowledge of what are best practices in its own context, to measure whether doctors and hospitals are applying this knowledge in practice, to reward excellent performance, and to refine strategies and tools that will assist performance. The strategy needs to involve two major aspects: 1) evaluating through measurement, improving through stronger systems; 2) learning through research directed at what practices work best for which patients and integration with clinical care providers to promote the translation of the practical science into efforts to strengthen systems so that they have exemplary performance.China needs better translation of clinical, outcomes and implementation research to the clinical setting and measures of performance that can promote quality improvement, greater transparency in performance, and better policies to reward value, so that every citizen has opportunity to be treated according to the highest-quality care.67 Over time a national health information exchange can provide for higher quality clinical data to be shared securely to promote better measures and research in the service of better care.China needs efficient systems for continuously and timely monitoring nationwide clinical practice. Ideally these systems could build on existing efforts. There are two existing platforms that could be leveraged. First, the HQMS, with a potential expansion to secondary and even primary hospitals in future, could be fostered as a national administrative claims database. In addition, its nationwide unique patient identification system allows linkage across time and venues. It can be used for not only descriptions of hospital utilization, but also quality assessments through risk-standardized outcomes measures, as the US Centres for Medicare & Medicaid Service does, serving to inform the public of hospital performance and to support policy initiatives to improve care.69 there is information about what test and treatments were paid for that is available to the central and local governments.9 This information can also be linked with the HQMS via insurance ID and social ID of patients to enable more detailed assessments of the patterns of care.To optimize the use of the HQMS, it will be useful to strengthen the system in several ways: 1) systems to assess, standardize and improve data quality will be important; 2) consideration of the addition of limited clinical data, as is in process in the US, would strengthen the utility of the database for risk adjustment, with accurate unique identifier allowing for record linkage; 3) the linkage of HQMS with other national databases such as death registry and insurance, can allow the assessment of mortality in standardized periods of follow up. Assessing out-of-hospital mortality is particularly important in China because many people leave the hospital just before death. In a universal public insurance system covering 96% of the population established in China,Second, the existing CPRSD in China, as well as the platforms of China PEACE and CCSR, as basis of national clinical registries focusing on quality improvement, can provide detailed clinical information for treatment patterns and outcomes assessment for specific diseases. The goal is to aggregate these data from hospitals across China and use them as part of the national quality assessment and improvement efforts. Currently the patient-level data in CPRSD are retained within each hospital – and yet these data, once combined, would provide detailed information on national practice. Concomitantly there is a need to invest in data quality. Also, the national and regional MQCCs can establish and continually refine the standardized data definition, operational instruction, and quality indicators through close collaboration with professional communities. These efforts should leverage existing registries, which have successfully developed standards, such as the US National Cardiovascular Data Registry (NCDR). Such alignment will enable the international comparison on quality of care for major CVD, which is of value for benchmarking performance and developing improvement interventions.Furthermore, to achieve more efficiencies in data collection, it is possible to merge different data capturing systems in order to reduce redundancy. Moreover, China can develop innovative ways via information technology to directly capture clinical information of every healthcare encounter from electronic medical records in real time. The goal of common data standards and interoperability should be a national priority so the quality of data that can be shared can improve over time.14 Policymakers responded with the strategies of mandating the recording of the measures and making them publicly available, which enabled performance on process measures, for instance door-to-balloon times, to quickly improve.70 Later, outcomes measures were introduced. This improvement in the quality of cardiovascular care in the US is undoubtedly an important driver of the profound decline in AMI mortality in recent years (102The performance of each hospital on key quality indicators should be publicly available, with national or regional comparisons and benchmarks. Transparency in measurement can provide a strong impetus for improvement. In the US, the introduction of a series of quality measures describing evidence-based care processes in AMI management in the 1990s revealed substantial variation.nt years .10272 Therefore, evaluations of interventions need to be designed and implement from the outset.The government can seek to influence practice and promote implementation of best practices by means of incentives, economic and otherwise. Nevertheless, the effectiveness of such interventions in China are not known and it is necessary to ensure the designs do not cause incentives for adverse risk selection and other unintended consequences, as have been noted before.Better evidence is not enough as China lacks a strong enough focus on implementation science to guide health care system design and to develop and evaluate policies and practices to ensure the full translation of evidence into clinical care. Implementation research remains in a very formative phase, and so little is known about how best to deliver care, especially across diverse venues of a massive country like China, where marked geographic variation in capacity and expertise exist. Implementation science lays the groundwork to learn from practice, including the post-approval experience with drugs and devices in Chinese populations, and then apply that knowledge to improvements in health care delivery. This research is essential to address the continuing need to determine what strategies work in which populations and how best to ensure that care is optimally delivered.73 In the future mHealth applications can play a more important role. To capitalize on this possibility there is a need to link the data by the unique identifier, which should be associated with every database – and every device, in which the mobile technology could extend the scope of data collection and feedback on care and outcomes. The linkage of the data, with the ability to track utilization and outcomes over time is critical to research and will enable a wide range of needed investigations and the possibility of new approaches to clinical monitoring and care.There are several feasible steps to achieve this vision. The databases can be made research ready by instituting systems to evaluate and promote the quality of the data. There also need to be incentives and accountability for data quality. Independent, random audits and the development of online tools to identify and correct errors can be instituted. One crucial step along the way is to build structured electronic medical record systems with unified standards for variable definition and coding, enabling research data collection, integration, and interoperability.74For the applied clinical research infrastructure, the country has already taken a first step with the funding of the Chinese NCRC. The expectation is that there will be more multidiscipline teams and sustainable networks in the future. The core strength of this approach is that it leads to the development and evaluation of new strategies, which are the second half of quality improvement feedback loop. By engaging people, leveraging data embedded in daily clinical practice, and applying information technologies, a learning health care system will be fostered.76 Since 2003, China has achieved substantial improvement in access to and use of health services, as well as in hospital capacity. However, the growing access to services needs to be accompanied by marked improvements in quality. Achieving the best possible outcomes will require pragmatic efforts to improve the quality of care and generate useful evidence through the achievement of a learning health care system. The experience with CVD can serve as a model for other conditions. Moreover, the work in China can serve as a model of moving to a learning health care system where every individual receives care based on best practices and every experience is used to strengthen the system and advance knowledge for the future. China can achieve this vision through a coordination of efforts, a commitment to transparency around performance, an investment in practical research, a leveraging of advances in technology and a focus on the experience of each individual who seeks care from health care professionals and the health care system.China has made remarkable recent advances in modernizing its health care system.


Mobile health  has been described as a health enabling tool that impacts positively on the health system in terms of improved access, quality and cost of health care. The proposed systematic review will examine the impact of mHealth on health systems by assessing access, quality and cost of health care as indicators.The systematic review will include literature from various sources including published and unpublished/grey literature. The databases to be searched include: PubMed, Cochrane Library, Google Scholar, NHS Health Technology Assessment Database and Web of Science. The reference lists of studies will be screened and conference proceedings searched for additional eligible reports. Literature to be included will have mHealth as the primary intervention. Two authors will independently screen the search output, select studies and extract data; discrepancies will be resolved by consensus and discussion with the assistance of the third author.The systematic review will inform policy makers, investors, health professionals, technologists and engineers about the impact of mHealth in strengthening the health system. In particular, it will focus on three metrics to determine whether mHealth strengthens the health system, namely quality of, access to and cost of health care services.CRD42015026070Systematic review registration: PROSPERO The online version of this article (doi:10.1186/s13643-016-0387-1) contains supplementary material, which is available to authorized users. A health system is defined as an organization that encompasses all institutions, people and actions whose core interest is to promote, restore or maintain health . It is fMobile health or mHealth refers to the use of wireless communication devices to support public health and clinical practice . It is cAs technology is evolving so are the capabilities of mobile phones; this has led to the widespread use of mobile phones and in turn the application of mobile health –7. GlobaThe purpose of this systematic review is to ascertain whether mHealth has an impact on the health system, particularly on quality, access and cost. These interrelated factors are some of the biggest challenges in delivering health care globally  and compThe systematic review will reveal whether mHealth solutions have an impact on improving access to health care, quality of health care and/or reducing the cost of delivering health care. It will also describe the implementation of relevant mHealth solutions, the target audiences and the outcomes. The data collected will be mapped to highlight the strengths and weakness of mHealth in terms of its impact on the health system. This will create opportunities for further research and development that results in new processes, products, publications and/or policies.This systematic review varies from similar studies as it examines three metrics for evaluating the impact of mhealth on the health system, namely access, quality and cost. Furthermore, the study focusses on developing regions.The aim of this review is to give an accurate account of how mHealth impacts on the health system. This impact would be described in terms of one or more of three metrics. The research question to be addressed is: Does mHealth improve the health system in terms of access, quality and cost compared to conventional health services?The participants in all studies assessed are human subjects. The intervention is mHealth, and the comparator is conventional health care methods. The outcome identifies if mHealth impacts the health system by assessing access, quality and/or cost of healthcare.This systematic protocol has been registered with PROSPERO, the International Database of Prospectively Register of Systematic Reviews . The regThe type of research to be included in this review focusses on quantitative studies. The study design includes randomized and non-randomized studies. The types of non-randomized studies includes case-control, cohort and cross-sectional studies in which mHealth is the primary intervention used.All studies that describe mHealth targeted at individuals or groups and aimed at that improving access to, quality of and cost of health care services will be eligible for inclusion. Study participants to be included will represent all ages, gender, ethnicity, employment status, occupation and roles in the reviewed study .mHealth interventions to be included in the study should aim to strengthen the health system by improving access to, quality of and reducing the cost of health care.The technology used for mHealth would include mobile devices which have cellular communication capabilities that allow for wireless interaction. The following mobile devices or mobile electronic devices, having wireless and/or 3G capabilities, will be considered as interventions for inclusion in the study: mobile phones , PDA and PDA phones, tablets, ultra-portable computers and smart books , 18.mHealth functions consist of voice calling, voice over internet protocol (VOIP), short message service (SMS) or text messaging, multimedia message service (MMS) and the Internet . The appThe primary outcome in this review would be to determine whether mHealth strengthens the health system. To measure the improvement, this study will extract data of concerning at least one of the three metrics with mHealth as the primary intervention. In this study, access would be defined as the prospect to acquire healthcare through the availability and supply of services . QualityDoes mHealth allow for patients and/or health professionals to access health services? The types of measurement that we would expect to obtain in the literature would refer to increase in patient attendance at health facilities or for services. Other measurements include patient adherence or decreases in the number of patients that are not compliant.When using mHealth, has the quality of service been maintained or has it improved? The type of answer would include whether waiting times have been reduced, or whether the time required to access specialist care has improved because of mHealth.What are the cost implications when using mHealth? The data to be extracted would contain information about whether mHealth has resulted in a cost benefit or cost saving.The setting of the study will be limited to developing countries as defined by the United Nations Millennium Development Goals (MDG) regions. The regions include Caucasus and Central Asia, eastern Asia, Latin America and the Caribbean, northern Africa, Oceania, South-eastern Asia, southern Asia, Sub-Saharan Africa and western Asia .We will identify relevant studies within the period 1 January 1973 through 31 December 2016 with no language restrictions. The start date has been selected as 1 January 1973, as this is the approximate time when Motorola introduced the first cell phone . The timThe databases to be searched include: PubMed (NLM); Scopus; PsycINFO, EMBASE; Cochrane Library (Wiley) , Cochrane Database of Systematic Reviews, Cochrane Methodology Register, NHS Health Technology Assessment Database, ISI Web of Science (Science Citation Index), POPLINE, Global Health (Ovid), Pan-African and WHO-International Clinical Trials Registry Platform (ICTRP)).The studies to be included will be selected using predefined search terms adapted for the databases to be used. The terms comprise both free text word and medical subject heading (MeSH). The terms will describe mHealth, health system, access, quality and cost. Table The search strategy was developed in consultation with a health sciences information specialist. The search strategy will be tested and revised in consultation with the information specialist prior to the final search.The reference lists of appropriate studies will be assessed. Full text articles of the studies extracted from the reference list will be obtained and reviewed for additional information. Unpublished studies/grey literature will be identified; this is an important component of the systematic review. These studies will be sourced through: contacting the corresponding authors for missing information or unpublished data and hand searching of relevant reports and conference proceedings. Some of the databases to be searched for unpublished literature include the New York Academy of Literature, OpenGrey and the World Health Organization Working Group on mHealth.Once the search strategy has been finalized and tested, the first author will retrieve all the relevant articles from the various databases. All the literature obtained will be saved in Endnote reference management software for further analysis.The titles and abstracts of studies identified by the literature search will be screened independently by two authors for eligibility. Two authors will make a final assessment for inclusion using the full text article, and discrepancies and disagreements will be resolved by a third author. Clear reasons for exclusion will be documented by each reviewer.author/s and year of the studycountry of study settingtype of facility/environment affiliation of authortype of participant/study population/demographic characteristics (e.g. children under 5 years attending pre-school)type of mobile device usednature of the mHealth interventiontype of study (i.e. study design)type of outcomes measuredfindings/resultsA standardized form will be developed and piloted to extract data from the eligible studies. Discrepancies amongst the two authors in the process of data extraction will be resolved through discussion. When no consensus is reached, a third author will mediate. Key information to be extracted includes:Data will be entered into Review Manager (RevMan) software, Version 5.1. Copenhagen: The Nordic Cochrane Centre, the Cochrane Collaboration, 2011 by JF. The second author will verify the data entered, for missing or incorrect data.Bias will be assessed by two authors independently using the criteria as stipulated by the International Cochrane Collaboration. The key elements of the criteria include randomization sequence generation, allocation concealment, blinding of participants, completeness of outcome data, selective outcome reporting and other sources of bias. For each included study, we will report our assessment of risk of bias, i.e. low, high or unclear risk for each domain, together with a descriptive summary of the information that influenced our judgement. Two authors will apply the criteria, and we will discuss any discrepancies and disagreement on bias, which will be resolved in consultation with a third author.This systematic review will determine the impact of mHealth on the health system focussing on three metrics, namely cost, quality and access. Despite the varying participants, study designs, geographical location and intervention, the most important component is to determine the impact of mHealth on the health system using one or more of the metrics.The result of each study will be expressed as a risk ratio with its corresponding 95% confidence interval (CI) for dichotomous data or a mean difference with its 95% CI for continuous data. The studies will be clustered around similar types of participants, interventions, study designs and outcomes for an overall estimate of effect. The data will be pooled from studies of similar interventions, participants, outcomes and study designs in a meta-analysis using the random-effects model if there is no significant statistical heterogeneity, methodological difference or high risk of bias. If variation between studies in the reported interventions, participants, study designs and outcome measures is encountered, we will not pool the results but summarize the findings in a narrative format. Regression analysis of the interrupted time series (ITS) studies will be conducted with time trends before and after the interventions. The presentation of results for the ITS study outcomes will be represented as change in level and slope . In the The findings will also be mapped to depict a holistic picture of the impact of mHealth on the health system. In particular, it will highlight the benefits and challenges in the various studies analysed according to the metrics cost, quality and access.When deemed necessary, the authors of studies will be contacted for all missing or incomplete data. Should there be no response from the authors, the limited data available will be included and the implications of missing/incomplete data will be discussed.Clinical heterogeneity will be assessed by examining types of participants, interventions and outcomes in each study. Those studies identified as being clinically homogenous will be pooled. Heterogeneity between studies will be evaluated using chi-square tests and I-squared statistics. If studies are found to be sufficiently homogenous, in terms of study population, intervention, geographical location and outcomes, the data will be pooled and estimate summary effect sizes will be determined using a fixed effects model. Alternatively, a random effects model will be used in case of heterogeneity.The purpose of the subgroup analysis in this study is to determine if varying mHealth applications have an effect on the health system and in what context this occurs.It is expected that the geographical location, mHealth intervention, health system structure and country income of various studies will be varied. Those countries with similar income levels as defined by the World Bank will be grouped . ParticiThe aim of the statistical analysis would be to determine whether the mHealth intervention has the same effect across varying subgroups, this is called a test of interaction. As we are testing more than one outcome, we are trying to explain that the mHealth intervention/common factor would yield the same positive result regardless of the characteristics such as geographical location, type of participant or structure of the health system. Conducting the subgroup analysis would add credibility to the review.A sensitivity analysis will be undertaken to determine study quality in terms of risk of bias, level of participant drop-out and statistical method (random-effect vs fixed-effect model). In addition, the sensitivity analysis will determine whether excluded studies have any impact.The recent proliferation of mobile communication devices has fuelled an increase in mHealth services. It is not clear whether the promise of greater access to, improved quality and reduced cost of health care has been realized. The proposed systematic review will inform further research and innovation in terms of benefits and shortcomings that mHealth may have in the health system. The review will particularly focus on whether mHealth is effective in improving access to and quality health care services and whether costs associated with mHealth are reduced.


There are varied and complex problems associated with the admission of students with disabilities into secondary (senior high) schools all over the world. This situation is further complicated by difficulties encountered in the built environment of these institutions and, in this, Ghana is no exception.Persons with Disability Act 2006, which allows for equal access to public buildings in Ghana.This exploratory study investigated the level of accessibility of the built environment in secondary schools in eight out of the ten regions of Ghana, in order to determine whether they conform to guidelines provided in international building standards and also assess the extent to which they have been designed and constructed to meet the provisions of the In total, 705 building elements in 264 facilities were surveyed using international standards, building codes, regulations and guidelines. These facilities included car parks, classrooms, dormitories, assembly halls, telephone booths and administration blocks.Our findings revealed that most of the building elements were barring and not disability-friendly. Just to name a few: there were obstructions on access routes to and around buildings, absence of designated car parks, unfriendly vertical and horizontal means of circulation in buildings and lack of accessible sanitary accommodations. In addition, the general lighting and signage were poor. As a result, very few students with disabilities are admitted and retained in these schools.Mainstreaming of people with disabilities into the Ghanaian educational system remains impossible unless urgent action is taken to alter the facilities at secondary schools. Based on this research outcome, recommendations have been made to the Ghanaian government and the Ghana Education Service, as well as non-governmental organisations and relevant professional bodies for the amelioration of the present situation in our secondary schools. Ghana is a middle-income country with a per capita income of $1600 in 2010 and was the first Black African nation to gain independence from British rule in 1957. Located on the west coast of Africa and with tropical climate, it is bounded by three French-speaking countries namely, Cote d’Ivoire, Burkina Faso and Togo to the west, north and east, respectively, and by the Gulf of Guinea to the south. In 1996, the Ghanaian government launched an ambitious pre-tertiary education programme, called the free, compulsory universal basic education (FCUBE) initiative, which sought to make basic (primary and junior secondary) education in Ghana compulsory and tuition-free. Aside from this, expenditure on education by the government has grown steadily from 1.5% of GDP in the early 1980s to about 3.5% in recent years. Despite these laudable initiatives, quality education remains inaccessible to a number of school children, most notably persons with disability.Persons with Disability Act 2006 (PDA) (Act No. 715 of 2006)  of the 1992 Constitution of Ghana  has an all-inclusive policy that seeks to provide education for all school children, including students with disabilities, and this has led to the establishment of specialist secondary schools such as Okuapeman Senior High School, Wa Senior High School for the Deaf and Mampong Akwapem Senior High Technical School. The aim was to provide a congenial, safe and an all-inclusive environment and specialist training for the students in these schools. However, the reality is that the built environments in most of these specialist schools include buildings which are not disability-friendly, making the establishment of these schools redundant. Furthermore, these specialist schools are not given the requisite financial, material and human resources needed for their specialist training. This often results in their abysmal academic performance, which is evidenced by the fact that none of the specialist secondary schools in the country belongs to the list of elite secondary (Category ‘A’ and ‘B’) schools provided by the GES. The quest for higher education by students with disabilities is therefore made more daunting because, apart from their physical disabilities, they are expected to compete on merit with students from the traditional elite secondary schools that have better facilities for placement into tertiary institutions in the country. It is therefore not surprising that very few of these students gain admission into tertiary institutions in Ghana. For this reason, in their quest to get quality education for their children with disabilities, most parents in Ghana prefer enrolling these children in traditional secondary schools.Draft Ghana building code . The results indicated that in most institutions there were moderate to severe restrictions in seven out of the nine elements; except in signage and audible communication, where the level of compliance ranged from no restrictions to mild restrictions .All the schools surveyed had car parks which were used by both staff and visitors. The results  indicateOn the contrary, the schools in the Ashanti Region generally had well laid out concrete or bituminous walkways that linked most of the buildings on their campuses. A school in the Western region also had an oval-shaped tarred road network that linked all eight dormitories and other facilities in the school.Vertical circulation refers to the vertical movement of people from one floor to another within or between buildings and facilities. Building components that are usually employed to scale these heights include staircases, ramps and lifts. Most of the buildings surveyed in this study were either two-storey (71%) or three-storey (3%) that were mostly accessed by staircases. A few of the staircases were complemented by ramps but none of the ramps had hand rails. For instance, only one ramp was seen in all the three schools surveyed in the Greater Accra Region. In all, only 10 ramps had been provided in all the 264 facilities, of which 3 were accessible and 7 had moderate to severe restrictions. A major restriction of the ramps was that the slopes were steeper than 1:12, the gradient ratio required by the building instruments. Also, whilst most staircases (94%) had adequate widths, uniform risers (height of a step) and goings (depth of a step), a few (9%) had no handrails.None of the schools had lifts or elevators, although it was required that all public buildings higher than one storey should have them. Secondly, to facilitate the movement of wheelchairs, thresholds (differences between outdoor and indoor levels) should be bevelled and not be higher than 20 mm. Nine out of ten entrances and doorways could not meet this specification. On the whole, 79% of the elements under vertical circulation had moderate to severe restrictions, whilst 21% had none to mild restrictions .The results of the building elements used for horizontal circulation  in the schools revealed that 68% of these elements were classified as having moderate to severe restrictions and 32% had none to mild restrictions. Most building entrances and doors had colours that contrasted with their backgrounds and this enhanced identification. Widths of doors were also generally adequate; at least 900 mm for single doors and over 1500 mm for double doors. Most doors also had mortise locks with lever handles. Compared with door handles with round knobs, the lever handles were easy to grip and therefore suitable for people with weak grips. For instance, 75%, 50% and 83% of the doors in the three Volta Region schools, respectively, met this ADAAG (USAB 1990) specification. On the contrary, most of the building entrances had thresholds that were higher than 20 mm and were bridged with steps without ramps. Floor finishes of most buildings were made of sand and cement screed although a few had polished terrazzo floors. In addition, most buildings had wide and straight corridors with level and slip-resistant surfaces and no obstructions.Signage is very important in the built environment for easy identification and problems identified with signage by the building instruments included orientation difficulties resulting from illegible directional signs, building or room names and numbering and/or lack of them. Others are pedestrian accidents and hazards that can result from the absence of or badly positioned signs and non-identification of access routes and accessible facilities in the built environment. About 87% of signage provided in the schools met the requirements of BS8300; that is, they had none to mild restrictions. In these cases, the signs and inscriptions were visible, clear, simple, and easy to read and understand. Contrasting colours were also employed to differentiate letters from their backgrounds. On the contrary, some signs in some of the schools surveyed were faded or were written in chalk which got washed away by the rains. Dormitories were the most signed buildings in the schools. A school in the Western Region had the names of all its dormitories signed boldly on their entrances. On the other hand, classrooms, laboratories, dining halls, libraries were rarely signed. The layout of one of the Kumasi schools was mounted near the main school entrance to direct first time visitors to their final destinations on the campus.The main forms of audible communication in the schools were centralised sirens and mechanical bells which were sounded at scheduled times of the day to call or signal students at the various parts of their campuses. These communication systems were complemented with public address systems when students congregated at assembly halls, churches and dining halls. Almost 91% of these devices had none to mild restrictions and only 9% had moderate restrictions . AudibleGeneral lighting constituted 24% of all items surveyed in the 264 facilities and it refers to natural and/or artificial lighting in the built environment. About a third (34%) of the facilities studied had severe restrictions, whilst 24% were without restrictions . It was For public telephones to remain accessible, the building instruments require that they are provided at accessible locations at suitable heights. Additionally, the telephones should be angled so that they can be used by people when seated and for the visually impaired persons, telephones should have well lit keypads, large embossed or raised numerals that contrast in colour and luminance with their background. Furthermore, the directions to and from these telephones should be clearly marked by combining the international symbol of access  and a teThe survey indicated that 14% of the schools did not have any public telephones and there was only one public telephone in a school in the Upper East Region at the time of the survey. For schools that had them, 100% of the public telephones had moderate to severe restrictions. These restrictions resulted from the fact that none of the phones had directional signs, induction couplers and well lit pads with raised numerals. Moreover, all the receivers were mounted at heights that were beyond the reach of wheelchair users.The results of the survey  revealedThere were no restrooms designated for persons with disability in all the schools and the existing restrooms had no vertical and horizontal grab rails.Doorways of the existing restrooms were not wide enough to admit wheelchair users and there were insufficient spaces in the cubicles for manoeuvring by wheelchairs users.Entrances to the restrooms were, in some cases, rigged with steps and other obstacles.A school in the Brong-Ahafo Region only had pit (the Kumasi Ventilated Improved Pit) latrines, which were not suitable for persons with disability.Some schools in the Western Region had cubicles with high level cisterns.Below are the highlights of responses gleaned from interviews with some school authorities:Almost all the buildings (98.9%) surveyed were built before 2006; that is, before the PDA  in Ghana. Also, as noted in the ‘Discussion’ section below, some of the results agreed with findings from similar studies in other countries.The absence of designated parking spaces in the car parks of the schools, coupled with the poor nature of the existing car parks, completely excluded persons with disabilities from using the of car parks. The state of the existing car parks was in sharp contrast to the requirements of the BS8300  persons in these schools. The BS8300  and 277 897 (1%) people out of a total estimated population of 24 339 840 people owned cell phones and fixed lines, respectively, in 2010  and the National building regulations (Ministry of Works and Housing As noted earlier, most of the buildings surveyed were built prior to the passing of the PDA in 2006 (Republic of Ghana Based on the above discussion, the following recommendations are made to ensure the accessibility of the above school buildings by persons with disability:Retrofitting: Facilities in all senior high schools should be improved or altered to meet the internationally accepted standards of a barrier-free educational environment. Elements such as car parks, access routes, door widths, staircases, and public telephones should be altered and others, such as ramps, underfoot warnings, Braille texts, grab rails in restrooms, signage and street lights, should be provided to facilitate the use of the school environment by people with disabilities, including students, employees and visitors. The government, as the owner of most of these public buildings, should provide budgetary allocations for this exercise.Workshop and seminars: Major stakeholders such as the government, policymakers, non-governmental organisations and persons with disability groups under the Ghana Federation of the Disabled should collaborate and organise workshops and seminars to educate the general public on the need for barrier-free built environments. Public education through the electronic and the print media can also be carried out. These activities will sensitise the general public, who are mostly oblivious to the needs of persons with disabilities in society, and this will eventually accelerate the rate of integration of these persons into mainstream society.Professional institutions: Professional institutions of the built environment, such as the Ghana Institute of Architects, the Ghana Institution of Engineers, the Ghana Institute of Planners and the Ghana Real Estate Developers Association, should organise workshops and seminars to retrain and sensitise their members on the need for barrier-free designs.Educational training: The GES should encourage institutions, such as the polytechnics and universities that train practitioners of the built environment, to introduce courses on universal design in their curriculum. This will equip their students for their subsequent professional lives.The future of every community or country is determined by the level of education of its citizens, of which persons with disabilities form part. From the findings of this study, it is evident that the access needs of persons with disabilities in the 21 secondary schools were barely considered in the design and construction of the schools. This anomaly was partly resulted from the fact that most of the buildings surveyed were constructed before the passage of the PDA in 2006 (Republic of Ghana


The South African government has introduced Performance Management and Development System (PMDS) as a tool to monitor and manage the performances of health institutions, in order to improve service delivery within primary health care settings. The aim of the study was to determine the knowledge and practices of supervisors regarding PMDS in primary health institutions of the Limpopo Province.A cross-sectional, descriptive, quantitative study was used. A total of 117 participants were sampled using stratified random sampling technique and a questionnaire was used to collect data. Statistical Package for Social Sciences (SPSS) version 22.0 was used to analyse both descriptive and inferential statistics.Generally all the respondents had an average (65.8%) understanding of the PMDS processes including the purpose and their roles as supervisors. However, a gap exists between the theoretical knowledge and the actual ability to practise PMDS which was found to be at 52%. There are areas of weakness that still need attention, such as unavailability of PMDS guidelines and lack of training of both supervisors and employees on PMDS.This study highlights the problem of lack of knowledge and skills, unavailability of PMDS policy and poor induction into PMDS. To improve the knowledge and ability to supervise PMDS, proper induction of all PMDS supervisors and periodic in-service training should be done; reference materials, the PMDS policy manuals, are to be made available in the facility and all supervisors be orientated on how to use these manuals. Such success include improved employee productivity, increased sales, quality of products, services as well as improvement of skills, since PMDS is linked with monitoring of service and skills development.4PMDS is a widely used system for managing performance globally. There has been a shift from performance appraisal (PA) which was mostly used by private companies in the United States, Norway and many more countries for decisions on merit awards, promotions and salary increases.5 since 1994, the South African public became aware of their rights, and this has increased their expectations and demand for quality services. In order to meet these demands, the government needed a public service that will perform effectively to create and sustain a better life for its citizens. Some of the policies that supported transformation, among others, were the Public Service Regulation, Chapter 1, Part Viii6; the White Paper on Transformation of Public Service, 19957; and the Skills Development Act, 1998,8 which provides for training and development of workers.Similarly, in South Africa, there were factors that motivated the government to improve the public services through a proper system of performance management. According to Kanyane,1PMDS is designed such that it allows for continuous assessment and timeous identification of performance gaps, and institution of corrective measures. Possession of knowledge and skills are a requirement to build an effective performance management system. There are PMDS benefits for both the employee and the employer. Employees are rewarded for outstanding performance through pay progression, cash bonuses and skills development. The employer on the contrary is able to fulfil the service delivery mandate through improved performance by employees.10 So far, it is not known why these challenges persist. This study focused on investigating the knowledge and practices of PMDS among supervisors in primary health care institutions, in the Greater Tzaneen sub-district, which is a rural area in the Limpopo Province.Although PMDS is believed to be a good tool to evaluate employee performance, major challenges exist in its implementation. Since its inception in 2002 in the Limpopo Department of Health, PMDS supervisors in the Greater Tzaneen sub-district still express frustrations during the signing of performance contracts and performance reviews. This challenge is nationwide, as was revealed in the studies conducted in various provinces in South Africa, including the Limpopo Province.A quantitative, cross-sectional design was used. Ethical clearance was obtained from the Medunsa Research and Ethical Committee (MREC) of the University of Limpopo, Provincial Department of Health Research Committee.A total of 117 nurses, comprising assistant managers (6), operational managers (20) and professional nurses (91) were sampled from a population of 274 nurses from the primary health care facilities in Greater Tzaneen. The sample size was calculated using the following formula:1.96 for 95% confidence level, where population proportion is assumed to be 0.5 (50%)and degree of accuracy (5%) is expressed as a proportion (0.05).@ All these participants were of supervisory cadre and had 1 to > 4 years of service as supervisors. The respondents were recruited via telephone and verbally, and those who agreed were sampled using stratified random sampling technique to reach the desired sample size per stratum, according to professional rank, health centres and sub-district offices. Ethical clearance was obtained from a university research ethics committee and permission from Limpopo Provincial Health Research Committee.11 The questionnaires comprised three parts: demographic information, knowledge of PMDS and practice or implementation of PMDS. Reliability of the instrument was ensured through pilot testing. Validity was ensured by using previously validated instruments from the research studies and supervisor and peers for content validity.Data were collected using a structured questionnaire adopted from the existing questionnaires for PMDS.p-value of < 0.05 was considered statistically significant.Data were coded and entered into the Statistical Package for Social Sciences (SPSS) version 22.0 for analysis. A total of 16 questions were used to establish the level of knowledge: the scales for knowledge were as follows: purpose of evaluation, processes used in evaluation and supervisor’s responsibilities. Furthermore, overall knowledge was classified into poor (< 50%), fair (50% – 60%), good (61% – 74%); and excellent (≥ 75%). For descriptive analysis, frequency distributions, central tendencies and mean and standard deviations were calculated. To determine the association between socio-demographic factors, knowledge and practice of PMDS, Chi-square analysis was used where a p = 0.071.p > 0.05). Also, there was no significant association between the years of experience and ability to implement PMDS (p > 0.05) and no difference between the respondents who attended training and those who did not in relation to their ability to implement PMDS.Professional nurses constituted the majority of participants in this study while close to a quarter were managers. Females were the most dominant group among the participants, according to the South African Nursing Council (SANC) statistics; females constituted 94%of professional nurses while males were only 6% (SANC 2007).Although these nurses differ in qualification, ranks and years of experience, in terms of PMDS supervision, they were all eligible to supervise anybody lower in rank, as stipulated in the PMDS circular no. 67 of 2010, 6.2.10. Because of the small number of assistant and operational managers, the situation warrants that the supervision of most of the PMDS is assigned to professional nurses as shown in this study.12 the supervisors’ years of experience influences how they perform their duties; correspondingly, their skills in assessing staff performance using PMDS also increases. Paile10 also suggested that the professional position of the supervisor, years of professional experience and the number of years of exposure to PMDS supervision may determine the success of PMDS implementation. Our results showed that the majority of managers and assistant managers had good–excellent knowledge compared with professional nurses and there was a significant association between professional category and knowledge.Our results revealed that most staff had less than 10 years of work experience. According to Letsoalo,1 Our study found that two-thirds of the respondents did not have the policy manual in their facilities, they depended on colleagues from other facilities as a source of reference and some did not refer at all. The absence of the PMDS policy manual poses a challenge in measuring the quality of the system; we therefore deduced that PMDS implementation in these facilities was by trial and error for some supervisors who never received training on the implementation of PMDS and for those who did not poses the PMDS manual.An effective PMDS is one that is aligned with the vision and mission, employee job description as well as the strategic and operational plans of the department. These documents describe what the department needs, and how, to achieve its objectives. In order for these documents to be of good use, they must be communicated to both the PMDS supervisors and the subordinates to ensure that they are used effectively. PMDS policy manual serves as a standard operating procedure, which guides in PMDS implementation, from the signing of the contract through to performance evaluation.13 and Smith,14 skills acquisition has a positive effect on the ability to implement PMDS; the success of PMDS implementation depends on the skills of the supervisor. A study conducted by Malefane15 in BaPhalaborwa, the Limpopo Province, confirms the positive linkage between training and good performance. It is therefore imperative that both the supervisor and the employee undergo training to assist them to understand PMDS processes.Training on PMDS of both the supervisor and the employee is crucial. According to Pulakos9 which revealed that the majority of the supervisors believed that training of employees improves their performance, which, in turn, ensures that employees score well on PMDS. On the contrary, our study found that the majority of the PMDS supervisors reported that they never received any training on PMDS, especially professional nurses, while managers reported that they did receive training. However, our study found no significant statistical difference in the ability to implement PMDS between the respondents who reported that they had attended training and those who did not attend training.This is supported by findings from a study conducted by Maluleke16The impression of these results is that most of the supervisors were operating on hearsay, while they are expected to be experts in order to be able to coach and mentor others. Training was not considered a priority in PMDS, especially to the professional nurses, most of whom have less years of work experience. The vision and strategic development of any company lies in the ability of supervisors to carry out the managerial functions which include ability to influence, inspire and develop subordinates that serve under him/her. Inadequate knowledge is a hindrance to effective implementation of one’s duties as a manager or supervisor.The good practice of PMDS is determined by the extent to which it complies with the standards of operation stipulated in the PMDS manual. The results revealed that only one half of the respondents were able to competently implement PMDS. This implies that the other half were operating sub-optimally or poorly in terms of using PMDS as a tool to evaluate service delivery by subordinates, which can lead to employees being over-scored or under-scored in terms of performance of their duties. Supervisors are responsible for ensuring quality service delivery. So, if they themselves do not understand the very quality assurance tool they are supposed to use to measure service delivery, they will never know whether their subordinates are performing sub-optimally or not. It is therefore recommended that the Limpopo Provincial department should ensure that all supervisors receive training on how to use PMDS, in order for them to correctly implement it to monitor service delivery.This study highlights the problem of lack of knowledge and skills, lack of PMDS policy and poor induction into PMDS. Most of the supervisors are professional nurses who were deprived of proper induction and training although they form a pool which supplies PMDS supervisors to the department of health. Our findings highlighted the need for training of supervisors to improve their knowledge, skills and implementation.The targeted population covered only one sub-district; therefore, it is difficult to generalise the findings to all PMDS supervisors in the Limpopo Province. However, previous studies have revealed poor knowledge in PMDS in other areas of the Limpopo Province.We recommend that proper induction be provided to all potential PMDS supervisors and they be equipped with the requisite skills to supervise their subordinates.There should be regular workshops and in-service training to all PMDS supervisors.Lastly, we recommend that there must be implementation of quality control measures to all performance instruments and completed review forms to reinforce compliance to the PMDS policy. All managers should ensure that PMDS policy manuals are made available for all employees.The most important strength of this study is the fact that it highlights the need for supervisors to be trained in order to strengthen health systems. This will in turn improve service delivery which in turn improves the monitoring of staff within the primary healthcare system.