Coaching for quality improvement under performance-based contracting: a theory-of-change evaluation in Honduras
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Introduction
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 those pathways, remain under-theorised. Using a theory-based 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 decentralised 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. Data comprised semi-structured interviews with 11 mid-level managers, 6 PHC team medical leads, and 2 regional managers, complemented by direct observation and document review. We applied combined deductive–inductive coding, thematic analysis, and pattern matching, and reporting per COREQ.
Findings
We identified four causal patterns that refined the initial programme theory. Three were activated pathways: (1) novel professional identity among participating managers; (2) collective efficacy and data-driven learning, sustained through verifiable progress on observable indicators, strong for CCS but null for ANC, where outcomes were less attributable to teams’ actions; and (3) 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, confining gains to localised “enabling bubbles.”
Conclusion
Coaching can activate meaningful QI pathways in LMIC primary care, but sustained, equitable impact requires deliberate 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.
KEY MESSAGES
What is already known on this topic
Practice coaching can improve clinical processes in primary care, but the evidence base is concentrated in high-income settings, effectiveness varies across contexts, and evaluations rarely test explicit causal hypotheses about how coaching produces change in LMIC health systems.
What this study adds
We identified four causal-link patterns: three activated pathways: novel managerial identity, data-driven collective efficacy, and relational coordination; and a fourth unanticipated pattern of misalignment between coaching’s enabling logic and the directive, punitive logic of performance-based contracting, which limited gains to localised “enabling bubbles” of improvement.
How this study might affect research, practice or policy
Sustained impact of coaching in decentralised LMIC PHC systems requires deliberate alignment between coaching’s learning-oriented principles and the performance verification and the system’s accountability architecture. Coaching investment should be matched to clinical processes whose outcomes are observable and attributable; field mentoring should be maintained during scale-up; and longitudinal, comparative research should characterise how directive and enabling performance-management logics interact over time.
