Improving health workforce performance in Ghana, Tanzania

and Uganda

Kaspar WyssSwiss Tropical and Public Health Institute

Contents• Introduction to PERFORM• Partners in the project• Key messages• Study countries• Action research and how it works in practice• Project stages and timeline• Outcomes and impact

What is PERFORM?

Project

Timescale

Funder

Start September 2011Ends August 2015

4 year programmeFocus: improving health workforce performance

European Union (EU)

Aim To understand how

management strengthening can improve workforce

performance

Who are our partners?

PERFORMConsortium

Ghana

Leeds

Liverpool

Switzerland

Tanzania

Uganda

College of Health Sciences, School of Public Health, Makerere University

International Health Group, Liverpool School of Tropical Medicine

School of Public Health, University of Ghana

Nuffield Centre for International Health and Development, University of Leeds

Institute of Development Studies, University of Dar-es-Salaam

Swiss Tropical and Public Health Institute

Key messages• Shortage of well performing health workers• Deficit needs to be addressed both by training

more new personnel and improving performance of the existing workforce

• Complex factors affect workforce performance• Decentralisation of planning and management

authority

Study countries• Ghana, Tanzania, Uganda – each face major

challenges in developing their health workforce• Selected from 57 World Health Organisation

(WHO) states that do not meet a minimum ratio of 2.3 key health workers per 1000 population

• Decentralised structures offer DHMTs greater decision-making opportunities

Ghana: health status profile• Life expectancy: 60 years (2007, World Bank)• Maternal Mortality Rate: range from 214 (1999, WHO) to

586 (2001, Hill) per 100,000 live births• Under five mortality rate: improved over last ten years to

80 per 1000 live births• Top 5 causes of mortality and morbidity:

– Malaria– Acute Respiratory Infections– Skin Diseases and Ulcers– Diarrhoea Diseases– Hypertension Source: Ghana Human Resources for

Health Country Profile, Edition 2011

Study districts in Ghana

Medical workers in health facilities: Diocese of Gaoso, Ghana

• Kwahu West• Akwapim North• Upper Manya Krobo

Challenges: Ghana health sector• Retaining health professionals• Improving health worker retention in rural areas

– Two teaching hospitals Korle Bu and Komfo Anokye employ more than 45% of the country’s Drs

– Less than 15% are present in district hospitals

• Addressing the shortage of trained midwives• Strengthening capacity of existing workforce• Developing the appropriate human resources in their

right mix and numbers in order to meet the health needs of the people in Ghana Source: Ghana Human Resources for

Health Country Profile, Edition 2011

Factors affecting workforce performanceConcept 1• Availability of health personnel• Utilisation of health personnelConcept 2• Retention – attrition, turnover rate• Distribution – vacancy rates by cadre, geographic

location, facility type• Effectiveness – Skills mix, levels of absence, quantity

of work output, quality of work output

Our research approach• A systems approach to human resource

management using a coordinated set of strategies to improve performance

• A health systems approach which views HR alongside other related factors e.g. Finance, Drugs, Equipment

• Action research methodology as the intervention for strengthening management at district level

What is Action Research?

Definition: “Action research is a period of inquiry

that describes, interprets and explains social situations while executing a change intervention aimed at improvement and involvement. It is problem focused, context-specific and future-oriented.”

How does it work in practice?

Plan

Act

Observe

Reflect

• Supported by PERFORM Researchers – the DHMTs will identify barriers to workforce performance and their causes (situation analysis) and then:

• Plan bundles of HR and health systems strategies

• Act to implement these strategies• Observe the impact of the

strategies on performance• Reflect on how well their plans

have been achieved and if necessary, revise the plan

Situation AnalysisThis will be a two step process: • Step 1: collect and analyse routine data such as

staffing and health service data using a standard form for all study sites

• Step 2: focus on collecting data to understand the causes of particular issues or problems emerging in step 1. After reviewing the findings, DHMTs will develop clear problem statements related to health workforce performance.

Development of HR/HS bundles• Using the situation analysis to design strategies to

address the problems• These strategies (known as bundles) will be a mixture of:

– Human resource (HR) strategies – e.g. developing skills through a training workshop

– Broad health systems (HS) strategies – e.g. repairing equipment so health workers can do better work

• In each district, the DHMT will select the HR / HS bundles

• Then develop a plan of how to implement the bundles and monitor their effects.

Project phases

Phase one

Phase two

Phase three

Preparation for implementation

Research implementation

Evaluation and feedback

Timeline Phases 2 and 3: June 2012 – Dec 2014

Initial Situation Analysis

Jun-Aug 2012

National workshop 1

Oct 2012

Development of HR/HS bundlesJan 2013

Consortium workshop 2Nov 2012

Implementation of bundles

Jan 2013 – Aug 2014

National workshop 3

Dec 2014

Final Situation Analysis

Aug-Oct 2014

Consortium workshop 3

Jan 2014

Roles of partners and DHMTs• Researchers

– To provide support to the DHMTs– To conduct the situation analysis – To hold the national review meetings– To develop the research methodology– To manage the research project

• DHMTs– To implement the action research process– To actively participate in the research– To collaborate with the researchers in the situation analysis

Outcomes and impact

Impact: improved health in Sub-Saharan Africa as a result of a responsive, effective and well equipped health service, provided

by skilled health workers

Outcome: research evidence contributes to knowledge of how strengthening

management in Sub-Saharan Africa can improve workforce performance and the

wider health system

Questions?