Management strengthening using health workforce performance problems in decentralised contexts: lessons from

Ghana, Tanzania and Uganda

@TimMartineau, M. Aikins, S. Baine, R. Huss, P. Kamuzora, K. Wyss

9th European Congress on Tropical Medicine and International Health 6-10 September 2015, Basel, Switzerland

@PERFORMtug

Rationale for PERFORM initiative

• Need to improve workforce performance to support UHC • Integrated HR (Buchan 2004)and health systems approach

required (de Savigny and Adam 2009)• District level managers in decentralised contexts in better

position to organise integrated approach and have sufficient “decision space” (Bossert 1998)

• Challenge to help DHMTs to think strategically and to be “entrepreneurial” within their resource and authority constraints.

• DHMT management strengthening not new, but little research

Partners

• School of Public Health, University of Ghana • Institute of Development Studies, University of Dar-

es-salaam, Tanzania • School of Public Health, College of Health Sciences,

Makerere , Uganda • Swiss Tropical and Public Health Institute • Nuffield Centre for International Health and

Development, University of Leeds, UK• Liverpool School of Tropical Medicine, UK

Purpose of the PERFORM project

To conduct comparative analyses across districts and countries of: 1. the management strengthening intervention

(using action research) to support improved workforce performance, and

2. processes of implementing the integrated HR and health systems strategies and intended and unintended effects on health workforce performance and the wider health system.

Study design

Plan

Act

Observe

Reflect

Timeline

Situation AnalysisJun-Aug

2012

National workshop 1

Initial problem analysisOct 2012

National workshop 2

Development of HR/HS bundlesFeb 2013

EvaluationSep 2014

Implementation of bundles: act, observe and

reflectMar 2013 – Aug 2014

p l a n

Management competencies promoted in PERFORM

Management competencies Development activities

Identification of root causes of problems

SA, NW1, NW2

Prioritisation of problems SA, NW1, NW2

Designing integrated HRM and health systems strategies appropriate to context

NW1 – introduction only; NW2

Resourcing NW2; follow-on activities

Following through the implementation to overcome barriers

follow-on activities (diaries, researcher visits and inter-district meetings)

Evaluation methods

• Analysis of data collected during the implementation period• reflective diaries• Researcher visit reports• workshop evaluation reports and inter-district

meeting reports• Post implementation

• Interviews and FGDs with DHMT members• Interviews with other managers, staff and

stakeholders• Management and service delivery data analysis

Examples of ‘bundles’ of strategies for improvement of workforce performance

• Strengthening supervision

• Controlling staff absence

• Improving competencies

• Incentives• Improved appraisal

Kwahu West district, Ghana

Appropriateness of approach

• Timing• Funding• Facilitation• Ownership• Duration

National Workshop, Tanzania

Identification of root causes of problemsand prioritisation

• Greater depth• Importance of small

problems• “If you do not do the

problem tree analysis, you will be doing things randomly without any specific objectives in mind” (Manager Tanzania).

National Workshop, Uganda

Designing integrated HRM and health systems strategies appropriate to context and resourcing

• HRM/HS integration• Use of selection

criteria• Less attention to

indicators• Incorporation into

regular budget or external funding

Incorporating the plan into the regular budget, Jinja DHMT, Uganda

Follow-up during the implementation phase

• Competing agendas• Monitoring• Reflection (including

diaries)• Modification of plans• Abandoning plans

Inter-district meeting Uganda

Additional effect on DHMT

• Empowerment: "we can push for change"

• Initiative and risk-taking culture

• Teamwork and collaboration

• Application to other areas of work National Workshop, Tanzania

Selected lessons from PERFORM project• Overall support for PERFORM's approach based on action

research• PERFORM activities led to improved problem analysis and

design of integrated HR/HS strategies for improving workforce performance

• DMHTs are able to resource additional planned work from regular funds or external partners

• DHMTs can monitor and modify implementation of plans, but recognise better indicators, baseline data and monitoring needed

• More support with reflection part of AR cycle may be needed• Process had other benefits for the operation of the DHMTs

Acknowledgements

Funding from the European Commission Seventh Framework programme

Ministries of health in Ghana, Uganda and Tanzania

District health management teams in: Jinja, Kabarole and Luwero districts (Uganda); Kwahu West, Akuapim North and Upper Manya Krobo districts (Ghana); Kilolo, Iringa Urban and Mufundi districts (Tanzania)

Contact details for further dialogue

• Project website: www.performconsortium.com

• Twitter: @PERFORMtug

• Project PI: tim.martineau@lstmed.ac.uk