Improving health workforce performance through better management in Ghana, Tanzania and Uganda: overview of the

PERFORM project

Tim Martineau, Liverpool School of Tropical Medicine, UK

Serena Hotel, Kampala21 August 2015

#healthworkers

Rationale for PERFORM initiative

• Need to improve workforce performance to support UHC • Integrated HR and health systems approach required• District level managers in decentralised contexts in better

position to organise integrated approach and have sufficient “decision space”

• Working in teams - better learning and retention of lessons• Challenge to help DHMT to think strategically and to be

“entrepreneurial” within their resource and authority constraints.

• DHMT 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; observation and

reflectionMar 2013 – Aug 2014Action

research

Key features of PERFORM approach

Management competenciesRoot cause analysis “Bundles” of human resource/health systems strategiesDiaries – for reflectionFunding of bundles of strategiesRoles of researchers – research + facilitator

Management competencies promoted in PERFORM

Management competencies Development strategies

Identification of root causes of problems

SA, NW1, NW2, follow-on activities

Prioritisation of problems SA, NW1, NW2, follow-on activities

Options appraisal SA, NW1, NW2, follow-on activities

Designing integrated HRM and health systems strategies appropriate to context

NW1 – introduction; NW2; follow-on activities

Resourcing NW2; follow-on activities

Following through the implementation to overcome barriers

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

Root cause analysis

Source document for developing HR strategies strategies

Source: District Health Management Team Methods Manual

Example of bundle of strategies

Problem identified HR/HS Bundle to address the problem

Activities

Poor implementation of new vaccine vaccination schedule leading to high dropout rate of pneumococcal (46.9%) and rotarix (19.1%) vaccination in the municipality

- Improve data management at all levels;

- Improve supportive supervision to sub- district as planned;

- Reward (Certificate and material) best performing facilities (drop rate of PCV & Rota 10% & below)

Train and retrain all staff including DHA on new vaccine (EPI)Conduct monthly data validation per facility by comparing tally booksEnforce use of separate log books for drop-in & drop-outTrain all staff on logistics managementObtain standard EPI supportive Supervision Checklist from DDPH/RHADiscuss checklist with sub-district staffInput from sub-district staff effected and final checklist circulated to all facilitiesOn-site supportive supervision in general but EPI in particular (2 visits per facility per year)Hold quarterly meetings to review performance & share best practicesPrepare and cascade a league table for measuring performance for awards of sub-district vaccinationAward prize to best performing health facilities

Kwahu West district, Ghana

Reflective diaries

General key messages from PERFORM

• Managers were able to develop appropriate integrated HR/HS strategies based on root cause analysis

• The process encouraged/strengthened team work• The approach created space for observation and

reflection• Lack of project funds not necessarily a barrier to

workforce improvement, but need to manage expectations

• Action research seems an appropriate way to strengthen management in this context, but ‘reflection’ seemed a weak point

Selected lessons from PERFORM from partner countriesGhana• “But with the coming of

PERFORM they made us aware that even when there are no funds something can be done and it is important to monitor and strategise on progress.” (DHMT member)

• Supportive supervision enhanced the performance of community health officers.

• PERFORM helped catalyse a more participatory approach.

Tanzania• “Before we used to wait a long

time for change, but the AR cycle has shown us that we can push change.” (Health Manager)

• The quality of supervision improved with a new focus on mentoring rather than inspection.

• Managers realised that they could have achieved more by collaborating with other partners.

Experience of PERFORM in Ghana

• Link to video: https://www.youtube.com/watch?v=YzQIsO8ubF8

Global Research Uptake activities for PERFORM• Compendium of materials to support PERFORM

approach (for use or adaptation)• Teaching materials, including case studies• Dialogue with WHO, GHWA and other global bodies• Blogs• Publications• Conference presentations (available on SlideShare)Also …

Website: www.performconsortium.com

PERFORM on twitter - @PERFORMtug

Plans for building on PERFORM in Tanzania• Develop a concept paper how to train trainers and upscale the PERFORM approach to

other districts in Tanzania. • Proposal for exchange and learning between districts teams should be facilitated in

each country through Face to Face (F2F) meetings and online exchanges and also include the sharing of experiences between countries.

• Key issues for further discussion with Ministry of Health:– How can the Bundle approach address challenges of service delivery in different

areas?– How can the action research method be used as method to strengthen Quality

Improvement (QI) teams in health facilities?– How can Diaries be used as management tool to record activities and promote

reflection in the district teams?– How can district leadership issues be addressed to strengthen governance and

performance in the district?– What can be done to address the late disbursement of annual district funds which

affects the performance of districts?– How can ad hoc activities of CHMTs be avoided or managed in a productive way?

Source: Tanzania PERFORM dissemination meeting, Iringa, 19 August 2015