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Experiences from PERFORM
Comfort Mshelia
Nuffield Centre for International Health and Development, University of Leeds
Twitter: @PERFORMtug
Website: www.performconsortium.com
Introduction to PERFORM- background, timeline, partners and study rationale
What we did- study design and approach, action research cycle
Challenges we faced- and how we tried to manage them
In Sub-Saharan settings there are too few health workers. The existing workforce could be better utilised
Supporting decentralised management to improve health workforce performance in Ghana, Uganda and Tanzania
Four year project funded by the FP7 program of the European Commission
Ghana, Tanzania and Uganda
Three districts in each country
Initial
Situation
Analysis
Jun-Aug
2012
National
workshop 1
Initial
problem
analysis
Oct 2012
National
workshop 2
Development
of HR/HS
bundles
Feb 2013
Final
Situation
Analysis
Sep 2014
Implementation of bundles
Mar 2013 – Aug 2014
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
Insufficient number of health workers
Health
worker
density
Country
Ghana
(2008)
Tanzania
(2006)
Uganda
(2005)
Ireland
(2008)
Physicians/
1000
0.11 0.01 0.12 3.08
Nurse,
midwife/1000
0.97 0.24 1.31 15.89
Source: World Health Organization statistics database
(http://knoema.com/WHOSDB/world-health-organization-statistics-
database?Category=1000010-human-resources-for-health&Location=1000740-
ghana)
Poor performance of existing staff
Country
Ghana Tanzania Uganda Ireland
Health
worker
Reach
index*
0.523 0.432 0.377 0.957
*The Health Workers Reach Index is an additive index which includes three
indicators: 1) a measure of health worker density, 2) DPT3 immunisation rate
and 3) skilled birth attendance rate.
(http://www.savethechildren.org.uk/sites/default/files/docs/HealthWorkerIndexmain_4.
pdf)
Help District Health Management Teams to think strategically and to be entrepreneurial within their resource and authority constraints
Improve health workforce performance in the districts
Plan
Act
Observe
Reflect
European partners
support Country
Research Teams
Country Research Teams
support District Health
Management Teams
District Health Management
Teams conduct action research
Kabarole District (Uganda), 2013
National workshop (Ghana), Feb 2013
Country Research Team and District Health Management Teams meeting (Ghana)
March 2013
Country Research Team and European Partners visit a District Health
Management Team in Ghana
Focus group discussion
Patient survey
In-depth interviews
Follow up visits by Country Research Teams
Diaries kept by District Health Management Teams
Bringing District Health Management Teams together in workshops
PERFORM used action research in nine study sites
Each district had their unique problems, interventions, and context
This made it very complicated to go through the action research cycle as timing of events in the districts were not synchronized
Comparative analysis also very complex
Deciding on how to record the processes, reflection, and learning required significant dialogue among partners
Researchers did not consult District Health Management Team on how action research should be implemented and how processes and reflection should be recorded
We used diaries which were filled in by the District Health Management Team members
It was most difficult for the District Health Management Team to record their reflections
‘As a group, (the District Health Management Team) may have had a meeting and discussed a few things then, on reflection, taken some decisions… but then when we go into their diaries, nothing shows. We realised that the diaries were only capturing major activities and training’ [Country Research Team member].
The District Health Management Team were not familiar with action research◦ It took some time before they assumed ownership
of the project
Frequent visits to the districts and other methods (e.g. telephone calls, emails) were used to provide guidance and support
Should the co-researchers (District Health Management Teams) be paid for participating (and held responsible)?
Should there be a dedicated researcher in each site?
What can be done to encourage reflection?
What is the best way to record processes, reflection and learning in action research projects?
http://www.performconsortium.com/
