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Semelhante a Findings from the Uganda PERFORM study
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Findings from the Uganda PERFORM study
- 1. Uganda study: methods and key findings Saul Kamukama, MUSPH Serena Hotel, Kampala 21 August 2015 #healthworkers
- 2. PERFORM project in Uganda • Investigates how a management strengthening intervention (action research) can be used to improve health workforce performance
- 3. Initial situation analysis • Research team with DHMTs conducted situation analysis on workforce performance in the district: secondary data collection, document review, interviews and FGDs and brainstorming Health Centre IV, Kabarole district
- 4. Initial problem identification and prioritisation Kabarole DHMT, NW1 Oct ‘12
- 5. Examples of problems identified District Key problems Kabarole 1. Weak leadership and management of team leaders 2. Weak supportive supervision 3. Health workers’ poor commitment 4. Poor working environment Jinja 1. Ineffective use of the traditional control mechanisms 2. Low staff motivation 3. Inadequate supportive supervision 4. Staff training not guided by available opportunities in district Luwero 1. Lack of professionalism 2. Poor communication 3. Inadequate capacity building 4. Inadequate supplies / equipment /medicines 5. Inadequate supportive supervision
- 6. Examples of problems identified District Key problems Kabarole 1. Weak leadership and management of team leaders 2. Weak supportive supervision 3. Health workers’ poor commitment 4. Poor working environment Jinja 1. Ineffective use of the traditional control mechanisms 2. Low staff motivation 3. Inadequate supportive supervision 4. Staff training not guided by available opportunities in district Luwero 1. Lack of professionalism 2. Poor communication 3. Inadequate capacity building 4. Inadequate supplies / equipment /medicines 5. Inadequate supportive supervision
- 7. Problem analysis (root causes) • Developed list of workforce problems • Prioritized problems • Workshops to do in depth problem tree analysis (NW2) Luwero DHMT, NW2 Feb ‘13
- 8. Plan: Development of “bundles” of strategies • Workshop to support development of bundles • Integrated into district work plan Jinja DHMT, NW2 Feb ‘13
- 9. Example of bundle (Kabarole and Jinja)
- 10. Supporting incorporation into district plans Kabarole DHMT, NW2, Feb ‘13
- 11. Act: Implementation of workplan • Kabarole DHMT was entrepreneurial: received funding for orientation of newly recruited staff from private sector • Jinja DHMT: adapted supervision tools, developed plan for supervision visits, focused on support and solving problems • Luwero DHMT: introduced duty rosters and attendance books at facilities; spot checks of facilities
- 12. Observation and reflection of bundles
- 13. Adapting the strategies during implementation… Kabarole DHMT identified a problem with the capacity of new supervisors to provide good quality supervision and so identified and trained mentors to support each supervisor “In the beginning some members did not understand the mentorship well. But after the discussions all members were in agreement and welcomed the mentorship idea” (Diary, 12/5/13).
- 14. Evaluation • FGDs and IDIs to explore perceptions of DHMT, sub- district managers, health staff and relevant stakeholders and the researchers themselves on management strengthening and health workforce improvement processes and changes • Document review: visit reports, diaries, workshop reports, DHMT minutes and plans were analysed
- 15. Effects on management strengthening • Improved team work • In-depth problem analysis - root causes • Integrated planning, resourcing and monitoring of processes and effects of plans • Entrepreneurial approaches • Address problems within existing resources • Inter-district learning
- 16. Effects on health workforce performance • Better supervision of staff • Reductions in absenteeism • More staff appraised • Reported increases in utilization of services Monthly supervision visit, Jinja district
- 17. Key messages • The management strengthening approach appears to be acceptable, effective and viable at district level. • There is now a critical mass in the DHMT with improved problem solving and planning skills and a better understanding of workforce performance problems and appropriate strategies. This momentum needs to be sustained. • Some improvements can be made without extra resources. With more resources even greater things could be achieved. • Managers have proved that they can be very resourceful when implementing their own plans. They could be encouraged to be more “entrepreneurial”. • Action research can be a powerful tool for management strengthening. Options for capitalizing on the investment made by the PERFORM are needed.
- 18. Acknowledgements Funding from the European Commission Seventh Framework programme Ministry of Health District health management teams in Jinja, Kabarole and Luwero districts
- 19. Contact details for further dialogue • Project PI: tim.martineau@lstmed.ac.uk • Uganda team PI: sbaine@musph.ac.ug • Project website: www.performconsortium.com • Twitter: @PERFORMtug
Notas do Editor
- 4 year project, funded by EC FP7, finishes in August In 3 countries – Ghana, Tanzania and Uganda, and 3 European partners – STPH, Nuffield Institute Leeds University, LSTM leads In this presentation we will focus on Uganda only Within Uganda, we carried out the study in there districts – Kabarole, Luwero and Jinja
- To identify major areas of exceptional performance (good or poor) in service delivery. To identify the major areas (geographical and/or service delivery) of staffing shortage. To identify key problems of health workforce performance (retention, distribution and effectiveness) To identify key health systems factors (e.g. resources, processes, gender or other forms of discrimination) affecting (positively or negatively) health workforce. To identify key contextual factors at the district (e.g. political situation, leadership, conflicts), regional and national levels affecting workforce performance. To identify current management and communication processes used by the health management team, dynamics of the DHMT (e.g. roles, power and gender relations among the team) and how these may affect levels of management performance
- This table shows the problems identified by the three districts. All districts identified supportive supervision as being a problem – weak, ineffective, not done well Other problems include lack of motivation to work / commitment; weak leadership and management of managers
- This table shows the problems identified by the three districts. All districts identified supportive supervision as being a problem – weak, ineffective, not done well Other problems include lack of motivation to work / commitment; weak leadership and management of managers
- The district health teams of the three districts were engaged to identify the factors that affect health workers performance, based on the initial situation analysis carried out with the research team. We did this at several stages in the process and this picture shows us at work in National Workshop 2. Each DHMT finalised their problem tree in this workshop. Each group identified the root causes of the problems identified and prioritised the problems they wanted to address. The next sides shows some examples of the problems identified by the districts
- Examples of mixed strategies: filling vacancies, coaching, supplies for ANC services The process of supporting the development of the bundles of HR/HS strategies was more challenging. Few members of the research teams are experts in human resource management and some of the concepts in the PERFORM process, are difficult to explain. Nevertheless the consortium developed and pretested a manual for the DHMT which explains the concepts and provides examples of developing appropriate HR/HS strategies. In addition workshop materials were to be developed to guide the DHMT groups, including planning templates. Some teams preferred to continue using visual display such as posting notes. Others transferred their planning to their laptops – especially when they got to the stage of integrating plans into the bigger district plan, as seen in the next slide.
- Check for
- We tried to get the plans integrated into the wider district plan as soon as possible to ensure that it would be implemented, and in the case of activities for the following financial year would be included in the budget request. The timing of the workshops did not fit the planning cycles everywhere. So some DHMTs identified activities that could be done with existing funds in the current financial year (FY); others obtained additional funds (Kabarole District induction example explained by Dr Nantamu ); others had to wait for next FY
- Here are some examples of what the DHMTs implemented: The DHMT showed initiative and creativity in searching for funding for orientation of newly recruited staff (which again in turn allowed for recruitment of new supervisors) when they approached potential partners in the private sector. “The newly recruited health workers have already been inducted into their roles and responsibilities with financial support sent from the Housing Finance Bank (Uganda) Limited” (Report of the mentoring/supervision of CRT visit to the DHMT Kabarole District 01st October 2013)
- There were several ways of observing and reflecting on the implementation of the bundles: Research team meeting with the DHMT and talking through the implementation, helping the DHMT reflect on what was happening – what worked well, what worked not so well, data to monitor effects of the bundles, what to adapt, what to add to make it work better Reflective diaries – each member of the DHMT could write in the diary how the strategies were implemented, what worked well, what worked not so well, and why, changes to be made, and how these were done We also had workshops which brought the three districts together in each country so they could share progress and challenges. In Uganda – partly because of the national district league tables – the DHMTs seemed quite competitive! Newsletter – “the Performer” – DHMT contributed to the newsletter to share experiences and their learning across the 3 districts. This promoted reflection So this monitoring of bundles or observation and reflection helped the DHMTs to adapt the bundles to work better; added more activities, for example:
- Kabarole DHMT identified a problem with the capacity of new supervisors to provide good quality supervision and so identified and trained mentors who were experienced and respected staff who could support each supervisor. “In the beginning some members did not understand the mentorship well. But after the discussions all members were in agreement and welcomed the mentorship idea” (Diary, 12/5/13).
- Here are some of the key findings from the evaluation
- The fact that PERFORM was not coming with additional financial resources was initially surprising for the DHMTs. However despite problems of funding affecting implementation of some of the interventions, the DHMTs found that some of the problems could be addressed within existing resources which overall strengthened their capacity for planning within budget limitations which is an important asset for district managers working in resource constrained settings.
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