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Perform overview given at Uganda meeting August 2015
1. 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, Kampala
21 August 2015
#healthworkers
2. 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
3. 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
4. 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.
7. Key features of PERFORM approach
Management competencies
Root cause analysis
“Bundles” of human resource/health systems
strategies
Diaries – for reflection
Funding of bundles of strategies
Roles of researchers – research + facilitator
8. 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)
10. Source document for developing HR strategies
strategies
Source: District Health Management Team Methods Manual
11. 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 books
Enforce use of separate log books for drop-in & drop-out
Train all staff on logistics management
Obtain standard EPI supportive Supervision Checklist from
DDPH/RHA
Discuss checklist with sub-district staff
Input from sub-district staff effected and final checklist
circulated to all facilities
On-site supportive supervision in general but EPI in
particular (2 visits per facility per year)
Hold quarterly meetings to review performance & share
best practices
Prepare and cascade a league table for measuring
performance for awards of sub-district vaccination
Award prize to best performing health facilities
Kwahu West district, Ghana
13. 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
14. Selected lessons from PERFORM from
partner countries
Ghana
• “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.
15. Experience of PERFORM in Ghana
• Link to video:
https://www.youtube.com/watch?v=YzQIsO8ubF8
16. 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 …
19. 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
Notas do Editor
[ignore current notes]
Taking a look at the participatory approaches in research - both clinical and social science research - issues such as the benefits and challenges of participatory research will be reviewed. Ethics and the inclusion of specific vulnerable and marginalised groups will be an important focus.
Key questions to address in your presentation:
What was the rationale behind conducting participatory research?
What was the approach used?
Did the research/project take into account vulnerable and marginalized individuals and groups? Which ones and how ?
What were the benefits, challenges and unintended effects that you encountered/are encountering?
Are there procedures in place to promote the sustainability of the participation approach in your project? Please elaborate
Evidence generation: Did your research/project generate any evidence on the effect of participation on any outputs/outcomes?
What would be the key recommendations you would make to an organisation planning to set up a similar research/project (key advice based on lessons learnt)
The single biggest barrier for countries in sub-Saharan Africa (SSA) to scale up the necessary health services for addressing the three health-related Millennium Development Goals and achieving Universal Health Coverage is the lack of an adequate and well-performing health workforce. This deficit needs to be addressed both by training more new health personnel and by improving the performance of the existing and future health workforce. However, efforts have mostly been focused on training new staff and less on improving the performance of the existing health workforce.
The ability to adopt a systems approach—combining an integrated set of HR and complementary HS strategies with the aim of achieving synergies and avoiding
negative unintended consequences—is only possible if managers have adequate room for manoeuvre of what Bossert and Beauvais18 refer to as ‘decision space’. The
increasing HS decentralisation of planning and management authority to lower levels and, in particular, to districts in SSA can make this space available to managers.
Need to improve workforce performance before scaling up; or instead of, if that is not possible
Integrated HR and health systems approach needed; the integrated HRM approach – which uses the concept of bundles of strategies – is not new, but explicitly linking this with wider health system strategies has not been widely reported.
Managers in decentralised contexts better position to organise and can learn; the assumption is they have more decisions based than their more centralised counterparts; closer to the problem, may be more pragmatic with developing solutions
SDHS process not new (Ghana, Nepal, etc) but researching it is (TEHIP an exception);
Challenge is to get DHMT to think strategically and to be entrepreneural within their resources and authority constraints
The EC call was for countries in Africa and our focus on decentralised contexts influenced our choice of research partners ….
4 year project, funded by EC FP7, finishes in August this year
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
Needed countries with decentralised health systems
Explain the importance of integration of HR strategies: training + follow-up; team work vs individual incentives – easier if one group in control
Other health systems components: transport; cold chain maintenance – working together with HR strategies
Unintended effects may be positive or negative
Action research cycle
Evaluating against two core objectives
The implementation stage has run for about 1 ½ years, though in some cases there were delays in getting started, partly because of delayed budgets.
We started in each of the nine districts (three districts in each of the three countries) with a situation analysis which focused on performance of the district and the nature and operation of the DHMT. This was carried out by researchers and DHMT members together and was used for beginning the process of problem analysis – either more generally about service delivery and the contributing HR performance factors, or – as in Uganda – focused specifically on HR performance problems.
Workshop materials were developed to guide the DHMTs through the process of problem analysis and strategy development.
These initial sets of problems were then analysed in more detail in the 1 ½ day long National Workshop 1 which took place separately in each of the three countries during October and November 2012. Further information was collected before a second workshop 2 ½ day in February 2013 at which the DHMTs further refined and prioritised the problem analysis and then developed strategies to address these problems. Where possible, these plans have been integrated into the wider district planning and budget process. In most cases the timing of the workshop fitted with the development of the new budget cycle, or DHMTs were able to use their existing budgets or get funding from development partners as described in the previous presentation. However in Tanzania the budget cycle was later and in addition late disbursements of funds meant that ?one district was able to implement only very little of their plans.
Final situation analysis also served as evaluation – using both process evaluation data – visit reports etc and data collected post implementation
I will now talk about some of the stages described in a little more detail.
The aim was to have at least one year for the DHMT to implement their plans. During that time the country research teams provided support through visits and organising workshops to bring participating districts together for about a day to share progress and challenges.
An important part of the action research cycle is that of reflection. The country research teams tried to help the DHMTs to reflect on the implementation of the strategies through the use of diary and through discussions progress on visits and workshops with the DHMTs.
We are now in the process of carrying out the final situation analysis which will allow us to develop country reports and carry out a comparative analysis across the three countries.
Note on funds – will have to struggle with this in the design of a new project in Asia – so welcome comments!
From tim’s paper on management development
Performance area/broad objective
Availability (posts filled/distribution/staff present)
Direction (on what staff should do and how well they are doing)
Competencies (appropriate skills, knowledge and attitudes to carry out the tasks assigned)
Rewards and sanctions (to influence their behaviour and therefore their performance)
Health systems (other 5 building blocks ?and more)
Performance area/broad objective
Availability (posts filled/distribution/staff present)
Direction (on what staff should do and how well they are doing)
Competencies (appropriate skills, knowledge and attitudes to carry out the tasks assigned)
Rewards and sanctions (to influence their behaviour and therefore their performance)
Health systems (other 5 building blocks ?and more)
Mentioned that the comparative analysis report has just been submitted and will be posted on the website shortly
Mentioned that the comparative analysis report has just been submitted and will be posted on the website shortly
Panel with WHO and Jinja DHO in Cape Town; Basel spring symposium and Basel Euro Trop med in Sept
Panel with WHO and Jinja DHO in Cape Town; Basel spring symposium and Basel Euro Trop med in Sept
Panel with WHO and Jinja DHO in Cape Town; Basel spring symposium and Basel Euro Trop med in Sept
Today (19 August 2015) the Tanzania PERFORM dissemination workshop took place in Iringa with 57 participants. These included the coordinator of district health services as representative from MoH, a representative of TACAIDS and NetworkPlus of Women living with HIV/AIDS. The Main Results of the workshop are to produce
an executive summary for the MOH how to strengthen district performance and
a concept paper how to train trainers and upscale the PERFORM approach to other districts in Tanzania.
The CHMTs proposed that 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 discussed during the meeting which will be covered in the executive summary for the MOH (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?
What can be done to address the late disbursement of annual district funds which affects the performance of districts?
How can district leadership issues be addressed to strengthen governance and performance in the district?
How can ad hoc activities of CHMTs be avoided or managed in a productive way?
PERFORM team Tanzania/Leeds
