How did the action research process strengthen health systems in Tanzania? You can read more about it on our website http://www.performconsortium.com/ or follow us on Twitter https://twitter.com/PERFORMtug
The CRT consulted the Coordinator of District Health Services in the Ministry of Health, who was a member of the Country Research Advisory Group (CRAG). The Coordinator informed us of the MoH’s policy requiring any health intervention introduced in any administrative region of Tanzania to cover the whole region and not only 3 districts as originally planned in the PERFORM research design. We consulted the higher MoH authorities (Chief Medical Officer) who insisted on the PERFORM project to adhere to the MoH policy of covering the whole region. We had to go for the regions with the smallest number of districts (at least 3 districts). We also considered accessibility of the region and districts. Three regions: Kigoma, Singida and Iringa qualified for selection. Iringa region was selected because of the accessibility advantage over the other two. Iringa has 4 districts – Mufindi, Kilolo, Iringa Rural and Iringa Urban distrcts. We selected Kilolo district because it is a typical rural district, Mufindi which has a mixture of rural and urban characteristics and Iringa Urban in order to capture the urban characteristics that the PERFORM project required. Although Iringa Rural district has typical rural characteristics like Kilolo district we left it out because it is adjacent to Iringa Urban district
[check selection criteria; and simplify]
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.
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.
A number of strategies were used by the Country Research Team (CRT) to strengthen the management capacity of the CHMT members to improve health workforce performance.
The main aims of the visits were to get an update on the implementation of the bundles and supervise recording of activities related to the project in the CHMT diary.
PERFORM study findings in Tanzania
PERFORM study and findings in
Institute of Development Studies
University of Dar es Salaam, Tanzania
Aim and objectives of PERFORM study
• Overall aim:
– To identify ways of strengthening decentralised management to
address health workforce inadequacies in order to improve
health workforce performance in sub-Saharan Africa
– To support health managers to carry out a situation analysis on
the health workforce performance, in the study districts
– To identify areas of health workforce performance to be
– To support health managers to design & implement integrated
Human Resources (HR) and Health Systems (HS) strategies to
improve health workforce performance
– To monitor implementation of the strategies and evaluate the
impact on health workforce performance, and the wider health
Selection of the Study Districts
• The Country Research Team (CRT) consulted the Coordinator of
District Health Services in the Ministry of Health & Social Welfare
(MoHSW), who was a member of the Country Research Advisory
• The Coordinator informed CRT of the MoHSW’s policy requiring
any health intervention introduced in any region of Tanzania to
cover the whole region and a few districts as originally planned in
the PERFORM research design.
• The CRT consulted the higher MoHSW authorities (Chief Medical
Officer) who insisted on the project to cover the whole region.
• Iringa region was ultimately selected because of the accessibility
advantage over the other qualified regions.
Selection of the Study Districts (Cont…..)
• Iringa has four districts
– Mufindi, Kilolo, Iringa
Rural and Iringa Urban
• Iringa Rural though had
Kilolo district was not
included because it is
adjacent to Iringa
Implementation of bundles
Mar 2013 – Aug 2014
National workshop ONE in
19-20 October 2012
National workshop TWO at
25-27 February 2013
The CRT, CHMTs for Kilolo,
Iringa Urban and Mufindi
districts and the RHMT for Iringa
Region attended the workshop
• Received and commented on
the findings of the situation
Started thinking about
formulating strategies to address
the identified health workforce
The CRT, CHMTs for Kilolo, Iringa
Urban and Mufindi districts and the
RHMT for Iringa Region attended the
• Refined and finalization of the
problem trees developed by the
Formulated the bundles of HR/HS
strategies to address the identified
health workforce performance
problems in the districts
CRT support to CHMTs
• Identification of bundles and
development of strategies to
improve health workforce
• Guidance to the CHMTs on how
to link the problems identified
in their districts with suitable
strategies and activities under
• Use of diary to record
implementation of the
• During the implementation of
the bundles, supportive visits to
the district took place every two
months in the first year and
every one month in year 4.
CHMTs in Iringa Urban identifying
CRT support to CHMTs cont...
• Review meetings were
scheduled for every four
months during year 1 and
every six months in year 2.
• Review meetings provided
opportunities for the
CHMT members to share
their experiences in the
implementation of bundles
and learning from other
districts. CRT, EU partner, CHMT & RHMT
members during inter-district review
CRT support to CHMTs cont...
• The CHMT members also
shared their experiences
too and gained support in
relation to the design of
bundles from the
• Additional support was
provided by the CRT to
the CHMT via phone and
emails CRT members facilitating inter-district
Benefits & unintended effects
Effects on management strengthening
• Improved teamwork among CHMT members (all)
• Improved participatory decisions among CHMT
members (Kilolo, Mufindi)
• Improved practices for problem analyses (all)
• Increased frequency and quality of supervision (all)
Benefits & unintended effects cont...
Effects on improving HW Performance
• Staff skills led to better services (Iringa, Kilolo)
• improved service quality (all)
• Introduction of incentives to retain/motivate staff
• Experience gained from PERFORM has trickled
down to other health services areas in the
Councils (Iringa and Mufindi)
• Late disbursement of funds from the central
government affected implementation of the bundles
• Ad hoc and competing tasks facing the CHMT
• Leadership problems at district level constraining
implementation of bundles (Kilolo & Mufindi)
• Involving key decision makers (national and regional)
from the early stages of the project implementation.
• District interactions through inter-district meetings are
important for networking and learning from each other
• Involving lower levels of the health systems i.e. sub-
district staff and community representatives
• Frequent meeting between researchers and district level
decision makers (CHMT) to reinforce implementation of