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Presentation by Tim Martineau at the European Congress on Tropical Medicine and International Health
- 1. Management strengthening using health workforce performance problems in decentralised contexts: lessons from Ghana, Tanzania and Uganda @TimMartineau, M. Aikins, S. Baine, R. Huss, P. Kamuzora, K. Wyss 9th European Congress on Tropical Medicine and International Health 6-10 September 2015, Basel, Switzerland @PERFORMtug
- 2. Rationale for PERFORM initiative • Need to improve workforce performance to support UHC • Integrated HR (Buchan 2004)and health systems approach required (de Savigny and Adam 2009) • District level managers in decentralised contexts in better position to organise integrated approach and have sufficient “decision space” (Bossert 1998) • Challenge to help DHMTs to think strategically and to be “entrepreneurial” within their resource and authority constraints. • DHMT management 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.
- 6. Timeline Situation Analysis Jun-Aug 2012 National workshop 1 Initial problem analysis Oct 2012 National workshop 2 Development of HR/HS bundles Feb 2013 Evaluation Sep 2014 Implementation of bundles: act, observe and reflect Mar 2013 – Aug 2014 p l a n
- 7. Management competencies promoted in PERFORM Management competencies Development activities Identification of root causes of problems SA, NW1, NW2 Prioritisation of problems SA, NW1, NW2 Designing integrated HRM and health systems strategies appropriate to context NW1 – introduction only; NW2 Resourcing NW2; follow-on activities Following through the implementation to overcome barriers follow-on activities (diaries, researcher visits and inter- district meetings)
- 8. Evaluation methods • Analysis of data collected during the implementation period • reflective diaries • Researcher visit reports • workshop evaluation reports and inter-district meeting reports • Post implementation • Interviews and FGDs with DHMT members • Interviews with other managers, staff and stakeholders • Management and service delivery data analysis
- 9. Examples of ‘bundles’ of strategies for improvement of workforce performance • Strengthening supervision • Controlling staff absence • Improving competencies • Incentives • Improved appraisal Kwahu West district, Ghana
- 10. Appropriateness of approach • Timing • Funding • Facilitation • Ownership • Duration National Workshop, Tanzania
- 11. Identification of root causes of problems and prioritisation • Greater depth • Importance of small problems • “If you do not do the problem tree analysis, you will be doing things randomly without any specific objectives in mind” (Manager Tanzania). National Workshop, Uganda
- 12. Designing integrated HRM and health systems strategies appropriate to context and resourcing • HRM/HS integration • Use of selection criteria • Less attention to indicators • Incorporation into regular budget or external funding Incorporating the plan into the regular budget, Jinja DHMT, Uganda
- 13. Follow-up during the implementation phase • Competing agendas • Monitoring • Reflection (including diaries) • Modification of plans • Abandoning plans Inter-district meeting Uganda
- 14. Additional effect on DHMT • Empowerment: "we can push for change" • Initiative and risk- taking culture • Teamwork and collaboration • Application to other areas of work National Workshop, Tanzania
- 15. Selected lessons from PERFORM project • Overall support for PERFORM's approach based on action research • PERFORM activities led to improved problem analysis and design of integrated HR/HS strategies for improving workforce performance • DMHTs are able to resource additional planned work from regular funds or external partners • DHMTs can monitor and modify implementation of plans, but recognise better indicators, baseline data and monitoring needed • More support with reflection part of AR cycle may be needed • Process had other benefits for the operation of the DHMTs
- 16. Acknowledgements Funding from the European Commission Seventh Framework programme Ministries of health in Ghana, Uganda and Tanzania District health management teams in: Jinja, Kabarole and Luwero districts (Uganda); Kwahu West, Akuapim North and Upper Manya Krobo districts (Ghana); Kilolo, Iringa Urban and Mufundi districts (Tanzania)
- 17. Contact details for further dialogue • Project website: www.performconsortium.com • Twitter: @PERFORMtug • Project PI: tim.martineau@lstmed.ac.uk
Editor's Notes
- I am presenting the results of a 4-year EC-funded project that has just ended on behalf of the other 5 partners. Please note the twitter handles if you are that way inclined
- We all know about staff shortages, but staff performance is also needed to achieve UHC Effective human resource management is achieved through what Buchan refers to as integrated the bundles of human resource strategies A health systems approach requires all aspects of the system to be considered when improving workforce performance To achieve this level of integration is challenging, but may be possible at the district level in health system, particularly in decentralised contexts where managers have greater autonomy or “decision space” – hence the selection of Ghana, Tanzania and Uganda It was assumed that working with district health management teams would produce better learning and develop a critical mass, particularly where there is a risk of high turnover The challenge of PERFORM was to help the DHMTs the strategiclly and make the best use of available resources within authoritaty constraints We recognise that there are many programme designed for DHMT’s management strengthening – going back to the HS program Ghana in the late 1980s, but our initial searches showed a gap in the research on this 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 ….
- The partnership was made up institutions in the 3 African countries, the Swiss tropical and Public health Institute, the Nuffield centre at Leeds in the UK and the consortium was led by the Liverpool School of tropical medicine UK
- The logic and related objectives was that an intervention for management strengthening was needed to enable the development of the integrated HR and health systems strategies. The focus of this presentation is on objective #1
- [remove ovals and shorten the summary] Our starting point was problems relating to quantity and performance of health workforce – with an emphasis on performance. We adopted a systems approach using integrated HR strategies, linked with other health systems strategies to address the problem, and observed unintended effects The intervention uses a standard approach to problem solving. We evaluated both the effects on workforce improvement and the effects of the management strengthening intervention – which we are focusing on’s presentation We used an action research approach used with the DHMTs, taking them through the cycle of planning, acting, observing, reflecting and replanning 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 worked with 3 districts in each of the 3 countries. This represents the overall plan of work, though there were variations by country. (District selection criteria – if anyone asks): 1) reasonably staffed district management team that was motivated to take part in the project 2) Mixture of good and less good performing (Ghana and Uganda); in agreement with Tz govt (had to be in one region)) We started working with the DHMTs to develop a situation analysis – looking at service provision, staffing etc. At this stage they began to develop a list of problems they had identified. In each country a selection of members of the 3 DHMTs came together for a short (1.5 day) National workshop, facilitated by the research teams, to analyse their problems in more detail and prioritise them. There was time to return to the full DHMT for further discussions before returning for a 2nd 2 ½ day workshop a few months later to further refine the problem analysis and develop an action plan that could be carried out using available resources. During the implementation period in which the action took place the research teams visited the district quite frequently and organised interdistrict meetings to facilitate the observation and reflection stages The evaluation was carried out in September 2014, but in many cases implementation continued. Some variations at national level 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.
- We identified a number of management competencies related to the intervention cycle shown earlier. The first 3 sets of competencies were largely developed through the situation analysis and the 2 national workshops Resourcing was started in National workshop 2 but largely led by the DHMTs themselves thereafter. Support for observation and reflection was provided through the introduction of reflective diaries for the DHMT, regular visits by the researchers and interdistrict meetings
- The evaluation used an analysis of much of the documentation – DHMT reflective diaries maintained during the implementation period, as well as data to get a retrospective perspective on the process and effects.
- You also get an idea from this slide of the type of integrated plan produced by the DHMTs The two most common strategies selected for improving workforce performance were strengthening supervision and controlling staff absence.[check] Other strategies included improving competencies, use of incentives, better appraisal systems, and increased use of volunteers. Modest improvements in workforce performance were reported. Wider health systems strategies were also included, such as setting performance indicators for immunisation logistics, to address service delivery problems Note – not the focus of this presentation
- Timing – not too long away for district; in some cases appropriate to support planning in budget cycle Funding – initial surprise/complaints about lack of implementation funds; then recognition by some Facilitation – enough, but did not take away control Ownership – owned problems and owned plans – not imposed from outside Duration – a number wanted a longer period of support
- Greater depth – not new for all, but got to the real problems Importance of small problems – could often be solved quite easily, but made a big difference [problems within the systems] “If you do not do the problem tree analysis, you will be doing things randomly without any specific objectives in mind” (Manager Tanzania).
- HRM/HS integration – challenging concept – possibly language; but evidence in plans; used table of options Use of selection criteria – e.g. link to district plan Less attention to indicators Incorporation into regular budget or external funding – entrepreneurial about getting funding
- Competing agendas – but worked around these Monitoring – began to see the importance and therefore the need for indicators and data Reflection (including diaries) – possibly the weakest point in AR process; not visible in reflective diaries; more in conversations and evidence in modifications Modification of plans e.g allocating mentors to supervisors in Uganda Abandoning plans – activity with fridges and solar panels in Ghana
- Ownership/empowerment: "we can push for change" Initiative and risk-taking – pushing the limits of decision space Teamwork and collaboration – slight myth about DHMTs (like any other organisation), but improved and links to other districts Application to other areas of work – not just workforce performance
- DHMTs demonstrated overall support for PERFORM's approach based on action research, in spite of lack of implementation funds and other constraints PERFORM activities led to improved problem analysis and design of integrated HR/HS strategies for improving workforce performance DMHTs are capable of able to resourcing additional planned work from regular funds or external partners (?if they feel sufficiently motivated) DHMTs can monitor and modify implementation of plans, but recognise better indicators, baseline data and monitoring needed More support with reflection part of AR cycle may be needed [difficult to see into their head - but seemed to be less time] Process had other benefits for the operation of the DHMTs [teamwork, collaboration with other disricts]
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- And a few brochures downloaded from web