The PERFORM project uses action research to help district health management teams in Ghana, Tanzania, and Uganda improve health workforce performance. Over four years, the project supports management teams to conduct situation analyses, plan and implement integrated human resource and health systems strategies ("bundles"), observe impacts, and reflect on lessons. The goal is to strengthen district management and ultimately improve service delivery. Key activities include national workshops to analyze problems, develop strategies, and compare results, as well as ongoing support from in-country research teams. Evaluation focuses on changes in workforce performance and health systems during and after implementing the management strengthening intervention.

1. PERFORM –
Overview, design and methods
Reinhard Huss, Comfort Mshelia, Tolib Mirzoev
LIHS/ Nuffield Centre
University of Leeds
United Kingdom

3. Outline
• Introduction: What is
PERFORM? Partners,
timeline, key background
information
• Study Design:
Objectives, What is action
research?
• Implementation:
Phases in the project,
comparative analysis

5. Project
Timescale
Funder
Start September 2011
Ends August 2015
4 year programme
Focus: improving health
workforce performance
European Union (EU)
Aim
To understand
how district
management
strengthening
can improve
workforce
performance
Overview

6. Partners
• School of Public Health, University of Ghana, 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, Switzerland
• Nuffield Centre for International Health and
Development, University of Leeds, UK
• Liverpool School of Tropical Medicine, UK

7. Key background information
• Global shortage of health workers
• Deficit can be addressed by:
– training more new personnel; and
– improving performance of the existing workforce
• Many factors and their interactions affect workforce
performance
• Local interventions may influence performance
• Opportunities available where planning and management is
decentralised to district level
• Action research is a local research intervention which may
strengthen district management and lead to improved
workforce performance

8. Study design

9. Objectives of PERFORM
• Use Action Research to:
– Help Council Health Management Teams (CHMTs)
to think strategically, to be entrepreneurial within
their resource and authority constraints and to
learn about their interventions
• Develop strategies aimed at:
– Improving health workforce performance and
ultimately service delivery in the district

10. Our approach
• Systems perspective to human resource
management using a coordinated set of
strategies to improve performance
• Health systems thinking which considers Human
Resources (HR) alongside other related health
system (HS) factors: Finance, Medicines,
Equipment, Information, Governance
• Action research methodology as the intervention
for strengthening management at district level

11. What is Action Research?
Definition:
“Action research is a period of inquiry that
describes, interprets and explains social
situations while executing a change
intervention aimed at improvement and
involvement. It is problem focused, context-
specific and future-oriented.”

12. How does it work in practice?
Plan
Act
Observe
Reflect
• Supported by PERFORM
Researchers – the CHMTs
identify barriers to workforce
performance and their causes
(situation analysis) and then:
• Plan bundles of HR and HS
strategies
• Act to implement these
strategies
• Observe the impact of the
strategies on performance
• Reflect on how well their plans
have been achieved and if
necessary, revise the plan

13. Research concept
Plan
Act
Observe
Reflect

14. European partners support
Country Research Teams
Country Research Teams support
Council Health Management
Teams
Council Health Management Teams
conduct action research
Nested action
research approach

15. What we did?

16. Project phases
Phase one
Phase two
Phase
three
Preparation
Implementation
Evaluation and feedback

17. Timeline
Phase 2 : June 2012 – Dec 2014
Initial
Situation
Analysis
Jun-Aug 2012
National
workshop 1:
Problem
analysis
Oct 2012
National
Workshop 2:
Development
of HR/HS
bundles
Jan 2013
Consortium
workshop 2
Nov 2012
Implementation
of bundles
Jan 2013 – Aug
2014
National
workshop 3:
Comparative
analysis
Dec 2014
Final Situation
Analysis
Aug-Oct 2014
Consortium
workshop 3
Jan 2014

18. Part 1: Entry - Initial Situation
Analysis
• Engagement
• Initial data collection- using qualitative and
quantitative methods
• Problem identification and analysis
• National workshop 1 – October ‘12
• Consortium workshop 2 to review and plan –
November ’12)

20. Part 2: Plan- Development of HR/HS
strategies
• Used the situation analysis to design strategies
to address the problems
• Strategies (known as bundles) were a mixture
of:
– Human resource (HR) strategies – e.g. developing
skills through a training workshop
– Health systems (HS) strategies – e.g. repairing
equipment so health workers can do better work
• CHMT selected the HR / HS bundles and
developed a plan of how to implement the
bundlesand monitor their effects.

22. Part 3: Act - Implementation of
Human Resource/Health System
bundles
• Check HR/HS bundles against specific criteria
(feasibility, cost, time, other+)
• Incorporate into routine district plans (CCHPs)

24. Part 4: Observe - Measure changes
during and after implementation
• Focus group discussion
• Patient survey
• In-depth interviews
• HMIS data

25. Part 5: Reflect - Supporting
knowledge generation and learning
• Follow up visits by Country Research Teams
• Diaries kept by CHMTs
• Bringing CHMTs together in workshops

27. Part 6: Comparative analysis
Conduct comparative analyses across districts
and countries of:
– The management strengthening intervention
(using action research) to support improved
workforce performance, and
– Processes of implementing the integrated HR
and HS strategies (bundles) and intended and
unintended effects on health workforce
performance and the wider health system.

28. Reflections on the PERFORM
approach
• Time availability of CHMT members
• Engagement
• Relevance
• Ownership and sustainability in the districts
• Changes in use of decision space
• Availability and use of quantitative data in AR
• Transferability of the process to other districts
or other parts of management

29. R.Huss@leeds.ac.uk
http://www.performconsortium.com/
For further information