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Improving health workforce performance in Ghana, Tanzania
and Uganda
Kaspar WyssSwiss Tropical and Public Health Institute
Contents• Introduction to PERFORM• Partners in the project• Key messages• Study countries• Action research and how it works in practice• Project stages and timeline• Outcomes and impact
What is PERFORM?
Project
Timescale
Funder
Start September 2011Ends August 2015
4 year programmeFocus: improving health workforce performance
European Union (EU)
Aim To understand how
management strengthening can improve workforce
performance
Who are our partners?
PERFORMConsortium
Ghana
Leeds
Liverpool
Switzerland
Tanzania
Uganda
College of Health Sciences, School of Public Health, Makerere University
International Health Group, Liverpool School of Tropical Medicine
School of Public Health, University of Ghana
Nuffield Centre for International Health and Development, University of Leeds
Institute of Development Studies, University of Dar-es-Salaam
Swiss Tropical and Public Health Institute
Key messages• Shortage of well performing health workers• Deficit needs to be addressed both by training
more new personnel and improving performance of the existing workforce
• Complex factors affect workforce performance• Decentralisation of planning and management
authority
Study countries• Ghana, Tanzania, Uganda – each face major
challenges in developing their health workforce• Selected from 57 World Health Organisation
(WHO) states that do not meet a minimum ratio of 2.3 key health workers per 1000 population
• Decentralised structures offer DHMTs greater decision-making opportunities
Ghana: health status profile• Life expectancy: 60 years (2007, World Bank)• Maternal Mortality Rate: range from 214 (1999, WHO) to
586 (2001, Hill) per 100,000 live births• Under five mortality rate: improved over last ten years to
80 per 1000 live births• Top 5 causes of mortality and morbidity:
– Malaria– Acute Respiratory Infections– Skin Diseases and Ulcers– Diarrhoea Diseases– Hypertension Source: Ghana Human Resources for
Health Country Profile, Edition 2011
Study districts in Ghana
Medical workers in health facilities: Diocese of Gaoso, Ghana
• Kwahu West• Akwapim North• Upper Manya Krobo
Challenges: Ghana health sector• Retaining health professionals• Improving health worker retention in rural areas
– Two teaching hospitals Korle Bu and Komfo Anokye employ more than 45% of the country’s Drs
– Less than 15% are present in district hospitals
• Addressing the shortage of trained midwives• Strengthening capacity of existing workforce• Developing the appropriate human resources in their
right mix and numbers in order to meet the health needs of the people in Ghana Source: Ghana Human Resources for
Health Country Profile, Edition 2011
Factors affecting workforce performanceConcept 1• Availability of health personnel• Utilisation of health personnelConcept 2• Retention – attrition, turnover rate• Distribution – vacancy rates by cadre, geographic
location, facility type• Effectiveness – Skills mix, levels of absence, quantity
of work output, quality of work output
Our research approach• A systems approach to human resource
management using a coordinated set of strategies to improve performance
• A health systems approach which views HR alongside other related factors e.g. Finance, Drugs, Equipment
• Action research methodology as the intervention for strengthening management at district level
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.”
How does it work in practice?
Plan
Act
Observe
Reflect
• Supported by PERFORM Researchers – the DHMTs will identify barriers to workforce performance and their causes (situation analysis) and then:
• Plan bundles of HR and health systems 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
Situation AnalysisThis will be a two step process: • Step 1: collect and analyse routine data such as
staffing and health service data using a standard form for all study sites
• Step 2: focus on collecting data to understand the causes of particular issues or problems emerging in step 1. After reviewing the findings, DHMTs will develop clear problem statements related to health workforce performance.
Development of HR/HS bundles• Using the situation analysis to design strategies to
address the problems• These strategies (known as bundles) will be a mixture of:
– Human resource (HR) strategies – e.g. developing skills through a training workshop
– Broad health systems (HS) strategies – e.g. repairing equipment so health workers can do better work
• In each district, the DHMT will select the HR / HS bundles
• Then develop a plan of how to implement the bundles and monitor their effects.
Project phases
Phase one
Phase two
Phase three
Preparation for implementation
Research implementation
Evaluation and feedback
Timeline Phases 2 and 3: June 2012 – Dec 2014
Initial Situation Analysis
Jun-Aug 2012
National workshop 1
Oct 2012
Development of HR/HS bundlesJan 2013
Consortium workshop 2Nov 2012
Implementation of bundles
Jan 2013 – Aug 2014
National workshop 3
Dec 2014
Final Situation Analysis
Aug-Oct 2014
Consortium workshop 3
Jan 2014
Roles of partners and DHMTs• Researchers
– To provide support to the DHMTs– To conduct the situation analysis – To hold the national review meetings– To develop the research methodology– To manage the research project
• DHMTs– To implement the action research process– To actively participate in the research– To collaborate with the researchers in the situation analysis
Outcomes and impact
Impact: improved health in Sub-Saharan Africa as a result of a responsive, effective and well equipped health service, provided
by skilled health workers
Outcome: research evidence contributes to knowledge of how strengthening
management in Sub-Saharan Africa can improve workforce performance and the
wider health system
Questions?