This presentation provides an overview of what we set out to do in the project.

1. Improving health workforce
performance in Ghana, Tanzania
and Uganda
Kaspar Wyss
Swiss Tropical and Public Health Institute

2. 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

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

4. Who are our partners?
PERFORM
Consortium
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

5. 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

6. 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

7. 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

8. Study districts in Ghana
Medical workers in health facilities: Diocese of Gaoso, Ghana
• Kwahu West
• Akwapim North
• Upper Manya Krobo

9. 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

10. Factors affecting workforce performance
Concept 1
• Availability of health personnel
• Utilisation of health personnel
Concept 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

11. 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

12. 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.”

13. 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

14. Situation Analysis
This 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.

15. 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.

16. Project phases
Phase one
Phase two
Phase
three
Preparation for implementation
Research implementation
Evaluation and feedback

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

18. 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

19. 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