Stage:Plan

The facilitators will make a separate visit to each of the participating districts. This is the first visit to the district and will include a meeting with the DHMT and other relevant stakeholders in the district. Allow for a whole day per district.  

+++ Even before meeting with the DHMT, a courtesy visit to the local government administrator may be needed. +++
Further, information on regional and national authorities in the planned location may be needed.

The purpose of the orientation visit is therefore to provide more information about the MSI, what is expected of the DHMT, and develop a plan for the first MSI cycle which synchronises with the other DHMTs in the District Group and is in line with the overall scale-up plan. It is also important to manage the expectations of the DHMT about the intervention, eg they may expect additional funding to implement the strategies.  

+++ If the principle of providing no additional funding to implement the strategies is adopted in the early stages +++
of the programme, this may need to be repeated frequently and firmly. 

During the orientation visit, the facilitators can give a presentation about the MSI, and answer any questions. During the visit, the facilitators will also introduce the two tools that are used for the district situation analysis, explaining the purpose of the tools and what data to collect. 

Making a good impression at the first meeting with the DHMT and communicating clearly are crucial. Here are some tools that will help ensure that the meeting goes as smoothly as possible: 

• Expanded briefing note for orientation visit (this example is from Uganda)

+++ This can be adapted for your programme. +++

• Draft presentation that can be adapted to the context
• Tips on how to facilitate an orientation meeting with DHMTs
• Introduction to the situation analysis tools

+++ This initial orientation visit is not necessary for the implementation of the second or subsequent cycles. +++

In this two-day MSI Workshop, members of DHMTs in the three districts of the District Group come together to review findings of their situation analyses and to conduct an analysis of one of the problems they have identified. 

+++ We sometimes found that two days was too little time to carry out a detailed root-cause analysis. +++
Consider extending the workshop by half or one day if this is affordable and if DHMTs can spare the extra time.

Bringing the three districts together will help DHMT learn from each other, as they critically review each other’s situation analysis and problem analysis. The workshop will also initiate comparing the findings across the districts and identify any further data requirements for the situation analysis. 

+++ Consider inviting extra people to the workshop who might have specific expertise about the problem selected. +++
We sometimes invited people like the district human resources officer, the district planner or a district health specialist related to the selected problem.

The DHMTs bring to the workshop: the completed District Situation Analysis Tool, the completed HMIS tool, and the list of prioritised problems - workforce performance problems or other problems with clear link to workforce performance. Each DHMT will present their situation analysis and their prioritised list of problems and receive feedback from the other DHMTs as well as the facilitators. Each DHMT will then select the problem that they want to address and do an in-depth analysis of this problem. 

There are several tools to help you run this workshop:    

• This guidance for MSI Workshop 1 provides sample aims and objectives and a guide on how the two days could be structured

+++ Email the template to the DHMTs in advance of the workshop to give them time to prepare their presentations +++
and to discuss them with other members of the DHMT who are unable to attend the workshop.

• This Power Point presentation provides an introduction to the MSI Workshop 1 that you can adapt
• A template for the presentation that the DHMT will make on their situation analysis and list of problems
• Observation checklist for situation analysis presentation. In the period before the workshop, you will have worked with DHMTs to conduct a situation analysis - identifying health workforce performance problems. This will include the collection and analysis of routine data such as staffing and health service information, review of existing report and documents, and discussions with DHMTs to better understand their role and health workforce performance. This will have led to the creation of a list of problems related to health workforce performance. The observation checklist will help workshop participants (each district takes turns) to critically review the situation analysis presentation. 
• Guidance for formulating the problem statement will help the DHMT to develop a clear problem statement that can then be further refined during the analysis

+++ We found the ‘gallery walk’ on Day 2 was a very good way for DHMTs to critically evaluate the problem analysis from the two other districts. +++
The process increases engagement and introduces a little bit of healthy competition between the districts.

• Worksheet for reviewing the problem analysis will help the DHMTs and facilitators to critically review the problem statement, and problem tree or fishbone, and provide feedback so that the DHMTs can refine the analysis 

+++ Take time to enable DHMTs to fill in the worksheet thoroughly; this is a great opportunity for the teams to learn +++
from the strengths and weaknesses of each other’s problem analyses. 

• Evaluation questionnaire. This tool allows DHMTs to provide feedback on Workshop 1. This will be important data for the process analysis

+++ This is a good opportunity for the facilitators to improve future workshops. +++

• Template for MSI Workshop 1 report
• List of energisers for workshops

+++ Invite participants to choose and/or lead energisers to increase levels of engagement. +++

There are several techniques that can be used to undertake problem analysis. If the DHMT is familiar with a technique already, then use this technique to do the problem analysis. Otherwise, there are some examples of problem analysis techniques below. The important point is that the DHMTs, with support from the facilitators, analyse the root causes of their problems. Two such techniques are: 

• Problem tree analysis
• Fishbone analysis

+++ We only used problem tree analysis, mainly because the facilitators and participants were more familiar with this +++
method and it was helpful for developing the objectives (see Workshop 2).  

The development of strategies will mainly be done in MSI Workshop 2. In this two and a half-day workshop, members of the DHMTs in the three districts of the District Group (it would be good if they are the same DHMT members that attended MSI Workshop 1) come together to refine the problem analysis and to develop a workplan for human resources/ health system strategies to address problems identified in the situation analysis. During the workshop, facilitators will agree with the DHMT on support processes during the implementation period, as well as ways to observe and reflect on the implementation and effects of the strategies.  

+++ Consider extending the workshop by half or one day if this is affordable and if DHMTs can spare the extra time. +++
Refining the problem analysis at the beginning of the workshop is an essential step and may take longer than expected.

+++ Consider inviting extra people to the workshop who might have specific expertise needed for developing the workplan +++
and who can help with support for implementation, ie getting the workplan into the district plan and budget.

Having selected the human resources/ health system strategies, the research team is now in a position to develop a workplan for implementation. Participating districts will likely have existing plans and targets, so first consider how these may be modified to address the prioritised problems. The plan is not necessarily a complex document. It can be as simple as a table noting the issues set out in bullet points:

• Identify the strategy you want to use
• Identify the activities needed to implement the strategy
• Develop targets based on expected improvements in performance when compared to the situation analysis. The targets should be time-bound.
• Identify linkages to other strategies in the workplan

Strategies should always be developed within budgets available to the DHMT, integrated into local planning cycles, and take account of authority constraints. Facilitators should focus on what is feasible for DHMTs to undertake within a limited period of time. They should also ensure that the selected strategies are compatible with the regional and national human resource priorities and strategies. DHMTs will already have human resource/ health systems strategies in place. These could also be included in their workplan or tweaked to be more effective. Strategies that are already in the routine plan will be funded so are more likely to be implemented. Do consider whether any new strategies may have negative unintended consequences on strategies already in place.  

There are several tools that will help facilitate the development of the strategies during Workshop 2: 

• The guidance for MSI Workshop 2 leads you through the final check of the problem analysis, developing human resource/ health system strategies to address selected problems, incorporating them into coherent workplans, using reflective diaries, and ensuring ongoing support and communication throughout the research process. It provides objectives, inputs, outputs and a programme for the workshop you can adapt.
• This PowerPoint presentation provides introductory slides for MSI Workshop 2.
• Checklist for improving problem analysis. This can be used to help participants improve and peer review their problem analysis.

+++ When developing the strategies, some facilitators encouraged the use of an ‘objectives tree’. +++
These could be created alongside the problem trees to ensure a clear link between the two types of tree.

• Developing human resource/ health system strategies. This PowerPoint presentation provides an overview of human resource/ health system strategies and the types of strategies that DHMTs might consider. It then helps participants to develop and evaluate different strategies.
• Guidance for choosing human resources/health systems strategies is a step-by-step guide to selecting the strategies. This document also includes two important annexes: a glossary of terms and a large table with ideas for strategies and activities.

+++ This document is a useful guide for developing the workplans. +++
There was quite a strong emphasis on improving the management of Human Resources for Health in both PERFORM and PERFORM2Scale,
which explains the very detailed 14-page table at the end. Some DHMTs used this, but not all.
Consider how helpful it would be for your purposes or whether it is likely to frighten people off!

• This template of the planning table for human resource/ health system strategies is to be used as a handout for the group work during the workshop.

+++ All DHMTs used this table, but some modified it to include columns for time frame and responsibilities. +++
The table could also be modified to better reflect existing planning formats.

• Worksheet for reviewing the human resource/ health system strategies to improve workforce performance. This tool enables workshop participants to review the strategies that are developed during the small group work.
• Guidance for using DHMT reflective diaries and reflecting using diaries presentation. These include a presentation and a handout that can be taken away from the workshop as a guide to ensure that appropriate process data is collected throughout the research process.

+++ ‘Reflection’ is an essential part of the action research process. It has also emerged as a very challenging process. +++
Helping the DHMTs to reflect on their plans, progress and achievements as well as what the feel they are learning is a very important part of the Action Research process.

• Guidance for ongoing support and communication session. This is a very important session to ensure continued collaboration between the facilitators and DHMTs. This guidance for workshop facilitators provides some ideas for this session - please adapt as you feel appropriate.
• It is important to evaluate the workshop. This questionnaire allows the DHMT to provide feedback on MSI Workshop 2.
• Template for MSI Workshop 2 report.