Stakeholders: How can we make PERFORM2Scale work in Ghana?
Professor Moses Aikins, of the School of Public Health, University of Ghana and member of the Country Research Team, talks about stakeholders in the Ghanaian strand of PERFORM2Scale.
The Ghana Health Service in recent times implemented a Management Strengthening Intervention (MSI) in the Eastern Region of Ghana, to improve health workforce performance. To implement the MSI, District Health Management Teams (DHMTs), supported by Country Research Teams (CRTs), engaged in processes of reflexive learning through the use of an action research cycle, seeking to develop work plans to address health workforce performance issues at the district level.
A series of interviews with district stakeholders was undertaken for the Ghana team’s initial country analysis. This was part of a baseline study to explore experiences and perceptions of health managers, policy makers and researchers with regard to previous management strengthening interventions and other resource allocation issues influencing policy implementation. One person observed that:
“I think the PERFORM2Scale is a good initiative in the first place and it is not so quite different from the way the system ought to be managed. If you look at the cycle, the planning stage level is done every year with management and facility level heads are expected to make their plans sometimes for the year or with some programmes probably you would be expected to give a 5-year plan and then we move through the same cycle but then at times we do lose focus. So then I believe this approach would give it more recognition and attach importance to what we already know. Just that we have not been giving it the needed attention. So I believe with help, it will rekindle us to live up to expectation.”
Stakeholders indicated that engagement of key national level health actors with decision-making powers enhances policy implementation, while at the district level collaboration between decentralised bodies results in improved resource allocation. However, the limited decision space of the decentralised health sector affects policy implementation.
Exploring experiences and perceptions of stakeholders
Prior to the MSI implementation at the district level, health managers, policy makers and researchers were interviewed as part of a baseline study to ascertain their views on engagement of national-level key actors, resource allocation and decision-space at the district level of the decentralized health system.
What were the findings?
Findings suggests that:
- In Ghana, administrative devolution has occurred without the corresponding transfer of financial control. Budgeting and expenditure still largely occur at the national level, or are earmarked to specific health programmes.
- Lack of funds and other resources within the health sector is a barrier to policy implementation, and that limited health financing may affect the resources available for the PERFORM2Scale MSI. A DHMT member noted that:
“The resources were an issue… because of the lack of resources you can get to a point and realize that you’re stuck... We were working with Plan Ghana and they were able to give us some financial support. So the Director was able to get some logistics from them, so resources were another issue."
- Most of the study participants had previously been involved in some sort of programme for strengthening management, yet none focused on strengthening managerial capacity at district level. Two major factors were identified that are of relevance to a successful MSI and its scale-up:
- strong stakeholder engagement at all levels, both during and post-implementation of the work plans developed by the DHMTs, and
- there should be both horizontal and vertical MSI scale-up* to ensure sustainability and alignment with/embedding in national health system priorities to promote ownership.
What is the importance of engagement and collaboration?
Deductions from the interviews suggests that implementation of the PERFORM2Scale MSI though challenging will require strong stakeholder engagement, collaboration and resource allocation from both national and local level. The effective MSI implementation may enhance workforce performance and its attendant improved service delivery.
*Horizontal scale-up refers to expansion and/or replication of the intervention across the country; vertical scale-up refers to: institutionalization through policy, political, legal, budgetary or other health systems changes in particular to support the horizontal scale-up.