The PERFORM Project

Health systems in Africa do not meet their full potential. Part of the reason is a lack of adequately-trained health care and related workers. However, we also need to focus on the existing workforce and help them to improve their performance and provide a better health service.

PERFORM sought to test a method for providing an adapted, cost-effective and sustainable way for researchers to support improvements in health worker performance within the health system. It did this through a management strengthening intervention.

PERFORM adopted and adapted an action research process to work on strengthening human resources for health policy and practice in Ghana, Tanzania, and Uganda. The toolkit explains the process that the team followed and to provide tools and tips to others who want to pursue a similar process or project. The full toolkit can be found here.

Introduction to how we used action research in PERFORM

Using an action research approach we supported health managers to carry out a situation analysis on the health system, with a particular focus on workforce performance, in nine study districts (three per country). They then identified the areas of health workforce performance to be improved, developed and to, implemented integrated human resource and health systems strategies feasible within the existing context to improve health workforce performance, and monitor the implementation of the strategies, evaluate the processes and impact on health workforce performance and the wider health system.

PERFORM researchers worked with district health managers in a process that led them through one or two cycles of action research. This enabled them to 1) Plan; 2) Act; 3) Observe; 4) Reflect.

Initial situational analysis

In this phase of the cycle researchers supported District Health Management Teams to conduct a situation analysis where they identified health workforce performance problems in their districts. They collected and analysed routine data such as staffing and health service information using a standard form, reviewed existing report and documents, and facilitated group discussion with District Health Management Teams to better understand their role and health workforce performance. From this they formulated problem statements related to health workforce performance.

Plan

In a series of facilitated meetings and workshops, the District Health Management Teams prioritised the problems and then analysed the root causes of these problems.

Based on the problem analysis, the district health management teams identified a mixture of human resource and health system strategies e.g. developing skills through a training workshop and repairing equipment so health workers can do better work.

These strategies needed to be:

•     Possible to implement (i.e. within the District Health Management Team’s boundaries of budget and authority)
•     Aligned to and embedded in annual priority/activity planning of districts
•     Focused on improving health workforce performance in the district
•     Likely to have a measurable and observable effect on workforce performance within 12-18 months
•     Implemented within resources available to the district
•     Reflected the data in the district report (i.e. based on evidence accumulated in the situation analysis).
•     Likely to be effective in the given situation.

Act

The strategies were implemented over a period of 18 months.

Observe

District Health Management Team diaries, visits by the research team, inter-district meetings were used to facilitate observation and reflection of the implementation of different strategies and their effects on workforce performance. In each district, qualitative and quantitative research methods were used to evaluate the intervention. Qualitative data collection and analysis: focus group discussions with District Health Management Team members, in depth interviews with District Health Management Team members, health facility managers and staff, and stakeholders were conducted. The recordings were transcribed verbatim, and analysed thematically with support from the NVivo software. Documents such as district annual workplans, budgets and reports, workshop reports and DHMT diaries were analysed thematically. Quantitative data collection and analysis: selected health systems and health services indicators were collated at the District Health Office from the Health Management Information System.

Reflect

If the District found that one of the strategies they were implementing was not working – or affecting another strategy negatively (for example there is a risk that the upgrading training will have a negative impact on the strategy of reducing staff absence – especially if the number of staff in the facilities is already very low) they were encouraged to consider modifying it or even dropping it from the bundle. Modifying or dropping a strategy was not considered a failure. The purpose of the action research approach being used was not only to try to solve immediate problems, but also to learn, collectively as the District Health Management Team, what sort of strategies worked under what circumstances. More challenging – but even more useful – is to learn why certain strategies do or do not work in a particular situation.