Observations during Performance Management training of district and facility health managers in Uganda: Who needs it more and why ?
The team from Makerere School of Public Health reflects on their recent training of district and facility health managers, run in collaboration with the resource team from the Ministry of Health
In December 2020, the PERFORM2Scale Country Research Team (CRT) at Makerere University School of Public Health collaborated with officials from the Ministry of Health (MOH) to conduct three-day Performance Management and Leadership training sessions in three districts - Luwero, Nakaseke and Wakiso. These districts are part of the PERFORM2Scale study scaling-up a Management Strengthening Intervention (MSI) in Uganda.
The training was a response to requests made by the district health managers to conduct in-service training of health facility managers at various levels in Performance Management and Leadership. The participants included members of the district health team (DHT), health facility in-charges across HC IVs, IIIs and IIs, and hospital administrators. The training combined a mix of practical and theoretical modes of delivery.
Globally, there is a shortage of health workers and Uganda is no exception. There is also a need to maximize the potential of the available health workforce, and therefore improving their performance becomes critical. Performance Management is an essential step towards improving health workforce performance. During the various PERFORM2Scale workshops held with the district health management teams (DHMTs), it was noted that the performance management system at the district level was weak. This was evidenced with the poor practice of developing health workforce individual schedules of duties and performance plans with unclear objectives, targets, and indicators, poor performance monitoring and evaluation. In many instances performance appraisals were done perfunctorily and did not meet their intended purpose to improve performance by rewarding good and sanctioning bad work. However, building capacity of district-level managers through training and availing them of the necessary tools is vital for improving the Performance Management system. According to the Uganda public service standing orders 2010, Performance Management is defined as a systematic process of managing the organization and its human resources to achieve a high and steady rate of performance.
For effective performance management, there is a need for strong leadership and management at all levels. Leadership and management are two related concepts, yet different. Management is doing things right whereas leadership is doing the right things (Peter Drucker). Managers and leaders in the health sector require leadership and management skills if they are to deliver the right services at the right time and of high quality to the population.
During the training, the CRT made the following observations.
In the beginning, many of the participants lacked a basic understanding of the meaning of the term 'schedule of duties' and they struggled to identify the key inputs of the schedule of duties. This was quite a huge gap identified along the Performance Management process, given that the schedule of duties sets the pace for the work planning and assessment process. During the group exercises, the facilitators asked participants to identify key outputs and related activities for the various health cadres within the training room. These examples were discussed in detail and corrections made. This process was repeated until the participants felt comfortable and capable of developing a proper schedule of duty for their respective supervisees.
Performance Appraisals is another topic that attracted a lot of interest for the training. Key questions included who should appraise who? How are the appraisal forms filled in? When should we appraise? What should happen in cases where there are disagreements between the appraiser and appraisee? There was also an issue of stubborn health workers who felt that they were ‘too big’ to be appraised. Also, it was not clear why an appraiser was very often at the same level as the appraisees. For example, why does a doctor appraise a doctor? The responses to each of these questions are outlined briefly here.
Who appraises who? The person who directly supervises someone should be the appraiser. For example, the in-charge of the facility appraises heads of departments because he/she directly supervises them, and the heads of department appraise their respective staff. In case of disagreements, appeals are directed to the managers the next line up in the hierarchy.
How are the appraisal forms filled in? During the session, the participants learnt that the schedule of duties and performance plans feed into the appraisal. They provide information about performance indicators that are evaluated during the appraisal. This required that prior targets were set and data examined to determine the performance of the health worker before filling in the appraisal form.
When should we appraise? Appraisals schedules should follow deadlines as stated in the public service standing orders. The latest prior appraisal form should set the targets and indicators to be used for the next appraisal session. This means that the appraisal starts one year or six months before the session.
Stubborn health workers: Managers need to make a report and forward the case to the Rewards and Sanctions Committee who will then advise on further action or sanctions. Where the committee is not active, the report should go to the supervisor of the person serving as the appraiser.
We still have fresh memories about the two rib-cracking theatric performances made by participants in Nakaseke district during the role play about appraisals. Four participants were selected to role-play two different scenarios of the appraisal process; one about a manager appraising a difficult staff member and another about a manager whose attention was divided during the appraisal meeting. This was another way of demonstrating the do’s and don’ts of performance appraisal meetings. The discussion was videotaped and played again during plenary sessions to share lessons learnt.
About Leadership and Management, 90% of the participants noted that they had never received any training on Leadership and Management. As clinical workers, they noted that they had only been assigned managerial roles. This created a problem of executing roles for which they had insufficient knowledge or competencies. Yet Leadership and Management play a critical role in service delivery. Lack of awareness about Leadership and Managerial skills was noted as a source of conflict at the facility level and a possible cause of repeated poor performance at the district level. During the evaluation, the training was perceived to have provided insight about Leadership and Management. Participants requested more training of this kind.
Outputs from the training
At the end of the training, district and health facility managers developed schedule of duties and performance plans with clear targets for their respective health cadres.
A plan on how to cascade the Performance Management processes with their respective staff at the district and health facilities was also developed.
Lessons learnt
• The Performance Appraisal process is not the entirety of the Performance Management process, rather a stage in the whole process. This means that if the performance management process is followed, the appraisals will be of good quality.
• Having schedules of duties with clear targets enables the health workers to have a sense of direction and intrinsic motivation which impact on their performance and teamwork.
• Collaboration with officials from the MOH and district human resource officers legitimizes training of district health managers concerning performance management.
The way forward
• The participants / in-charges were expected to cascade the skills obtained from the meeting to lower facilities.
• The district managers will continuously monitor the health facility staff performance, provide support supervision and promote compliance with Performance Management guidelines, standards and procedures to facilitate improved service delivery.
• Makerere University School of Public Health and Ministry of Health will continue to support the district managers during the PERFORM2Scale MSI support visits.
• There is a need for more training of managers in Leadership and Management as well as Performance Management and this should be at least once a year. The line ministries need to take charge of planning for such training.