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 GhanaLeedsLiverpoolSwitzerlandTanzaniaUganda 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.” 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? PlanActObserveReflect 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 onePhase 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

20. Questions?