Improving health workforce
performance in Ghana, Tanzania
and Uganda
Kaspar Wyss
Swiss Tropical and Public Health Institute
Contents
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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
What is PERFORM?
Project
Aim
To understand
how
management
strengthening
can improve
workforce
performance
4 year programme
Focus: improving health
workforce performance
Timescale
Funder
Start September 2011
Ends August 2015
European Union (EU)
Who are our partners?
School of Public Health,
University of Ghana
College of Health
Sciences, School of Public
Health, Makerere
University
Ghana
Uganda
Leeds
Nuffield Centre for
International Health and
Development, University
of Leeds
PERFORM
Consortium
Institute of
Development Studies,
University of Dar-esSalaam
Tanzania
Liverpool
Switzerland
Swiss Tropical and Public
Health Institute
International Health
Group, Liverpool School
of Tropical Medicine
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
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
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:
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Malaria
Acute Respiratory Infections
Skin Diseases and Ulcers
Diarrhoea Diseases
Hypertension
Source: Ghana Human Resources for
Health Country Profile, Edition 2011
Study districts in Ghana
• Kwahu West
• Akwapim North
• Upper Manya Krobo
Medical workers in health facilities: Diocese of Gaoso, Ghana
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
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
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
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, contextspecific and future-oriented.”
How does it work in practice?
• 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
Plan
Reflect
Act
Observe
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.
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.
Project phases
Phase one
Preparation for implementation
Phase two
Research implementation
Phase
three
Evaluation and feedback
Timeline
Phases 2 and 3: June 2012 – Dec 2014
Initial
Situation
Analysis
Jun-Aug 2012
Consortium
workshop 2
Nov 2012
National
workshop 1
Oct 2012
Implementation
of bundles
Jan 2013 – Aug
2014
Development
of HR/HS
bundles
Jan 2013
Final Situation
Analysis
Aug-Oct 2014
Consortium
workshop 3
Jan 2014
National
workshop 3
Dec 2014
Roles of partners and DHMTs
• Researchers
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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
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
Questions?