Uganda study: methods and key findings

Saul Kamukama, MUSPH

Serena Hotel, Kampala21 August 2015

#healthworkers

PERFORM project in Uganda • Investigates how a

management strengthening intervention (action research) can be used to improve health workforce performance

Initial situation analysis

• Research team with DHMTs conducted situation analysis on workforce performance in the district: secondary data collection, document review, interviews and FGDs and brainstorming

Health Centre IV, Kabarole district

Initial problem identification and prioritisation

Kabarole DHMT, NW1 Oct ‘12

Examples of problems identified District Key problems Kabarole 1. Weak leadership and management of team leaders

2. Weak supportive supervision 3. Health workers’ poor commitment 4. Poor working environment

Jinja 1. Ineffective use of the traditional control mechanisms 2. Low staff motivation 3. Inadequate supportive supervision 4. Staff training not guided by available opportunities in district

Luwero 1. Lack of professionalism 2. Poor communication 3. Inadequate capacity building 4. Inadequate supplies / equipment /medicines 5. Inadequate supportive supervision

Examples of problems identified District Key problems Kabarole 1. Weak leadership and management of team leaders

2. Weak supportive supervision 3. Health workers’ poor commitment 4. Poor working environment

Jinja 1. Ineffective use of the traditional control mechanisms 2. Low staff motivation 3. Inadequate supportive supervision 4. Staff training not guided by available opportunities in district

Luwero 1. Lack of professionalism 2. Poor communication 3. Inadequate capacity building 4. Inadequate supplies / equipment /medicines 5. Inadequate supportive supervision

Problem analysis (root causes)

• Developed list of workforce problems

• Prioritized problems • Workshops to do in

depth problem tree analysis (NW2)

Luwero DHMT, NW2 Feb ‘13

Plan: Development of “bundles” of strategies

• Workshop to support development of bundles

• Integrated into district work plan

Jinja DHMT, NW2 Feb ‘13

Example of bundle (Kabarole and Jinja)

Supporting incorporation into district plans

Kabarole DHMT, NW2, Feb ‘13

Act: Implementation of workplan

• Kabarole DHMT was entrepreneurial: received funding for orientation of newly recruited staff from private sector

• Jinja DHMT: adapted supervision tools, developed plan for supervision visits, focused on support and solving problems

• Luwero DHMT: introduced duty rosters and attendance books at facilities; spot checks of facilities

Observation and reflection of bundles

Adapting the strategies during implementation…

Kabarole DHMT identified a problem with the capacity of new supervisors to provide good quality supervision and so identified and trained mentors to support each supervisor

“In the beginning some members did not understand the mentorship well. But after the discussions all members were in agreement and welcomed the mentorship idea” (Diary, 12/5/13).

Evaluation

• FGDs and IDIs to explore perceptions of DHMT, sub-district managers, health staff and relevant stakeholders and the researchers themselves on management strengthening and health workforce improvement processes and changes

• Document review: visit reports, diaries, workshop reports, DHMT minutes and plans were analysed

Effects on management strengthening

• Improved team work• In-depth problem analysis - root causes • Integrated planning, resourcing and monitoring of

processes and effects of plans • Entrepreneurial approaches • Address problems within existing resources• Inter-district learning

Effects on health workforce performance

• Better supervision of staff

• Reductions in absenteeism

• More staff appraised • Reported increases in

utilization of services

Monthly supervision visit, Jinja district

Key messages

• The management strengthening approach appears to be acceptable, effective and viable at district level.

• There is now a critical mass in the DHMT with improved problem solving and planning skills and a better understanding of workforce performance problems and appropriate strategies. This momentum needs to be sustained.

• Some improvements can be made without extra resources. With more resources even greater things could be achieved.

• Managers have proved that they can be very resourceful when implementing their own plans. They could be encouraged to be more “entrepreneurial”.

• Action research can be a powerful tool for management strengthening. Options for capitalizing on the investment made by the PERFORM are needed.

Acknowledgements

Funding from the European Commission Seventh Framework programme

Ministry of Health

District health management teams in Jinja, Kabarole and Luwero districts

Contact details for further dialogue

• Project PI: tim.martineau@lstmed.ac.uk

• Uganda team PI: sbaine@musph.ac.ug

• Project website: www.performconsortium.com

• Twitter: @PERFORMtug