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Martineau T, Mansour W, Dieleman M, Akweongo P, Amon S, Chikaphupha K, Mubiri P, Raven J. Using the integration of human resource management strategies at district level to improve workforce performance: analysis of workplan designs in three African countries. HUMAN RESOURCES FOR HEALTH 2023; 21:57. [PMID: 37488651 PMCID: PMC10367416 DOI: 10.1186/s12960-023-00838-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 06/15/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND There is a worldwide shortage of health workers against WHO recommended staffing levels to achieve Universal Health Coverage. To improve the performance of the existing health workforce a set of integrated human resources (HR) strategies are needed to address the root causes of these shortages. The PERFORM2Scale project uses an action research approach to support district level management teams to develop appropriate workplans to address service delivery and workforce-related problems using a set of integrated human resources strategies. This paper provides evidence of the feasibility of supporting managers at district level to design appropriate integrated workplans to address these problems. METHODS The study used content analysis of documents including problem trees and 43 workplans developed by 28 district health management teams (DHMT) across three countries between 2018 and 2021 to identify how appropriate basic planning principles and the use of integrated human resource and health systems strategies were used in the design of the workplans developed. Four categories of HR strategies were used for the analysis (availability, direction, competencies, rewards and sanctions) and the relationship between HR and wider health systems strategies was also examined. RESULTS About half (49%) of the DHMTs selected service-delivery problems while others selected workforce performance (46%) or general management (5%) problems, yet all workplans addressed health workforce-related causes through integrated workplans. Most DHMTs used a combination of strategies for improving direction and competencies. The use of strategies to improve availability and the use of rewards and sanctions was more common amongst DHMTs in Ghana; this may be related to availability of decision-space in these areas. Other planning considerations such as link between problem and strategy, inclusion of gender and use of indicators were evident in the design of the workplans. CONCLUSIONS The study has demonstrated that, with appropriate support using an action research approach, DHMTs are able to design workplans which include integrated HR strategies. This process will help districts to address workforce and other service delivery problems as well as improving 'health workforce literacy' of DHMT members which will benefit the country more broadly if and when any of the team members is promoted.
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Affiliation(s)
- Tim Martineau
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Wesam Mansour
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom.
| | - Marjolein Dieleman
- KIT Royal Tropical Institute, Amsterdam, The Netherlands
- Athena Institute, VU University, Amsterdam, The Netherlands
| | - Patricia Akweongo
- Department of Health Policy, Planning and Management, School of Public Health, College of Health Sciences, University of Ghana, Legon, Accra, Ghana
| | - Samuel Amon
- Department of Health Policy, Planning and Management, School of Public Health, College of Health Sciences, University of Ghana, Legon, Accra, Ghana
| | | | - Paul Mubiri
- Makerere University School of Public Health, Kampala, Uganda
| | - Joanna Raven
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
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Rodríguez DC, Balaji LN, Chamdimba E, Kafumba J, Koon AD, Mazalale J, Mkombe D, Munywoki J, Mwase-Vuma T, Namakula J, Nambiar B, Neel AH, Nsabagasani X, Paina L, Rogers B, Tsoka M, Waweru E, Munthali A, Ssengooba F, Tsofa B. Political economy analysis of subnational health management in Kenya, Malawi and Uganda. Health Policy Plan 2023; 38:631-647. [PMID: 37084282 DOI: 10.1093/heapol/czad021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 01/27/2023] [Accepted: 04/10/2023] [Indexed: 04/23/2023] Open
Abstract
The need to bolster primary health care (PHC) to achieve the Sustainable Development Goal (SDG) targets for health is well recognized. In Eastern and Southern Africa, where governments have progressively decentralized health decision-making, health management is critical to PHC performance. While investments in health management capacity are important, so is improving the environment in which managers operate. Governance arrangements, management systems and power dynamics of actors can have a significant influence on health managers' ability to improve PHC access and quality. We conducted a problem-driven political economy analysis (PEA) in Kenya, Malawi and Uganda to explore local decision-making environments and how they affect management and governance practices for health. This PEA used document review and key informant interviews (N = 112) with government actors, development partners and civil societies in three districts or counties in each country (N = 9). We found that while decentralization should improve PHC by supporting better decisions in line with local priorities from community input, it has been accompanied by thick bureaucracy, path-dependent and underfunded budgets that result in trade-offs and unfulfilled plans, management support systems that are less aligned to local priorities, weak accountability between local government and development partners, uneven community engagement and insufficient public administration capacity to negotiate these challenges. Emergent findings suggest that coronavirus disease 2019 (COVID-19) not only resulted in greater pressures on health teams and budgets but also improved relations with central government related to better communication and flexible funding, offering some lessons. Without addressing the disconnection between the vision for decentralization and the reality of health managers mired in unhelpful processes and politics, delivering on PHC and universal health coverage goals and the SDG agenda will remain out of reach.
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Affiliation(s)
- Daniela C Rodríguez
- International Health, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD 21205, USA
| | | | - Elita Chamdimba
- Centre for Social Research, University of Malawi, P.O. Box 280, Zomba, Malawi
| | - Juba Kafumba
- Centre for Social Research, University of Malawi, P.O. Box 280, Zomba, Malawi
| | - Adam D Koon
- International Health, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD 21205, USA
| | - Jacob Mazalale
- Centre for Social Research, University of Malawi, P.O. Box 280, Zomba, Malawi
| | - Dadirai Mkombe
- Centre for Social Research, University of Malawi, P.O. Box 280, Zomba, Malawi
| | - Joshua Munywoki
- KEMRI-Wellcome Trust Research Programme, Hospital Road, P.O. Box 230, Kilifi, Kenya
| | - Tawonga Mwase-Vuma
- Centre for Social Research, University of Malawi, P.O. Box 280, Zomba, Malawi
| | - Justine Namakula
- School of Public Health, Makerere University, New Mulago Hill Road, Mulago, Kampala, Uganda
| | - Bejoy Nambiar
- UNICEF Malawi, PO Box 30375, Airtel Complex Area 40/31, Lilongwe, Malawi
| | - Abigail H Neel
- International Health, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD 21205, USA
| | - Xavier Nsabagasani
- School of Public Health, Makerere University, New Mulago Hill Road, Mulago, Kampala, Uganda
| | - Ligia Paina
- International Health, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD 21205, USA
| | - Braeden Rogers
- Health Section, UNICEF Eastern and Southern Africa Regional Office, United Nations Complex, Gigiri, P.O. Box 44145-00100, Nairobi, Kenya
| | - Maxton Tsoka
- Centre for Social Research, University of Malawi, P.O. Box 280, Zomba, Malawi
| | - Evelyn Waweru
- KEMRI-Wellcome Trust Research Programme, Hospital Road, P.O. Box 230, Kilifi, Kenya
| | - Alister Munthali
- Centre for Social Research, University of Malawi, P.O. Box 280, Zomba, Malawi
| | - Freddie Ssengooba
- School of Public Health, Makerere University, New Mulago Hill Road, Mulago, Kampala, Uganda
| | - Benjamin Tsofa
- KEMRI-Wellcome Trust Research Programme, Hospital Road, P.O. Box 230, Kilifi, Kenya
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Kok M, Bulthuis S, Dieleman M, Onvlee O, Murphy R, Akweongo P, Namakula J, Banda H, Wyss K, Raven J, Martineau T. Using a theory of change in monitoring, evaluating and steering scale-up of a district-level health management strengthening intervention in Ghana, Malawi, and Uganda - lessons from the PERFORM2Scale consortium. BMC Health Serv Res 2022; 22:1001. [PMID: 35932015 PMCID: PMC9356464 DOI: 10.1186/s12913-022-08354-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 07/12/2022] [Indexed: 11/29/2022] Open
Abstract
Background Since 2017, PERFORM2Scale, a research consortium with partners from seven countries in Africa and Europe, has steered the implementation and scale-up of a district-level health management strengthening intervention in Ghana, Malawi and Uganda. This article presents PERFORM2Scale’s theory of change (ToC) and reflections upon and adaptations of the ToC over time. The article aims to contribute to understanding the benefits and challenges of using a ToC-based approach for monitoring and evaluating the scale-up of health system strengthening interventions, because there is limited documentation of this in the literature. Methods The consortium held annual ToC reflections that entailed multiple participatory methods, including individual scoring exercises, country and consortium-wide group discussions and visualizations. The reflections were captured in detailed annual reports, on which this article is based. Results The PERFORM2Scale ToC describes how the management strengthening intervention, which targets district health management teams, was expected to improve health workforce performance and service delivery at scale, and which assumptions were instrumental to track over time. The annual ToC reflections proved valuable in gaining a nuanced understanding of how change did (and did not) happen. This helped in strategizing on actions to further steer the scale-up the intervention. It also led to adaptations of the ToC over time. Based on the annual reflections, these actions and adaptations related to: assessing the scalability of the intervention, documentation and dissemination of evidence about the effects of the intervention, understanding power relationships between key stakeholders, the importance of developing and monitoring a scale-up strategy and identification of opportunities to integrate (parts of) the intervention into existing structures and strategies. Conclusions PERFORM2Scale’s experience provides lessons for using ToCs to monitor and evaluate the scale-up of health system strengthening interventions. ToCs can help in establishing a common vision on intervention scale-up. ToC-based approaches should include a variety of stakeholders and require their continued commitment to reflection and learning on intervention implementation and scale-up. ToC-based approaches can help in adapting interventions as well as scale-up processes to be in tune with contextual changes and stakeholders involved, to potentially increase chances for successful scale-up.
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Affiliation(s)
- Maryse Kok
- KIT Royal Tropical Institute, Amsterdam, the Netherlands.
| | - Susan Bulthuis
- KIT Royal Tropical Institute, Amsterdam, the Netherlands.,Athena Institute, VU University, Amsterdam, the Netherlands
| | - Marjolein Dieleman
- KIT Royal Tropical Institute, Amsterdam, the Netherlands.,Athena Institute, VU University, Amsterdam, the Netherlands
| | - Olivier Onvlee
- KIT Royal Tropical Institute, Amsterdam, the Netherlands
| | - Rebecca Murphy
- Department of Psychology, Maynooth University, Kildare, Ireland
| | - Patricia Akweongo
- Department of Health Policy, Planning & Management, School of Public Health, College of Health Sciences, University of Ghana, Legon, Accra, Ghana
| | | | - Hastings Banda
- Research for Equity and Community Health (REACH) Trust, Lilongwe, Malawi
| | - Kaspar Wyss
- Swiss Centre for International Health, Swiss Tropical and Public Health Institute, Allschwil, Switzerland.,University of Basel, Basel, Switzerland
| | - Joanna Raven
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Tim Martineau
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
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