By Joanna Raven, Liverpool School of Tropical Medicine and a member of Health Systems Global
The single biggest barrier for countries in sub-Saharan Africa to achieving Universal Health Coverage is the lack of an adequate and well-performing health workforce. This deficit can be addressed by training more new health personnel and/or by improving the performance of the existing health workforce. So far efforts have mostly focused on training new staff and less on improving the performance of the existing health workforce.
PERFORM is a research consortium funded from the European Commission Seventh Framework programme, comprising research teams from three African and three European Universities. The research focused on building local capacity and ownership for processes supporting human resource management and related health systems activities in Ghana, Tanzania and Uganda. Specifically, PERFORM supported three District Health Management Teams (DHMT) in each country, who, through a series of workshops and review meetings used Action Research to develop and then test context-specific strategies focused on improving workforce performance. Action Research involves a cycle comprising four steps – plan, act, observe and reflect. The DHMTs identified areas of health workforce performance to be improved, planned their own human resource and health systems strategies. For example, strengthening supervision through adaptation of tools, development of plans, organising transport, and including health facility management committees in supervision. These strategies all had to be feasible within the existing context. Over a period of about 18 months they implemented these strategies, and observed the impact on health workforce performance. They then reflected on how well their plans have been achieved and if necessary, revised the plans or addressed new challenges thus beginning to embed the process within their districts.
We are in the process of writing academic articles, policy briefs and other products for communicating the PERFORM approach and the outcomes of the research. In the meantime what we have learned so far can be distilled into seven main messages:
- The health workforce is an important component of complex health systems. So adopting a systems approach to human resource management is vital.
- Decisions about health system planning – and the health workforce more generally – are increasingly devolved to lower levels of authority, particularly districts. However, in practice the degree of authority available at local levels is often constrained by centrally-managed key functions such as recruitment and financing. Districts are where health systems play out and research needs to acknowledge and support the decentralisation process.
- Ownership by stakeholders and decision makers is necessary if research is to lead to change. Action research methods enabled local managers to identify, act on and monitor areas of concern related to the health workforce and empower them to make changes based on local context.
- Change for the better needs to be based on an analysis of the root causes of a performance problem. For some of the managers and health care workers involved in PERFORM this was the first opportunity that they had to identify the root causes of problems that they were experiencing, in depth, and from multiple perspectives. This needs to be the norm rather than the exception.
- Money is not necessarily the main precondition for workforce performance improvement – and in fact small changes in management practice, such as introducing log books so that there is clarity about where staff are working and what they are doing during the working day, can make a big difference.
- Building on existing systems is important. In PERFORM the human resource strategies that were introduced added value to existing systems (for example in supervision or appraisal) rather than introducing entirely new systems.
- PERFORM helped managers to recognise a wider range of choices available to them, even when there are challenges, for example budgets that arrive late. This encouraged innovation.