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Strengthening health district management competencies in Ghana, Tanzania and Uganda: lessons from using action research to improve health workforce performance


Background To achieve Universal Health Coverage (UHC), more health workers are needed; also critical is supporting optimal performance of existing staff. Integrated human resource management (HRM) strategies, complemented by other health systems strategies, are needed to improve health workforce performance, which is possible at district level in decentralised contexts. To strengthen the capacity of district management teams to develop and implement workplans containing integrated strategies for workforce performance improvement, we introduced an action-research-based management strengthening intervention (MSI). This consisted of two workshops, follow-up by facilitators and meetings between participating districts. Although often used in the health sector, there is little evaluation of this approach in middle-income and low-income country contexts. The MSI was tested in three districts in Ghana, Tanzania and Uganda. This paper reports on the appropriateness of the MSI to the contexts and its effects.

Methods Documentary evidence (workshop reports, workplans, diaries, follow-up visit reports) was collected throughout the implementation of the MSI in each district and interviews (50) and focus-group discussions (6) were conducted with managers at the end of the MSI. The findings were analysed using Kirkpatrick’s evaluation framework to identify effects at different levels.

Findings The MSI was appropriate to the needs and work patterns of District Health Management Teams (DHMTs) in all contexts. DHMT members improved management competencies for problem analysis, prioritisation and integrated HRM and health systems strategy development. They learnt how to refine plans as more information became available and the importance of monitoring implementation. The MSI produced changes in team behaviours and confidence. There were positive results regarding workforce performance or service delivery; these would increase with repetition of the MSI.

Conclusions The MSI is appropriate to the contexts where tested and can improve staff performance. However, for significant impact on service delivery and UHC, a method of scaling up and sustaining the MSI is required.

  • intervention study
  • health services research
  • public health

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  • Handling editor Stephanie M Topp

  • Contributors All authors were involved in conceptualising this paper. All authors were involved in the design and implementation of the project and the data collection and analysis for the evaluation. TM and JR drafted the paper. All authors reviewed and provided critical inputs to the drafts. All authors read and approved the final manuscript.

  • Funding This document is an output from the PERFORM project: improving health workforce performance in Ghana, Tanzania and Uganda, funded by the European Commission’s Seventh Framework programme (FP7 Theme Health: 2010.3.4-1, grant agreement number 266 334). The project involved a consortium of six partners: Liverpool School of Tropical Medicine, University of Leeds, University of Ghana, Swiss Tropical and Public Health Institute, Institute of Development Studies, University of Dar-es-Salaam, School of Public Health, Makerere University.

  • Disclaimer The views expressed and information contained in the article are not necessarily those of or endorsed by the EC, which can accept no responsibility for such views or information or for any reliance placed on them.

  • Competing interests None declared.

  • Patient consent Not required.

  • Ethics approval Liverpool School of Tropical Medicine, UK (reference number 12.09); Makerere University, College of Health Sciences, School of Public Health, Higher Degrees, Research and Ethics Committee, Uganda; National Institute for Medical Research, Tanzania; Ghana Health Service Ethical Review Committee.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement No additional data are available.

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