This is the second in a series of three blogs each addressing a specific question on ‘How can governance be strengthened in decentralised health systems’ from the session on District Performance hosted by PERFORM at the Third Global Symposium on Health Systems Research 2014 in Cape Town. The PERFORM consortium, funded by the European Union, is supporting decentralised management to improve health workforce performance in Ghana, Uganda and Tanzania.
The best ways to support managers at district level to claim and use management decision space to strengthen health systems was an area of debate during a panel hosted by the PERFORM project at the Health Systems Global Conference in Cape Town. PERFORM deploys participatory action research approaches at district level to make better use of the current health workforce through supporting integrated human resource and management strategies. PERFORM is taking place in 3 decentralised African settings– Tanzania, Uganda and Ghana and conducting a comparative analysis across districts and countries to identify strategic management strengthening interventions for integrating HR strategies and identifying unintended consequences.
The PERFORM Ghana experience: Patricia Akweongo, University of Ghana presented on her experience of being part of the Country Research Team (CRT) that supported DMHTs to undertake a reflective action research process to improve workforce performance in 3 Ghanaian districts. She explained how the CRTs supported DHMTs to identify problems and integrate them into district plans. They prioritised the problems they wanted to address and used an iterative process to review the cause and effect of each of the problems and in many cases these related to time and staff’s ability to proactively deliver on their key tasks. For example in Upper Manya Krobo the main problem is low coverage in ANC and maternal health, women are not attending these vital services and there are problems with the roads and the community health officers tasked with service delivery were not following the protocol as they didn’t have appropriate transport. They had a contract with the local taxi office who dropped them off where they needed to be but didn’t always pick them up in time which constrained the ability of CHOs to both plan deliver on their vital work. DHMTs also highlighted how much of their time was taken up receiving visitors or waiting to receive visitors. In both cases solution were found within the district using their own resources and initiative – in the former case the taxis were requested to be more timely and in the latter and district vehicle scheduled to drop them off early while alternative arrangements were made to pick them up later. DHMTs where possible minimised hosting visitors and also used waiting time productively on other tasks. Patricia highlighted the importance for sustainability and ownership of identifying and solving problems at district level and with funding available at district level.
Models for mentoring: Kaspar Wyss from the Swiss TPH explained that most managers at district level are medically trained and don’t have exposure to HRH management skill and approaches and that these are really crucial and needs to be a focus of mentoring and support. Soraya Elloker stressed the importance of mentoring for implementers and the challenges in identifying appropriate mentors and argued that academic institutions can help with mentorship here by bringing different skills and perspectives and upgrading staff through these training and that this has worked well in the DIAHLS project. In addition to mentoring she stated there is need for further fora and mechanisms to share good practice and that there are not enough conferences for implementers. Others also highlighted the importance of developing partnerships for mentoring and that NGOs civil society, who have experience with the wider social determinants of health can offer critical expertise to support mentoring. Other options for mentoring and management that were suggested from the audience included critical incident review and failure review.
Please read the two other blogs in this series: What decision space or room for manoeuvre is available to health service managers within decentralised contexts and what key factors influence this? and How can good practice be shared across decentralised structure to improve governance structures more widely?
This blog also appears on the PERFORM website on 30 October 2014