PERFORM study and findings in Tanzania

PERFORM ResearchersInstitute of Development Studies

University of Dar es Salaam, Tanzania

Aim and objectives of PERFORM study• Overall aim:

– To identify ways of strengthening decentralised management to address health workforce inadequacies in order to improve health workforce performance in sub-Saharan Africa

• Objectives:– To support health managers to carry out a situation analysis on

the health workforce performance, in the study districts – To identify areas of health workforce performance to be

improved– To support health managers to design & implement integrated

Human Resources (HR) and Health Systems (HS) strategies to improve health workforce performance

– To monitor implementation of the strategies and evaluate the impact on health workforce performance, and the wider health system.

Selection of the Study Districts

• The Country Research Team (CRT) consulted the Coordinator of District Health Services in the Ministry of Health & Social Welfare (MoHSW), who was a member of the Country Research Advisory Group (CRAG).

• The Coordinator informed CRT of the MoHSW’s policy requiring any health intervention introduced in any region of Tanzania to cover the whole region and a few districts as originally planned in the PERFORM research design.

• The CRT consulted the higher MoHSW authorities (Chief Medical Officer) who insisted on the project to cover the whole region.

• Iringa region was ultimately selected because of the accessibility advantage over the other qualified regions.

Selection of the Study Districts (Cont…..)

• Iringa has four districts – Mufindi, Kilolo, Iringa Rural and Iringa Urban districts.

• Iringa Rural though had typical rural characteristics like Kilolo district was not included because it is adjacent to Iringa Urban district

Timeline

Initial Situation AnalysisJun-Aug

2012

National workshop 1

Initial problem analysisOct 2012

National workshop 2

Development of HR/HS bundles

Feb 2013

Final Situation Analysis

Sep 2014

Implementation of bundlesMar 2013 – Aug 2014

National Workshops National workshop ONE

in Iringa 19-20 October 2012

National workshop TWO at Makambako

25-27 February 2013The CRT, CHMTs for Kilolo, Iringa Urban and Mufindi districts and the RHMT for Iringa Region attended the workshop • Received and commented

on the findings of the situation analysis

Started thinking about formulating strategies to address the identified health workforce performance problems.

The CRT, CHMTs for Kilolo, Iringa Urban and Mufindi districts and the RHMT for Iringa Region attended the workshop • Refined and finalization of

the problem trees developed by the CHMTs

Formulated the bundles of HR/HS strategies to address the identified health workforce performance problems in the districts

CRT support to CHMTs• Identification of bundles and

development of strategies to improve health workforce performance.

• Guidance to the CHMTs on how to link the problems identified in their districts with suitable strategies and activities under each strategy.

• Use of diary to record implementation of the bundles.

• During the implementation of the bundles, supportive visits to the district took place every two months in the first year and every one month in year 4. CHMTs in Iringa Urban identifying

HR/HS bundles

CRT support to CHMTs cont...

• Review meetings were scheduled for every four months during year 1 and every six months in year 2.

• Review meetings provided opportunities for the CHMT members to share their experiences in the implementation of bundles and learning from other districts. CRT, EU partner, CHMT & RHMT

members during inter-district review meeting

CRT support to CHMTs cont...

• The CHMT members also shared their experiences too and gained support in relation to the design of bundles from the Regional Health Management Team (RHMT).

• Additional support was provided by the CRT to the CHMT via phone and emails CRT members facilitating inter-district

review meeting

Benefits & unintended effects

Effects on management strengthening • Improved teamwork among CHMT members (all) • Improved participatory decisions among CHMT

members (Kilolo, Mufindi)• Improved practices for problem analyses (all) • Increased frequency and quality of supervision (all)

Benefits & unintended effects cont...

Effects on improving HW Performance• Staff skills led to better services (Iringa, Kilolo) • improved service quality (all) • Introduction of incentives to retain/motivate staff

(Mufindi, Kilolo)

Unintended Effects• Experience gained from PERFORM has trickled

down to other health services areas in the Councils (Iringa and Mufindi)

Key Challenges

• Late disbursement of funds from the central government affected implementation of the bundles (all)

• Ad hoc and competing tasks facing the CHMT members (all)

• Leadership problems at district level constraining implementation of bundles (Kilolo & Mufindi)

Key recommendations • Involving key decision makers (national and regional)

from the early stages of the project implementation.• District interactions through inter-district meetings are

important for networking and learning from each other• Involving lower levels of the health systems i.e. sub-

district staff and community representatives • Frequent meeting between researchers and district level

decision makers (CHMT) to reinforce implementation of the project