The document summarizes experiences from the PERFORM project, which used action research to improve health workforce performance in Ghana, Uganda, and Tanzania. The project was conducted over four years in nine study sites across three districts in each country. It faced challenges with implementing the action research cycle across multiple contexts and recording reflection. Lessons learned included considering payment for co-researchers, dedicating researchers to each site, encouraging reflection, and determining the best way to document processes, reflection, and learning.
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What can we learn from using action research to strengthen district health management in African countries?
1. Experiences from PERFORM
Comfort Mshelia
Nuffield Centre for International Health and Development,
University of Leeds
Twitter: @PERFORMtug
Website: www.performconsortium.com
2. Introduction to PERFORM- background,
timeline, partners and study rationale
What we did- study design and approach,
action research cycle
Challenges we faced- and how we tried to
manage them
3.
4. In Sub-Saharan settings there are too few
health workers. The existing workforce could
be better utilised
Supporting decentralised management to
improve health workforce performance in
Ghana, Uganda and Tanzania
Four year project funded by the FP7 program
of the European Commission
Ghana, Tanzania and Uganda
Three districts in each country
7. School of Public Health, University of Ghana
Institute of Development Studies, University of
Dar-es-Salaam, Tanzania
School of Public Health, College of Health
Sciences, Makerere, Uganda
Swiss Tropical and Public Health Institute
Nuffield Centre for International Health and
Development, University of Leeds, UK
Liverpool School of Tropical Medicine, UK
8. Insufficient number of health workers
Health
worker
density
Country
Ghana
(2008)
Tanzania
(2006)
Uganda
(2005)
Ireland
(2008)
Physicians/
1000
0.11 0.01 0.12 3.08
Nurse,
midwife/1000
0.97 0.24 1.31 15.89
Source: World Health Organization statistics database
(http://knoema.com/WHOSDB/world-health-organization-statistics-
database?Category=1000010-human-resources-for-health&Location=1000740-
ghana)
9. Poor performance of existing staff
Country
Ghana Tanzania Uganda Ireland
Health
worker
Reach
index*
0.523 0.432 0.377 0.957
*The Health Workers Reach Index is an additive index which includes three
indicators: 1) a measure of health worker density, 2) DPT3 immunisation rate
and 3) skilled birth attendance rate.
(http://www.savethechildren.org.uk/sites/default/files/docs/HealthWorkerIndexmain_4.
pdf)
10. Help District Health Management Teams to
think strategically and to be entrepreneurial
within their resource and authority
constraints
Improve health workforce performance in the
districts
13. European partners
support Country
Research Teams
Country Research Teams
support District Health
Management Teams
District Health Management
Teams conduct action research
19. Follow up visits by
Country Research
Teams
Diaries kept by
District Health
Management Teams
Bringing District
Health Management
Teams together in
workshops
20.
21. PERFORM used action research in nine study
sites
Each district had their unique problems,
interventions, and context
This made it very complicated to go through
the action research cycle as timing of events
in the districts were not synchronized
Comparative analysis also very complex
22. Deciding on how to record the processes,
reflection, and learning required significant
dialogue among partners
Researchers did not consult District Health
Management Team on how action research
should be implemented and how processes
and reflection should be recorded
23. We used diaries which were filled in by the
District Health Management Team members
It was most difficult for the District Health
Management Team to record their reflections
‘As a group, (the District Health Management
Team) may have had a meeting and discussed a
few things then, on reflection, taken some
decisions… but then when we go into their
diaries, nothing shows. We realised that the
diaries were only capturing major activities and
training’ [Country Research Team member].
24. The District Health Management Team were
not familiar with action research
◦ It took some time before they assumed ownership
of the project
Frequent visits to the districts and other
methods (e.g. telephone calls, emails) were
used to provide guidance and support
25. Should the co-researchers (District Health
Management Teams) be paid for participating
(and held responsible)?
Should there be a dedicated researcher in
each site?
What can be done to encourage reflection?
What is the best way to record processes,
reflection and learning in action research
projects?
