Stakeholder meeting in Tanzania
Defining the problem
A new research focus
Understanding workforce performance in a systems context
Overview of the research project concept
Aim and objectives of the research project
The countries who are involved


Defining the problem

A number of complex factors affect workforce performance. Of particular importance are the maldistribution of staff, inappropriate task allocations and poor working conditions (including training, management and support). These factors also lead to high staff losses (brain drain) from the public sector to other employers (particularly the private sector) or other countries. Understanding the nature of these factors and developing appropriate responses will both improve the performance of the existing workforce and reduce staff losses. It will also increase the effectiveness of future new health personnel trained and deployed under scaling up investments. The complexity of, and interrelations between, the factors suggests that there is unlikely to be a single universal ‘magic bullet’ strategy. Rather, sets of integrated strategies which are context-specific will be necessary. Under such circumstances it is critical that managers have the tools and skills to identify such factors and develop responses appropriate to their particular context.



A new research focus

Health systems in SSA are increasingly decentralising authority to lower levels, and in particular to districts, in planning and management. Research has been conducted, such as through the well-known Tanzania Essential Health Interventions Project (TEHIP), to understand how to allocate resources more efficiently at this level. However, there has been no equivalent research to understand how such decentralised authority can be effectively used, within available resources, to improve health workforce performance at district level. This research project will enhance our understanding of how, and under what conditions, a management strengthening intervention can improve workforce performance within their districts.

The most effective management strengthening approaches address real problems and use planning and management tools that managers are familiar with and for which they are likely to get support in future. The management strengthening intervention will employ locally available tools and draw on the concepts of action research. In particular the district managers will be supported in the conduct of a situational analysis of the workforce problem, identification of appropriate local strategies to respond to this, implementation of such strategies and evaluation – leading where appropriate to a redesign of the strategies. The research will assess the effectiveness of such an approach.



Understanding workforce performance in a systems context

The research will use a systems approach to understand both the factors affecting, and the potential for strategies developed and implemented at the district level to improve, workforce performance. It will do this in three ways:

  1. A systems approach to human resource management means using a coordinated set of strategies to improve performance (for example improving skills and reducing staff absence)
  2. A health systems approach views human resources as a sub-system alongside and closely related to other sub-systems such as information, finance, drugs and equipment. Effective human resource strategies will require complementary action in other sub-systems. For example, improving skills and reducing absence will only improve workforce performance if health personnel have adequate drugs and supplies
  3. Actions in one sub-system may have unintended consequences for another part of the system. For example, incentives to improve performance of the TB programme may lead to neglect of maternal health services. A holistic approach to workforce performance is therefore needed.



The overall structure of the research project is summarised in Figure 1 below.

Figure 1: Overview of the research project concept



Aim and objectives of the research project
The overall aim is to identify ways of strengthening decentralised management to address health workforce inadequacies by improving health workforce performance in sub-Saharan Africa.
The specific objectives are:

  1. To support health managers to carry out a situation analysis on the health workforce, with a particular focus on performance, in the study districts.
  2. To develop and test context-specific management strengthening processes, focused on improving workforce performance, which will:
    1. identify areas of health workforce performance to be improved
    2. implement integrated HR and health systems strategies feasible within the existing context, to improve health workforce performance;
    3. monitor the implementation of the strategies and evaluate the intermediate processes and impact on health workforce performance, and the wider health system.
  3. To conduct comparative analyses across districts and countries of:
    1. the management strengthening intervention to support improved workforce performance, and
    2. processes of implementing the integrated HR and health systems strategies and intended and unintended effects on health workforce performance and the wider health system.
  4. To provide ongoing communication of the research process, findings and conclusions, in order to raise awareness and change attitudes of sub-national, national and international stakeholders.
  5. To consolidate research capacity of partners on integrated approaches to workforce performance improvement and contribute to strengthening capacities of decentralised management of district health systems.
  6. To establish and maintain effective partnerships amongst academia, civil society, policy-makers, and health managers in study countries and amongst partners.



The countries who are involved

The research will be conducted in Ghana, Tanzania and Uganda. Each of these countries face major problems of inadequate health workforce. They also have decentralised management structures that offer management teams greater decision-making opportunities including in the area of human resources. The research will study how management strengthening interventions can be used, and under what conditions, to enhance workforce performance. A comparative analysis of the findings from three study districts in each country will add new knowledge as to the effect of different country contexts on these interventions. This will lead to insights into the application of the new approaches in different SSA country contexts.