From 2011 to 2015 the PERFORM project focused on improving the performance of health workers in the face of their current constraints. The outcomes of this project demonstrate that enhancing health workforce performance could solve some of the major healthcare challenges in Ghana.

Staff training and regular District Health Management Team (DHMT) meetings helped to boost performance and strengthened management in Kwahu West Municipal, one of the three study districts.

The role of facility meetings organised by DHMTs has been recognized in finding lasting solutions to workforce problems. In Akwapim North, the number of parents who do not take children for immunisation has reduced due to improved monitoring/supervision visits and regular home visits.

Introducing activities such as spot checks, attendance books, event registers, movement books and staff appraisal in Upper Manya Krobo has reduced health worker absenteeism.            

Challenges faced by the DHMTs 

In Ghana, three districts were selected to participate in the PERFORM project and they identified their main problems namely; poor uptake of vaccines/immunisation and low coverage of antenatal services.

  • In Akwapim North District, there was a 40% dropout rate in the expanded programme on immunisation on the new vaccines (ROTA and Pneumo) during the first half of 2012
  • High dropout rate of pneumococcal (46.9%) and rotarix (19.1%) vaccines in Kwahu West District (attributed to the poor implementation of the new vaccination schedule)
  • Low coverage of antenatal care services in Upper Manya Krobo District

Initial analysis demonstrated that these problems were linked to factors such as attitude and a lack of necessary skills among health care staff. DHMTs agreed that addressing these factors would be the first step in finding lasting solutions to their problems and improve the quality of healthcare in the selected districts.

What we did

An action research approach was chosen to ensure that District Health Managers’ role in the study was not restricted to ‘study participants’ but, rather co-researchers and partners in achieving joint objectives. PERFORM did not provide extra funding for this but looked for interventions that fitted within the existing budget ceiling.

The project drew on the wisdom and influence of the DHMTs to gain insights in the problem, identify and implement the selected solutions. DHMTs were involved in the orientation, research design, situation analysis, close monitoring and throughout the implementation process.  

The input of health workers and users of health services was crucial in measuring the impact of the project strategies.

It wasn’t all easy

“Project funding was limited and in the initial stages District Health Management Teams would ask; What kind of project is this? How are we going to implement activities without any money? The transparency and motives of the project were questioned in the initial stages. It took us [Country Research Team] a lot of time to convince them that the project did not have money for district activities.” Samuel Amon, CRT, Ghana

Money to pay for fuel for field visits and stationary to print out review documents was also very limited. Limited financial resources for logistical costs constrained the activities of DHMTs and scope of monitoring.

Sometimes DHMTs had to postpone planned district activities in order to participate in unplanned regional strategy meetings.

“Sometimes, we had to wait for political or regional leaders to make decisions. There was one director who was always away from his office and yet, sometimes we needed his support or approval to implement certain activities. Such events delayed implementation of activities.” Samuel Amon, CRT, Ghana

Things changed

Overall, the impact of PERFORM project has trickled down to the grass root health centres and service delivery has reportedly improved.

As in many Sub-Saharan African countries, health sector financing is largely insufficient in Ghana. This lack of adequate funding is often used to justify poor service delivery. Yet DHMTs welcomed PERFORM’s approach of working within the resource constraints to improve the health system and workforce performance.

“[...] the coming of PERFORM made us aware that even when there are no funds something can be done and it is important to monitor and strategise on progress.” (DHMT member)

As part of the activities, funds were raised to train Community Health Officers to support and strengthen antenatal care services in rural areas where access to qualified midwives is usually limited.

In Ghana, some of the people who have participated in the PERFORM project are now using action research to improve other healthcare challenges such as TB prevention.


Looking forward

A dissemination workshop is planned for December 2015 to share lessons learned and recommendations with policy makers and stakeholders in Ghana.

“District Health Management Teams have specifically requested that we visit them once in a while to see how activities are going. I hope that we will have this regular interaction to sustain the legacy of PERFORM and continue to improve our health systems.” Samuel Amon, CRT, Ghana.