Thursday, 05 Nov 2015

Countries facing a shortage of health human resources often rush to increase the number of health workers. However often the financial resources are not readily available to increase the numbers of staff and increased numbers are often counterbalanced with the poor performance of the existing workforce.

PERFORM has strengthened the capacity of Council Health Management Teams (CHMTs) to improve the supervision and performance of existing health workers in Tanzania.

PERFORM’s approach proves that if the available (human and financial) resources are used appropriately, the quality of healthcare can improve significantly.

Challenges in the health workforce

Each of the three districts in Tanzania that were part of the PERFORM project prioritized a problem to be addressed; (a) in 2011 almost half of women delayed booking their first antenatal care visit (Kilolo District), (b) high prevalence of HIV/AIDS (Mufindi District), and (c) low coverage and quality of Care and Treatment Clinic services (for HIV) (Iringa Urban).

Further analysis revealed that the biggest barrier to scaling up health services was the lack of an adequate and well performing health workforce.

On the surface, shortage of human resource seems to be the biggest challenge in the health sector and yet the performance of existing health workers was not optimal because they were poorly supported.

“PERFORM agrees that increasing the number of health workers is important. But how are you managing the ones you have?” Peter Kamuzora, Country Research Team (CRT), Tanzania.

Rising to the challenge set by the CHMT

Action research was specifically chosen for the PERFORM project in order to stimulate, and ensure maximum participation of, different stakeholders. Regional Health Management Teams (RHMTs) were invited to participate in review meetings and inter-district meetings were organised to increase collaboration among the district teams.

This multi-directional problem solving approach encouraged different stakeholders to participate not only in the identification of the problems and strategies to overcome them but also in the implementation and evaluation of the identified strategies.

The nature of the PERFORM project was to strengthen health workforce performance – this is particularly pertinent to the CHMTs as this is one of the day to day challenges that they face.

District Health Managers were encouraged to use “diaries” to document their activities throughout the project life cycle. These records were used to reflect, share lessons learned and pave the way forward during monthly review meetings involving researchers and CHMT members.

It wasn’t all easy

All districts depend on central government funds to implement district based health activities in their comprehensive council health plans (CCHPs). During the implementation of the PERFORM project, funds that were expected in July were disbursed in December. Even though such delays did not completely halt the implementation of activities they were inconvenient.

District Health Managers have very busy schedules and this affected the amount of time they allocated to the project activities. In other instances, District Health Managers had to cancel some activities to participate in PERFORM activities. Unplanned activities such as seminars and workshops affected the implementation of district health plans in Tanzania.

During the project there have been a succession of three District Health Officers in Mufindi district. These frequent leadership changes affected the progress in planning, budgeting for the intervention and the implementation of the project in general.

What effect did we have?

"An official from the Ministry of Health asked us to summarize the key lessons and recommendations from this project to guide the ministry in improving health worker performance. This shows that the Ministry not only appreciates our work, they are also willing to learn from our experience.” Peter Kamuzora, CRT, Tanzania

The quality of supervision of health facilities has reportedly improved over the period 2011 to 2015. Before this project, supervision visits were ad hoc. Now, CHMTs take time to talk to the health workers when they visit the health facilities.      

“Honestly, there are changes, nowadays we have what we call supportive supervisions. They [CHMTs] have moved away from the old style of perceiving a worker always knows nothing. That was an embarrassment”. (Health centre staff member)

“Their supervision is instructive by nature. They [CHMTs] look [at] for example the way we fill in different reports; in case of mistake then they correct us”. (Health centre manager)                          

As a result of implementation of the interventions in Mufindi district, community awareness, willingness and demand for HIV services increased considerably and the quality of services also improved.                                           

“There is progress in that most of the children born from mothers who got PMTCT services were HIV negative.” (Health facility staff)             

As far as workforce performance is concerned, there were a number of perceived positive changes. The quality and coverage of CTC services was reported to have improved significantly. It was evident that the CHMT members in collaboration with stakeholders had renovated and constructed CTC buildings, as well as established new CTCs.

Overall, the PERFORM project has enhanced the understanding of how, and under what conditions, a management strengthening intervention can improve workforce performance using limited resources.           

Moving forward

The review meetings have proven to be a very important platform to reflect, strategise and share lessons. The participation of RHMTs has particularly been commended as a very crucial resource in these meetings. CHMTs are hoping that these meetings will continue.

“I am hoping that the different policy makers will embrace the achievements and challenges of this project to improve health worker performance and strengthen health systems in Tanzania. The action research approach in particular could be a very useful tool in solving health sector challenges in Tanzania.” Peter Kamuzora, CRT, Tanzania