From 2011 to 2015 the PERFORM project used a participatory action research approach to strengthen District Health Management Teams’ (DHMT) capacities to improve workforce performance in Uganda.

PERFORM created a platform for DHMTs to collaborate and share knowledge/ experiences with their counterparts in other districts. These inter-district interactions stimulated performance and also benefited districts that were originally not involved in the implementation of PERFORM. For example, when the DHMTs from Nwoya District visited Kabarole District, they were impressed by the activities and they decided to adopt Kabarole’s work plan.

Evaluation reports show that supervision visits have improved substantially as a result of the project. Staff have been motivated to keep the health facilities clean, supervisors spend more time at facilities to help solve problems, medicine stock-outs have significantly reduced among many other positive effects.                           

Challenges faced in Uganda

In general, all the districts involved in PERFORM lacked a well-performing health workforce.

In Kabarole District, four key problems were identified namely; (a) leadership and management of team leaders, (b) strengthening of support supervision, (c) enhancing health workers’ commitment, and (d) improving working environment.

In Jinja District, four problems were identified namely; (a) ineffective use of the traditional control mechanisms, (b) low staff motivation, (c) inadequate supportive supervision, and (d) staff training that is not guided by available opportunities in the district.

In Luwero District, five problems were identified namely; (a) lack of professionalism, (b) poor communication, (c) inadequate capacity building, (d) insufficient medicines/equipment/supplies, and (e) inadequate Support Supervision. 

An abrupt supervision visit conducted by Luwero District Health Officer in April 2012 found that 6 out of 10 in-charges were not at the health facility during working hours. At some health centres, there were no health workers to attend to the patients due to rampant absenteeism. (Luwero DHMT meeting minutes 16/04/2012)

Tackling the challenge

The DHMTs worked with health staff to identify the root causes of the problems.

CRTs supported DHMTs to discuss the problem analysis with the other districts in PERFORM (inter-district meetings). Some DHMTs were able to share the approach with other districts outside of PERFORM.

Initial situation analysis: Researchers supported the DHMTs to conduct a situation analysis where they identified health workforce performance problems in their districts.

Problem analysis:In a series of facilitated meetings and workshops, the DHMTs prioritised the problems and then analysed the root causes of these problems.

Development of a mixture of strategies to address problems:In a facilitated workshop, the DHMTs then developed human resource and health system strategies to address these problems.

Implementation of the strategies: The strategies were implemented over a period of 18 months. 

Evaluation: In each district, qualitative and quantitative research methods were used to assess how DHMTs changed the way that they work, and the effect on workforce performance.

It wasn’t all easy

Implementation of some of the planned strategies was delayed due to lack of funding. In Kabarole, for example, the project had hoped to engage Health Unit Management Committees in supervision but this did not take off as planned because the financing was later than anticipated.

There was anxiety when the District Health Officer in Kabarole quit his job to pursue further studies. This could have thrown the project off course. However, a member of the DHMT was selected to temporarily fill this position. This mitigated any possible decision making delays and challenges that usually come with sudden leadership changes.

Change started to happen            

Luwero DHMTs reactivated the quality improvement teams; Jinja started to recognise best performing staff and facilities, and introduced the attendance book; and Kabarole introduced spot check supervision visits. These ‘minor’ interventions have significantly reduced health worker absenteeism and improved workforce performance at health centre level.

In Kabarole District, members of the DHMT reported that the PERFORM project built their capacity to identify problems in their district, perform in-depth analysis of problems, and find solution.                       

“Through PERFORM I realized that before you start crying of a problem you first identify what the problem is, find out what is the root cause and if you find one root cause don’t say that is that, go deeper, think about it deeper.” (DHMT member)    

This research found that districts receive substantial technical support from different development partners and attributing success to one project is usually hard but, several health workers correlated the improvement in supportive supervision with the PERFORM project.

Hopes for the future 

Some members of the DHMTs would like support to continue exploring PERFORM’s problem solving approach and more facilitated communication between participating districts to share experiences.

The country research team is eager to explore opportunities to stay in touch with DHMTs and follow their progress. The purpose is to know whether the DHMTs will continue to use the skills they have acquired through this project to improve health systems in their localities. The CRT will continue to engage at the national and international levels.

“We [the country research team] plan to meet the Director of General of Health Services and the European Commission to share PERFORM’s findings and recommendations. We hope that they will take the key lessons and interventions forward, and replicate them in all districts of Uganda.” Saul Kamukama, Country Research Team, Uganda.