Martineau T, Raven J, Aikins M, Alonso-Garbayo, A, Baine S, Huss R, Maluka S & Wyss K. Strengthening health district management competencies in Ghana, Tanzania and Uganda: lessons from using action research to improve health workforce performance. BMJ Global Health 2018;3: e000619. doi:10.1136/bmjgh-2017-000619

To strengthen the capacity of district management teams to develop and deliver integrated strategies for workforce performance improvement, this study introduced an action research-based management strengthening intervention (MSI) to nine districts across three countries. It comprised two workshops, follow-up by facilitators and meetings between participating districts. The MSI was found to be an appropriate form of management strengthening for District Health Management Teams (DHMTs), and indicates strong potential for workforce performance improvement. However, to reinforce and deepen their learning and to have significant impact on workforce performance, the MSI needs to be continued with participating DHMTs and service delivery needs to be scaled up to cover many more districts in each country.

Alonso-Garbayo A, Raven J, Theobald S, Ssengooba F, Nattimba M & Martineau T.
Decision space for health workforce management in decentralized settings: a case study in Uganda. Health Policy and Planning, 32, 2017, iii59–iii66. doi: 10.1093/heapol/czx116

This paper aims to improve understanding about how district health managers perceive and use their decision space for human resource management (HRM) and how this compares with national policies and regulatory frameworks governing HRM. It compares the roles allocated by Uganda’s policy and regulatory frameworks with the actual room for decision-making that district health managers perceive that they have. Results show that in some areas District Health Management Team (DHMT) members make decisions beyond their conferred authority, while in others they do not use all the space allocated by policy. The study concluded that to improve workforce performance decentralisation needs to devolve power further down from district authorities onto district health managers. DHMTs need not only more power and authority to make decisions about their workforce but also more control over resources to be able to implement these decisions.


Mshelia, C, Le, G., Mirzoev, T., Amon, S., Kessy, A., Olikira Baine, S. and Huss, R. (2016) Developing learning diaries for action research on healthcare management in Ghana, Tanzania and Uganda, Action Research, 0(0) 1-23

Action research (AR) can be an effective form of ‘on the job’ training. However, it is critical that AR cycles can be appropriately recorded in order to contribute to reflection and learning. One form of recording is for coresearchers to keep a diary. We found no previous literature describing the use of diaries in AR in sub-Saharan Africa. We therefore use this paper to reflect on how diaries were used by district health management teams in the PERFORM project. We share five lessons from our experience. First, it is important to foster ownership of the diary by the people who are responsible for filling it in. Second, the purpose of keeping a diary needs to be clear and shared between researchers and practitioners from the very beginning. Third, diaries should be allowed to evolve. Fourth, it is a challenge for busy practitioners to record the reflection and learning processes that they go through. Last, diaries on their own are not sufficient to capture reflection and learning. In conclusion, there is no best way for practitioners to keep a diary; rather the focus should be on ensuring that an AR recording process (whether diary or otherwise) is locally owned and complements the specific practice setting.

Bonenberger, M., Aikins, M., Akweongo, P. and Wyss, K (2016) Factors influencing the work efficiency of district health managers in low-resource settings: a qualitative study in Ghana, BMC Health Services Research, 201616:12

There is increasing evidence that good district management practices can improve health system performance and conversely, that poor and inefficient management practices have detrimental effects. The aim of the present study was to identify factors contributing to inefficient management practices of district health managers and ways to improve their overall efficiency. Nineteen semi-structured interviews were conducted with district health managers in three districts of the Eastern Region in Ghana. The 19 interviews conducted comprised 90% of the managerial workforce in these districts in 2013. A thematic analysis was carried out using the WHO’s leadership and management strengthening framework to structure the results. Key factors for inefficient district health management practices were identified to be: human resource shortages, inadequate planning and communication skills, financial constraints, and a narrow decision space that constrains the authority of district health managers and their ability to influence decision-making. Strategies that may improve managerial efficiency at both an individual and organizational level included improvements to planning, communication, and time management skills, and ensuring the timely release of district funds. Filling District Health Management Team vacancies, developing leadership and management skills of district health managers, ensuring a better flow of district funds, and delegating more authority to the districts seems to be a promising intervention package, which may result in better and more efficient management practices and stronger health system performance.

Bonenberger, M., Aikins, M., Akweongo, P. and Wyss, K. (2014) The effects of health worker motivation and job satisfaction on turnover intention in Ghana: a cross-sectional study, Human Resources for Health, 2014, 12:43

Motivation and job satisfaction have been identified as key factors for health worker retention and turnover in low- and middle-income countries. District health managers in decentralized health systems usually have a broadened ‘decision space’ that enables them to positively influence health worker motivation and job satisfaction, which in turn impacts on retention and performance at district-level. The study explored the effects of motivation and job satisfaction on turnover intention and how motivation and satisfaction can be improved by district health managers in order to increase retention of health workers. Read more...

Mshelia, C., R. Huss, T. Mirzoev, H. Elsey, S. O. Baine, M. Aikins, P. Kamuzora, X. Bosch-Capblanch, J. Raven, K. Wyss, A. Green and T. Martineau (2013). "Can action research strengthen district health management and improve health workforce performance? A research protocol." BMJ Open 3(8): e003625. 

The single biggest barrier for countries in sub-Saharan Africa (SSA) to scale up the necessary health services for addressing the three health-related Millennium Development Goals and achieving Universal Health Coverage is the lack of an adequate and well-performing health workforce. This deficit needs to be addressed both by training more new health personnel and by improving the performance of the existing and future health workforce. However, efforts have mostly been focused on training new staff and less on improving the performance of the existing health workforce. The purpose of this paper is to disseminate the protocol for the PERFORM project and reflect on the key challenges encountered during the development of this methodology and how they are being overcome. Read more...

Research tools

Handbook on how to use action research to strengthen District Health Management Teams

District Health Management Team Methods manual


Case study: the PERFORM effect in Tanzania

Case study: the PERFORM effect in Ghana

Case study: the PERFORM effect in Uganda

A very short introduction to PERFORM

A summary of the methodology that we used in PERFORM

Results and recommendations from the PERFORM project in Tanzania

Summary of our comparative analysis of Uganda, Ghana and Tanzania

Research reports

Comparative Analysis Report: Uganda, Ghana and Tanzania

Uganda Country Report, Aug 2015

Tanzania Country Report, Dec 2015

Ghana Country Report, Dec 2015

Ghana, National Workshop 1 Report, Nov 2012

Ghana, National Workshop 2 Report, Mar 2013

Tanzania, National Workshop 1 Report, Oct 2012

Tanzania, National Workshop 2 Report, Feb 2013

Uganda, National Workshop 1 Report, Oct 2012

Uganda, National Workshop 2 Report, Feb 2013


Implementing a district management strengthening intervention in Ghana, Uganda and Tanzania; reflections from an Action Research project

Decision space for health workforce management in decentralised settings

PERFORM overview presentation at Second National Summit of Health and Population Scientists in Nepal. April 11-12, 2016 Kathmandu, Nepal

Introduction to the PERFORM project: Improving health workforce performance in Ghana, Uganda and Tanzania

PERFORM overview, design and methods: Presentation from our meeting in Tanzania

Experience of using diaries to encourage reflective practice among District Health Management Teams

Improving health workforce performance in Uganda: linking research and practice through action research

What can we learn from using action research to strengthen district health management in African countries?

Perform overview given at Uganda meeting August 2015

Methods and findings from Uganda

PERFORM findings from Tanzania

Media reporting

An interview with Sebastian and Tim in Uganda by NBS

PERFORM national dissemination meeting in Uganda on UBC TV


Short film on how we improved district-level health systems in Uganda

Sam Amon from Ghana talks about PERFORM and action research

Stephen Maluka on health workforce management in Tanzania