Workplan development
During the implementation of PERFORM2Scale, 43 workplans were developed across the three countries over two or three cycles (see Table 3). Several districts in Uganda and one in Malawi used the same problem in more than one cycle, but the workplans were modified in the second cycle – even if only slightly – and were therefore treated as different workplans. This number of workplans was developed despite the arrival of the COVID-19 pandemic in 2020 which led to some disruption to the schedule of the MSI workshops, support visits and delays to implementation of the workplans.
Table 3: Number of MSI workplans developed by country and district group
District group (DG)/country
|
#Districts
|
#MSI cycles
|
Total # workplans
|
Ghana
|
|
|
|
DG1
|
3
|
2
|
6
|
DG2
|
3
|
1
|
3
|
DG3
|
4
|
1
|
4
|
Uganda
|
|
|
|
DG1
|
3
|
3
|
9
|
DG2
|
3
|
2
|
6
|
DG3
|
3
|
1
|
3
|
Malawi
|
|
|
|
DG1
|
3
|
2
|
6
|
DG2
|
3
|
1
|
3
|
DG3
|
3
|
1
|
3
|
Totals
|
28
|
14
|
43
|
Note: District Group (DG) is composed of three neighbouring DHMTs. For more details see Additional File 3. In DG3 in Ghana 2 workplans were developed (one for each subdistrict) in Atiwa district.
The findings represent the decisions made by the DHMTs related to the problem analysis and subsequent design of a relevant workplan and the use of the guidance in the planning table for all 43 MSI cycles (see Table 2). Some examples, where relevant, are presented for illustration.
1. Type of core problem selected
Out of the 43 MSI cycles there were 21 (49%) problem statements which are based on ‘service delivery’ (SD) problems e.g., ‘low case detection of neglected tropical disease (Yaws)’; 20 (46%) based on ‘human resource’ (HR) problems e.g., ‘high-level absenteeism among health workers’; and two (5%) based on general management (GM) problems. The two GM problems– both from Malawi - included ‘Late data entry to DHS2 (the information system)’ and ‘departmental heads do not compile and submit descriptive reports’.
Whereas the overall split between SD and HR problems is even, when disaggregated by country there is a clear difference between Ghana where all 13 (100%) problems were framed as relating to service delivery and between Malawi where 75% of the problems (9/12) were framed as relating to HR. In Uganda, there was a more even mix with 11 of the 18 (61%) problems being related to HR. Some switching by the DHMT after the first MSI cycle from SD to HR related problems in subsequent cycles (but not the other way around) was observed in Uganda. Some districts continued with the same problem (eg low tuberculosis cure rate in cycles 1 and 2 in Luwero, Uganda; and Ntchisi and Salima districts in Malawi worked on improving staff appraisal in both Cycles 1 and 2), though with improved workplans as the problem was not fully addressed in the first cycle. In Cycle 2, Yilo Krobo district (Ghana) continued working on the problem selected for Cycle 1 (Yaws case detection) but added other Neglected Tropical Diseases (NTDs) (Leprosy and Buruli Ulcer).
2. Clear link between core problem and workplans
There was a clear logical link between the core problem selected and the workplan eventually produced in all 43 MSI cycles, though not all factors identified as contributing to the problem were covered by the workplan. Some of the problem areas could not be addressed within the constraints of the MSI cycle (resources, time or authority) or may not have been high priority.
3. Consideration of gender
All but three (7%) workplans contained at least one reference to gender. This was mainly in relation to health staff and it was often simply noted that equal opportunity policies would be followed. However, there were some more specific factors noted such as the challenges for women using motorcycles for fieldwork in Luwero district, Uganda (Cycle 1). Nakaseke district (Uganda, Cycle 1) DHMT included strategies to improve fairness in absence management and to better disaggregate absence data by gender. Gender was also considered in service delivery elements of some plans such as differently tailored messages regarding antenatal care (ANC) attendance for males and females and the involvement of men in ANC services in Suhum district in Ghana in Cycle 1.
4. Presence of indicators in workplans
Almost all (42/43 – 98%) workplans included at least one indicator for monitoring and evaluation and many included an indicator for each strategy in the workplan. One example from Fantekwa district, Ghana (Cycle 1) demonstrated clear strategic thinking in relation to improving staff retention. It had an activity of ‘Identify and implement both financial and non-financial incentive packages that can be contained in the District Health Authority annual budget’ for which the expected change was ‘staff motivated to accept postings in rural areas’ (Column D in the workplan – see Fig 2) and the indicator was ‘number of vacancies in selected facilities filled with staff’.
5. Use of HR strategy
All workplans – regardless of problem type (SD, HR or MD) – included one or more types of HR strategy (availability, direction, competencies and rewards/sanctions). In a few cases (6 in Ghana, 3 in Uganda and 2 in Malawi) it was necessary to review the workplans at activity level to make the categorisation. For example, Yilo DHMT (Ghana, Cycle 2) had included the activity of ‘Institute rewards for well-performing staff’ (categorized as ‘Rewards/Sanctions’) to support the broader strategy of ‘Use of health workers to search for NTD cases’ in order to address the problem of ‘Low NTDs case detection’.
On average nearly three out of the four categories of HR strategy/activity were included in the workplans (see Table 4 below), with a minimum of 2 HR categories in 15 of DHMT workplans and a maximum of 4 HR categories in 10 DHMT workplans. The inclusion of strategies related to ‘direction’ (42 – 97%) and ‘competencies’ (39 – 93%) was common in all intervention districts in the three study countries. The use of strategies related to ‘availability’ was common in Ghana at 92%; less common in Uganda at 39% and only 8% in Malawi. The use of strategies related to ‘rewards/sanctions’ was common in Ghana (85%) and less in Malawi and Uganda (both at 50%).
Table 4: use of HR strategies by category and average per workplan
Categories of HR strategies
|
Availability
|
Direction
|
Competencies
|
Reward/
Sanction (Incentives)
|
Av #HR categories per workplan
|
Ghana
|
12/13 (92%)
|
13/13 (100%)
|
13/13 100%)
|
11/13 (85%)
|
3.77/4 (94%)
|
Malawi
|
1/12 (8%)
|
11/12 (92%)
|
10/12 (83%)
|
6/12 (50%)
|
2.33/4 (58%)
|
Uganda
|
7/18 (39%)
|
18/18 (100%)
|
17/18 (94%)
|
9/18 (50%)
|
2.83/4 (71%)
|
Totals/av
|
20/43 (47%)
|
42/43 (97%)
|
39/43 (93%)
|
20/43 (60%)
|
2.98/4 (75%)
|
An example of a multi-strategy workplan (including all four types of HR strategy) is found in Fantekwa District in Ghana for Cycle 1. The DHMT identified low out-patient department (OPD) attendance as the problem. Based on their problem analysis, they identified multiple strategies to include in their workplan which covered availability (lobbying for more enrolled nurses and improving retention through offering study leave and reposting staff to urban areas after serving two years in rural area; and improving attendance through regular supervision); improving direction through job description orientation and staff appraisal; improving competencies in “customer care”; and an award for the best performing staff member (reward).
In addition to the mix of categories of HR strategy, there were often multiple strategies within one category. For example, the workplan of Bunyangabu District (Uganda, Cycle 2) aimed to reduce malaria positivity rates through two complementary strategy/activities to improve ‘direction’: 1) ensuring that facility in-charges included malaria management in schedules of duties and performance plans of health workers; and 2) supervising and mentoring Village Health Teams (VHT) with a focus on malaria prevention). Two complementary strategies were also used to improve the ‘competencies’ of District Health Teams through the use of key malaria prevention guidelines and the provision of training for health assistants on key messages for sensitising VHTs on malaria prevention.
6. Use of health systems strategy
Most workplans (32/43 – 74%) included at least one HS strategy that complemented the HR strategy (see Table 5). For example, Fantekwa’s (Ghana) Cycle 1 workplan to increase OPD attendance (described above) includes the strengthening of community engagement (classed as an HS strategy) to increase demand. Salima DHMT (Malawi, Cycle 1) complemented several HR strategies (including clearer direction and on-job training) to improve supervision with the provision of mobile phones and better transport.
Table 5: Number of workplans including HS strategies by study country
Inclusion of HS strategy
|
HS strategies
|
Ghana
|
12/13 (92%)
|
Malawi
|
9/12 (75%)
|
Uganda
|
11/18 (61%)
|
Total/average
|
32/43 (74%)
|
Overall, Ghana and Malawi MSI workplan had more HS strategies (12/13 and 9/12 respectively) while Uganda MSI workplans had a more even mix of both HR and HS strategies. Combining HR and HS strategies does make the workplan more complex, with Fantekwa DHMT’s workplan (Ghana, Cycle 2) including 14 different strategies, but most workplans were less ambitious.