PERFORM Districts Posting Impressive Results

Partnership Forming and Support being Realised In a bid to effectively implement their bundles of human resource and health systems strategies, the districts have worked within their environment and sought partnerships and support. So far, these efforts are yielding impressive results in the areas of support for training, support supervision and other bundles. In Kabarole district, Baylor Childrens Foundation has taken up the training of health workers in support supervision, which has been done successfully. In Jinja, allocation of funds for supervision has improved and increased support supervision. Funds have been secured from the GAVI Alliance for immunisation supervision while funds have also been secured from The Global Fund to Fight AIDS, Tuberculosis & Malaria, for TB supervision. Jinja district also received funding from the Uganda AIDS Commission and conducted training in M & E to improve the skills of the health workers. The recent M & E training has increased the capacity of in-charges to look at data and see where gaps exist, one DHMT member noted. Luwero district has been able to conduct regular support supervision with support from USAID-funded Strengthening Decentralisation for Sustainability (SDS) initiative. Health Sub District in-charges have also been empowered to appraise their staff. By the time of the visit, Luwero had developed a new supervision tool which is expected to capture more information than the old tool. For the three districts; the end is not yet near, but progress made is impressive. In Jinja, where the bundles consisted of strengthening the appraisal mechanism and strengthening support supervision, resources have been identified and allocated to support supervision. As one member of the Jinja team noted, PERFORM does not introduce anything new. What it does is to activate us, do the things we are expected to do. In Kabarole, one element of the bundles was increasing the number of supervisors, 12 new supervisors were recruited and mentored. Management skills have actually improved; judging from the past when things were in a mess at some facilities. Now you find things done well, one member of the Kabarole team pointed out. The district has also put in place a reward scheme to recognize the best performing staff/facility. Appraisal has also improved, especially how it is conducted. Those days we used to do appraisal just for the sake of it, but now we do it with meaning, another member of the Kabarole team emphasized.

How Small Deliberate actions can Lead to Amazing Changes It was a day for sharing successes, innovations and interesting experiences in the journey to implementing their bundles of human resources/health systems strategies. Members of District Health (Management) Teams from Luwero, Jinja and Kabarole; the three districts where the Improving Health Workforce Performance (PERFORM) project is implemented, on November 15th 2013 converged at Kolping Hotel in Kampala.
Tanzania and Uganda

District teams during group discussions at the meeting

The Performer is a Publication of the Uganda team of the PERFORM Project ; Improving health workforce performance in Ghana,

The Performer Issue 2: December 2013 In Luwero district, the open appraisal system was re -instated. Before PERFORM came our core problem was absenteeism but after PERFORM we realized we could do a number of things without more resources. We were ranked very low, but now we have improved to 9th position up from 56th position, said one Luwero team member. PERFORM didnt give us new things, but opened our eyes, yet another one asserted. Looking forward districts are planning to strengthen implementation of their bundles by; improving management skills of heads of units, re-activation quality improvement teams, improving faulty payroll, improving communication between the DHMTs and the PERFORM Country Research Team, inducting Health Unit Management Committees, expanding the responsibilities of the rewards and sanctions committee, explore opportunities for training health managers in health performance management, engaging district leadership to support capacity building of health workforce in leadership and management.

DHMT Experiences and Challenges in Using the Diary

Documentation and Information Sharing within the DHMTs Documentation and information sharing is a key element in the implementation of the PERFORM project, for it facilitates reflection and learning across team members. Documentation in PERFORM is mainly done through recording of key learning details of events in diaries at each of the three DHMTs. District Experiences using the Diary so far For purposes of clarity, the composition of the district teams differs across the three districts; Luwero and Kabarole districts have District Health Management Teams (expanded to include Health Sub district in-charges) while Jinja has a District Health Team (only includes officers based at the District Health Office) by Sept/Oct 2013 when we last visited. This composition has therefore impacted how the dairy has been used. The Luwero diary is a dairy on the road; moving from one health sub district to another. This therefore means that at the time it is in one HSD (say Nyimbwa), others are not able to access it until someone at headquarters deliberately makes sure it leaves Nyimbwa or when there is a meeting and the person from Nyimbwa carries it along. In this mix too, is the factor of time constraints on the part of the health workers. The implication is that even writing in the book may not happen. Although the teams reported that it has improved sharing information within the DHMT, its accessibility is still a major challenge. In Luwero, the travelling diary had been to Kalagala HSD for long, before it found its way to Nyimbwa. The team in Nyimbwa though didnt know how to fill it in. We still need to start using Facebook for online sharing, said some members of the Luwero DHMT. Although the Jinja diary is based at the District Health Office within easy access to the DHT members, documenting is still a challenge. As we go out, most of us when you come back you try to write. We have been working out of office most of the time (morning to evening) and not getting time to enter this in the diary.

The Luwero diary has undergone metamorphosis to accommodate reflection and learning Several people wait to use it at the same time; sometimes people keep it in their offices and you have to be keen to look for it, one member noted. Indeed the last entry then was on 23/09/2013 while the one before that was entered in May 2013. The Kabarole team has designated one member of the DHMT; Tonny Mugisa to keep the diary and spot things that should go into the diary and enter them. They also noted that they have challenges with the format. The reflection column; we are not really sure all people would understand what to put there, noted that DHO, Richard Mugahi. All is not lost however, despite all the challenges, the diary is still appreciated. Me I have learnt something from that book. It doesnt target only meetings; it also captures things from facility visits. It is also a centre of sharing by the DHMT one member of the Kabarole DHMT said. It is a good book but some of our members have not embraced it because a lot has been done but not written in the diary. Some visitors came and saw it and they liked it a lot, they thought it is a very good book. The fact is that there are many things done but few are written is clear testimony that there is something wrong, yet another added. In all the three districts, there were suggestions for improvement in this area and they included the following:

Using the diary should be put on the monthly meeting agenda to review what has been written in the diary. Trying out Facebook to go hand-in-hand with the book/diary in the district where the book takes long on its journey from one place to another.

The Performer is a Publication of the Uganda team of the PERFORM Project ; Improving health workforce performance in Ghana,

Tanzania and Uganda

The Performer

Issue 2: 2013

Makerere University School of Public Health Successfully Hosts Third PERFORM Consortium Meeting
The PERFORM consortium consists of three African institutions; Makerere University (Uganda), University of Dar es Salaam (Tanzania) and University of Ghana (Ghana). Each of the three institutions is paired with a European partner with whom they collaborate in the implementation of the Action Research activities; Liverpool School of Tropical Medicine with Makerere University, University of Leeds with University of Dar es Salaam and Swiss School of Tropical and Public Health with University of Ghana. The three countries where PERFORM is conducted (Ghana, Tanzania and Uganda) face major problems of inadequate health workforce. They also have decentralised management structures that offer management teams greater decision-making space including in the area of human resources. PERFORM is studying how management strengthening interventions can be used, and under what conditions, to enhance workforce performance November 18th 22nd 2013, all partners converged at Ridar Hotel in Seeta near Kampala to take stock of the previous year as well as plan for the subsequent year. This is the last consortium meeting (CW3) for the action research project that ends in 2015. PERFORM (Improving Health Workforce Performance) is an action research project that supports District Health Management Teams in the three countries to carry out situation analyses on their health workforce focusing on performance. Teams then develop and test contextspecific management strengthening processes, focused on improving workforce performance (identify areas to be improved, implement integrated human resource and health systems strategies within existing contexts) and monitor the implementation of the strategies. Country progress reports indicated that all the three countries are in the process of implementing bundles of human resource and health system strategies with varying degrees of success and challenges. While in some countries, the documentation of experiences and reflections by the district teams( a key element in action research) is still weak; in some settings like Tanzania districts lack leadership to manage the process of implementation. Successes include noticeable innovation in the implementation of the bundles of strategies, including in resource mobilization, Country Research Teams being creative around provision of support as well as a general

The MUSPH team with the European partners during a group discussion. Back to camera is Dr. Sebastian Olikira Baine the PI

appreciation of the approach by the district and national technical leadership. With just less than two years of the project left, a big part of the discussion at the consortium meeting focused on how best comparative analyses across countries and districts will be conducted and how lessons learnt will be shared across the consortium and globally. The comparative analysis of the findings will add new knowledge as to the effect of different country contexts on these interventions, hopefully leading to insights into the application of the new approaches in different Sub Saharan Africa country contexts. The CW3 meeting also involved visits to two of the three sites where PERFORM is implemented in Uganda; Luwero district and Jinja district. The visits involved sharing of progress, successes and challenges between the consortium members and the district health management teams. This focused on technical review of bundles, action research and documentation.

A Luwero field visit discussion. In the meeting were consortium members from Leeds, Liverpool, Ghana, Switzerland, Tanzania and Uganda

The Performer is a Publication of the Uganda team of the PERFORM Project ; Improving health workforce performance in Ghana,

Tanzania and Uganda

The Performer Issue 2: December 2013

District Support Visits Reveal Impressive Progress and Growing Enthusiasm

Strengthening Support Supervision yields Results for Jinja District
Through strengthened support supervision, there is observed improvement in the performance of health workers. One of the districts broad objectives was to strengthen the appraisal system as one of the ways of improving staff performance in the district. The district now has an effective appraisal system and all staff were appraised at the time of the support visit. The timely appraisal enabled the team to identify and know those who were not working, according to the discussion with the Country Research Team (CRT). The district team therefore reported some improvements in conducting the appraisal process, although some more support is still needed.
Some members of the Jinja DHT during the support visit meeting

Controlling Arrival and Departure at the Health Facility Improves staff Availability
In the months of September and October, the Country Research Team (CRT) conducted support visits to the three districts. The discussions held during the visits indicated the enormous effort that DHMTs have put in to implement their bundles. In Luwero district, the DHO, Dr. Joseph Okware said that the objective of the partnership is now very clear to all; even at facility level. We are deliberately pursuing change for the better. It cannot be left to luck but need to focus on a few things. The district appreciates where it is; understanding its position and working through the why to improve. He said PERFORM has worked to sensitise the team on weak performance, but although they believe they are on the right track, they still had challenges in data management. The district has also been able to conduct regular support supervision with support from USAIDfunded Strengthening Decentralisation for

Four people have already faced the disciplinary committee and two of these accepted that they were ineffective and promised to style up. However, they were being followed up to ensure that they are available at their workstations said the DHMT members present at the meeting. Good Practice: Good performers have been motivated by the DHO; recognizing in-charges who performed well at Kakaire, Kakira and Lukola Health Centre IIIs. The recognition was at a public meeting (during a workshop) in front of everybody and we believe this motivates.

Sustainability. Health Sub District in-charges have also been empowered to appraise their staff. By the time of the visit, Luwero had developed a new supervision tool which is expected to capture more information than the old tool.

The Performer is a Publication of the Uganda team of the PERFORM Project ; Improving health workforce performance in Ghana,

Tanzania and Uganda

From page 1

Partnerships Forming...

Kabarole PERFORM progress on a Rollercoaster

The Kabarole team has formed five supervisory teams each of four members, with each team supervising specific areas. The team said it is still concerned with improvement of leadership and management since this is where results come from. Health Sub District (HSD) in-charges have been attached to the District Health Office to know and learn what happens at top management. They also chair Monday morning meetings as a way of building potential. their management and leadership

An element in one of their bundles is to increase the number of staff present at work. In realising this, attendance monitoring has been instituted with arrival and departure books put at every health facility for this purpose. Letters of caution have also been issued to those found not performing to the expected standards. The team reported that this has reduced on absenteeism. Regular meetings at Health Sub District (HSD) and Health facility level are also happening, although members mentioned that the quality of meetings may be an area that needs improving.
Luwero DHO, Dr. Joseph Okware with part of his team

The DHO has initiated mentorship of HSD incharges for 2 days for each in-charge; they can see how things are done so that there is no leadership gap. When the DHO is not there, any of the DHT members can be in charge and it is working out well, one of the DHMT members noted. Innovation: the DHO has special meetings with the medical doctors; every two weeks on weekends. He meets them at social places and they discuss among others things, management issues. If you do not support them socially, even If you put in more money they can resign. Someone else can match what you are paying, said the DHO.

The Performer is a Publication of the Uganda team of the PERFORM Project ; Improving health workforce performance in Ghana,

Tanzania and Uganda

The Performer Issue 2: December 2013 From page 5...

Kabarole on Rollercoaster progress

Innovation: the DHO holds special meetings with the medical doctors; every two weeks on weekends. He meets them at social places and they discuss among others things, management issues. If you do not support them socially, even if you put in more money they can resign. Someone else can match what you are paying, said the DHO.

the HSD in-charges are expected to pass on the knowledge and skills to the lower levels. The DHMT also agreed to have junior staff as in-charges as long as they have leadership qualities. These are attached to senior mentors (about 20) who have been trained in complete mentorship package

Whatever mentorship and support happens,

Some Tips on recording Reflections in the Diary

What does reflection involve? During the October district Support visits and the interaction with other PERFORM districts, it was observed that recoding DHMT experiences in the diary is still a challenge. Specifically, it was noted that the area of reflection is quite weak. In the following article, are some tips on how to improve our reflection. When we reflect, we consider deeply something which we might not otherwise have given much thought to. We sit back and look at the event (from a distance) and dissect it. When we reflect on our activities, we examine them deeply and in detail as opposed to just living them or doing them and walking away. Reflection enables us learn from our activities, actions and experiences from which we learn. We can reflect on a meeting, an interaction, an event or an entire project. The great benefit of reflecting in our activities is that, by understanding why we do something in a particular way and recognising how we feel about it, we can spot where we are doing well and where we are not doing so well, which gives us the chance to consolidate our successes and address the gaps. We are encouraged to be descriptive, analytical and evaluative in our reflection.

Sources:
http://www.alara.net.au/aral/actionresearch http://cadres.pepperdine.edu/ccar/define.html

The Performer is a Publication of the Uganda team of the PERFORM Project ; Improving health workforce performance in Ghana,

Tanzania and Uganda

Reflection can focus on some or all of the elements in the table below:
Facts (about the meeting, event, etc) why the meeting, who is attending, how many attending, etc. Questions (why did we do it this way? What If we did it another way? What are the implications of continuing with this strategy?)

Ideas (how else we can do it, how we can share our successes, how we can overcome the challenges, etc)

Feelings ( I am happy we agreed on that issue, I am feeling a little nervous about continuing with this bundle, I like working with this team, etc)

Sample Questions for Reflection Who was there? (descriptive) What did she say? (descriptive) What did I say? (descriptive) Why did I respond in that way? (analytical/reflective) How did each of us feel as a result? (analytical/reflective) What if I had chosen my words more carefully? (analytical/reflective) So what? Would that have made any difference to the outcome? (reflective/evaluative) Where can I go from here in my interactions with this person? (reflective/evaluative)

Check list/Tips Start your reflection as soon as you can. You will forget things with time and may lose valuable l learning experiences or even marks as a result. Do some free writing on your experiences to get you started Remember that reflective writing is personal; its OK to write about your feelings and emotions. Get the balance right, dont be too descriptive. Its easy to write about what happened where; its the why, how and what if which is really important.

The Performer is a Publication of the Uganda team of the PERFORM Project ; Improving health workforce performance in Ghana,

Tanzania and Uganda

The Performer Issue 2: December ce The 2013

The PERFORM Uganda Partnership

Makerere University College of Health Sciences, School of Public Health, Uganda 1. Dr. Sebastian Olikira Baine (PI) 2. Dr. Freddie Ssengooba 3. Mr. Saul Kamukama 4. Milly Nattimba Liverpool School of Tropical Medicine, UK

1. Mr. Tim Martineau (PI) 2. Dr. Joanna Raven

Study Districts 1. Luwero District Health Management Team (DHMT) 2. Jinja District Health Management Team (DHMT) 3. Kabarole District Health Management Team

More information about PERFORM can be accessed on the consortium website: http://www.performconsortium.com/

The Performer is a Publication of the Uganda team of the PERFORM Project ; Improving health workforce performance in Ghana,

Tanzania and Uganda