Periodic Reporting for period 4 - Perform 2 scale (Strengthening management at district level to support the achievement of Universal Health Coverage (PERFORM2scale))
Reporting period: 2021-07-01 to 2022-03-31
The current challenge in global health is to achieve Universal Health Coverage (UHC) by 2030. Having an adequate workforce is critical to achieving the societal goal of UHC. Efforts are in place to scale-up the numbers of health workers, however, improving health workforce performance is equally important, if more challenging. Workforce performance improvement can be better achieved at levels closer to frontline workers. The PERFORM project (2011-15) developed a problem-based management strengthening intervention (MSI) based on an Action Research approach for District Health Management Teams (DHMTs) at sub-national level in three African countries to improve both health workforce performance and service delivery more generally. The evaluation of the MSI demonstrated its effectiveness in enabling the management teams to both solve workforce performance and other problems locally and to become better managers. To have a wider impact the PERFORM management strengthening intervention needs to be scaled up.
The overall aim of the PERFORM2scale project was “to develop and evaluate a sustainable approach to scaling-up a district-level management strengthening intervention in different and changing contexts”. To achieve this aim the project was guided by the following research and enabling objectives:
1. To develop a framework and strategy for scaling-up the MSI.
2. To implement and validate the framework and strategy for scaling-up the MSI.
3. To identify the facilitators and barriers to scale-up of the MSI in different and changing contexts.
4. To identify the costs and effects of scaling-up the MSI.
5. To develop the individual and institutional capacity at regional and national levels to implement and sustain the use of the scaling-up framework and strategy.
6. To ensure engagement of stakeholders and institutions needed to implement and sustain the scale-up of the intervention.
7. To provide ongoing communications for and about the scale-up process and to disseminate the validated framework and strategy for scaling-up the MSI.
The overall aim of the project has been achieved and all objectives were achieved.
The overall aim of the PERFORM2scale project was “to develop and evaluate a sustainable approach to scaling-up a district-level management strengthening intervention in different and changing contexts”. To achieve this aim the project was guided by the following research and enabling objectives:
1. To develop a framework and strategy for scaling-up the MSI.
2. To implement and validate the framework and strategy for scaling-up the MSI.
3. To identify the facilitators and barriers to scale-up of the MSI in different and changing contexts.
4. To identify the costs and effects of scaling-up the MSI.
5. To develop the individual and institutional capacity at regional and national levels to implement and sustain the use of the scaling-up framework and strategy.
6. To ensure engagement of stakeholders and institutions needed to implement and sustain the scale-up of the intervention.
7. To provide ongoing communications for and about the scale-up process and to disseminate the validated framework and strategy for scaling-up the MSI.
The overall aim of the project has been achieved and all objectives were achieved.
The project ran from January 2017 to March 2022, which included a three-month no-cost extension to compensate for implementation time lost during the COVID-19 pandemic.
This was an implementation project and was designed using a model of scale-up based on the experience of ExpandNet.
The research started with the Initial Context Analysis (ICA) studies in Ghana, Malawi and Uganda, and thereafter the processes and outcomes of both the MSI and its scale-up – including costs – were evaluated throughout the project.
The implementation phase of started with the establishment of the organisational structure for scaling-up the MSI and was followed by the gradual roll-out of the MSI in groups of three districts (District Groups), expanding by one group per year over a period of about three years. By mid-2021 the MSI had been scaled up to 27 districts across the three countries. To continue the process of management strengthening and to embed the lessons learned, the earlier District Groups continued with second and third cycles of the MSI. There was good evidence of management strengthening in all countries and, though beyond PERFORM2Scale's sphere of control, some evidence of improved workforce performance and service delivery.
Scale-up in Ghana was in one region and the establishment of the supportive structures to ensure sustainability was relatively straightforward. In Uganda, the challenge was in setting up meetings with busy officials, though participation in the management strengthening activities by individual officials was good. In Malawi, where devolution is unfolding, it was initially unclear from where the lead for scale-up should come. The Ministry of Health subsequently became very engaged.
While the scale-up of the MSI during the project led to a steady increase in the number of districts covered, there has been a divergence in the way in which the continuation of the scale-up has been planned. In Ghana and Malawi, there are plans to absorb the MSI, with some modifications, into existing structures. In Uganda, certain elements of the MSI have been incorporated into the quality improvement strategy and framework. Securing the funding for these three different pathways has so far remained a challenge.
The project was supported by a capacity development component for the facilitation of the MSI, the scale-up process and the research activities. IA communications component supported stakeholder engagement at district, regional and national levels in the three countries. Findings from the research have been disseminated throughout the lifetime of the project in a variety of fora at country level, including relevant ministries and technical working groups, charities and religious organisations involved in health provision, and academia. The MSI toolkit will be made available.
This was an implementation project and was designed using a model of scale-up based on the experience of ExpandNet.
The research started with the Initial Context Analysis (ICA) studies in Ghana, Malawi and Uganda, and thereafter the processes and outcomes of both the MSI and its scale-up – including costs – were evaluated throughout the project.
The implementation phase of started with the establishment of the organisational structure for scaling-up the MSI and was followed by the gradual roll-out of the MSI in groups of three districts (District Groups), expanding by one group per year over a period of about three years. By mid-2021 the MSI had been scaled up to 27 districts across the three countries. To continue the process of management strengthening and to embed the lessons learned, the earlier District Groups continued with second and third cycles of the MSI. There was good evidence of management strengthening in all countries and, though beyond PERFORM2Scale's sphere of control, some evidence of improved workforce performance and service delivery.
Scale-up in Ghana was in one region and the establishment of the supportive structures to ensure sustainability was relatively straightforward. In Uganda, the challenge was in setting up meetings with busy officials, though participation in the management strengthening activities by individual officials was good. In Malawi, where devolution is unfolding, it was initially unclear from where the lead for scale-up should come. The Ministry of Health subsequently became very engaged.
While the scale-up of the MSI during the project led to a steady increase in the number of districts covered, there has been a divergence in the way in which the continuation of the scale-up has been planned. In Ghana and Malawi, there are plans to absorb the MSI, with some modifications, into existing structures. In Uganda, certain elements of the MSI have been incorporated into the quality improvement strategy and framework. Securing the funding for these three different pathways has so far remained a challenge.
The project was supported by a capacity development component for the facilitation of the MSI, the scale-up process and the research activities. IA communications component supported stakeholder engagement at district, regional and national levels in the three countries. Findings from the research have been disseminated throughout the lifetime of the project in a variety of fora at country level, including relevant ministries and technical working groups, charities and religious organisations involved in health provision, and academia. The MSI toolkit will be made available.
New knowledge about the impact of the MSI over several consecutive cycles includes:
• The MSI is an effective intervention for management strengthening and can contribute to improved service delivery.
• Deepening of management learning occurs through multiple MSI cycles.
• The absence of extra implementation funds can help DHMTs to become more resourceful.
• The MSI provides opportunities for district managers to learn from each other.
• The MSI was adaptable to local needs and systems.
Lessons about scaling-up a complex intervention (ie the MSI). These include:
• Scale-up of a complex intervention can be effected if it is valued and funds are available for scale-up.
• However, scale-up is not a linear process, and is influenced by a complex set of factors.
• Vertical scale up - the institutionalisation of the MSI through policy, political, legal, budgetary or other health systems changes – is necessary to support sustainable horizontal scale-up.
• Critical to successful vertical scale-up is having time and a clear, shared vision among the different stakeholders and a strategic plan for scale-up to institutionalise the intervention into existing systems
• The ExpandNet approach, adapted for PERFORM2Scale, provides a good guide for scale-up, which needs to be flexible to the context and should be adapted on the scale-up journey. Creating parallel structures should be avoided.
• Alignment of the intervention to existing policies and interests needs to be considered at the outset and frequently thereafter. Reappraisal of the need and demand for the intervention at an early stage is important.
• Evidence is needed to convince stakeholders about scale-up.
• The identification of champions and supportive stakeholders to advocate for further funded scale-up to ensure maximum impact and sustainability of the intervention is necessary.
• Thinking and working politically is essential to gain and maintain support of key stakeholders and decision-makers to support scale-up.
PERFORM2Scale has generated new knowledge about strengthening management at district level and improving both health workforce performance and service delivery more generally. The project has also developed new knowledge about scaling-up the MSI to have a wider impact and thus contribute to the achievement of UHC. This new knowledge is highly relevant to other complex health systems interventions which in turn could also contribute to UHC, and thus contribute a positive impact to society.
• The MSI is an effective intervention for management strengthening and can contribute to improved service delivery.
• Deepening of management learning occurs through multiple MSI cycles.
• The absence of extra implementation funds can help DHMTs to become more resourceful.
• The MSI provides opportunities for district managers to learn from each other.
• The MSI was adaptable to local needs and systems.
Lessons about scaling-up a complex intervention (ie the MSI). These include:
• Scale-up of a complex intervention can be effected if it is valued and funds are available for scale-up.
• However, scale-up is not a linear process, and is influenced by a complex set of factors.
• Vertical scale up - the institutionalisation of the MSI through policy, political, legal, budgetary or other health systems changes – is necessary to support sustainable horizontal scale-up.
• Critical to successful vertical scale-up is having time and a clear, shared vision among the different stakeholders and a strategic plan for scale-up to institutionalise the intervention into existing systems
• The ExpandNet approach, adapted for PERFORM2Scale, provides a good guide for scale-up, which needs to be flexible to the context and should be adapted on the scale-up journey. Creating parallel structures should be avoided.
• Alignment of the intervention to existing policies and interests needs to be considered at the outset and frequently thereafter. Reappraisal of the need and demand for the intervention at an early stage is important.
• Evidence is needed to convince stakeholders about scale-up.
• The identification of champions and supportive stakeholders to advocate for further funded scale-up to ensure maximum impact and sustainability of the intervention is necessary.
• Thinking and working politically is essential to gain and maintain support of key stakeholders and decision-makers to support scale-up.
PERFORM2Scale has generated new knowledge about strengthening management at district level and improving both health workforce performance and service delivery more generally. The project has also developed new knowledge about scaling-up the MSI to have a wider impact and thus contribute to the achievement of UHC. This new knowledge is highly relevant to other complex health systems interventions which in turn could also contribute to UHC, and thus contribute a positive impact to society.