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Strengthening management at district level to support the achievement of Universal Health Coverage (PERFORM2scale)

Periodic Reporting for period 3 - Perform 2 scale (Strengthening management at district level to support the achievement of Universal Health Coverage (PERFORM2scale))

Reporting period: 2020-01-01 to 2021-06-30

The new challenge in global health is to achieve Universal Health Care (UHC) by 2030. This involves addressing three dimensions of who is covered (population coverage), what is covered (health-care benefits) and how much of the cost is covered (financial protection). In the next decade, an increasing number of African countries will become able to finance essential health services from domestic resources and will then face critical decisions on how to invest these funds most effectively to accelerate progress towards UHC (Brandford 2007). Having an adequate workforce is critical to achieving societal goal of UHC. Efforts are in place to scale up the numbers of health worker. Improving health workforce performance is equally important as the quantity of health workers, but more challenging. Workforce performance improvement can be achieved better at levels closer to front-line workers. The PERFORM project (2011-15) developed a problem-based management strengthening intervention for management teams at district level in three African countries to improve both health workforce performance and service delivery more generally. The evaluation of the management strengthening intervention 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 and thus contribute to the achievement of UHC the PERFORM management strengthening intervention needs to be scaled up and embedded.

The overall aim of the PERFORM2scale project is “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 has the following research and enabling objectives:
1. To develop a framework and strategy for scaling up the management strengthening intervention
2. To implement and validate the framework and strategy for scaling up the management strengthening intervention
3. To identify the facilitators and barriers to scale-up of the management strengthening intervention in different and changing contexts
4. To identify the costs and effects of scaling up the management strengthening intervention
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 communication for and about the scale-up process and to disseminate the validated framework and strategy for scaling up the management strengthening intervention.
January 2017 – June 2018. Because of the complexity of the research design, developing the methods took longer than anticipated. This had implications for the start of the Initial Context Analysis (ICA) studies and consequently the start of the Management Strengthening Interventions (MSIs). The Country Research Teams (CRTs) in Ghana, Malawi and Uganda undertook stakeholder engagement to create the National Scale-up Steering Groups (NSSG) and ultimately the national Resource Teams (RT). The Initial Context Analysis studies were completed in draft. The Management Strengthening Initiative (MSI) cycles have been initiated in each country, and by 30th June the problem analysis workshops (Workshop 1) had been conducted in all three countries in District Group 1 (DG1) and the second strategy development workshop (Workshop 2) completed in Ghana. Data collection for the process and outcome evaluation has started in all three countries.
July 2018 - December 2019. The second MISI cycle in DG1 districts has been started in each of the countries in the process of deepening the management strengthening process. As part of the horizontal scale-up process, all three countries have now started the MSI with a second group of districts (DG2) in parallel to DG1. Uganda has made plans to start in a third set of districts (DG3) in early 2020. The major recent focus has therefore been on further developing the framework for planning the scale-up with the National Scale-up Steering Groups (NSSG).
January 2020 to June 2021. In January 2020 the horizontal expansion of the MSI was progressing well in all three countries. Structured discussions on the scale up strategy started in early 2020 and were due to be followed up with NSSG members in person at the consortium workshop in Malawi in March 2020. Understandably, both the field work for the MSI and work on the scale-up have been delayed because of the COVID-19 pandemic. However, the horizontal expansion of the Management Strengthening Intervention (MSI) has continued and now covers 27 districts in three countries. Three districts are already on to their third MSI cycle – increasing the depth of the management strengthening process. Whereas the primary purpose of the MSI is to improve district level management, there are also the benefits of improving workforce performance and service delivery. While the MSI may be scaled up in more or less its original form in Ghana, the plans for Malawi are to absorb the initiative into existing structures in what the government counterparts are referring to as ‘institutionalisation’. In Uganda, elements of the MSI (in particular the focus on health workforce performance and reflection) are being absorbed into the existing quality improvement (QI) strategy (now approved) and will be implemented by regional QI teams . All these variations of scale-up strategies are, as of 30th June 2021, are still ‘living plans’. The second round of data collection for the process and outcome evaluations has been carried out under COVID-19 secure conditions in the first half of 2021. The data is currently being analysed in preparation for inclusion in the country reports. Because of the delays caused by the pandemic, a request to the EC for a three-month no-cost extension has been made.
The project is building on the lessons learnt about management strengthening for improved workforce performance during the PERFORM project. This project was designed with a model of scale-up based on the experience of ExpandNet. In one country, where the scale-up has initially been focused in on region, the establishment of the supportive structures for scale-up to ensure sustainability has been relatively straight-forward. In another country the challenge has been setting up meetings with busy officials, though participation in the management strengthening activities by individual officials has been good. In our third country, where devolution is unfolding, it was initially unclear where the lead for scale-up should come. Now the Ministry of Health has become very engaged. The project is now generating important new knowledge about the impact of management strengthening using a number of continuous cycles whereby DHMTs can build on the management knowledge over time (for example, in contrast to a one-off management training). We are developing more lessons about scaling up a complex intervention and the resulting adaptation of the interventions through stakeholder consultation.