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.
