the performer issue 2 dec 2013-final version
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PERFORM Districts Posting Impressive Results
Partnership Forming and Support being Realised
In a bid to effectively implement their bundles of humanresource and health systems strategies, the districts have
worked within their environment and sought
partnerships and support. So far, these efforts areyielding impressive results in the areas of support fortraining, support supervision and other bundles.
In Kabarole district, Baylor Childrens Foundation has
taken up the training of health workers in supportsupervision, which has been done successfully.
In Jinja, allocation of funds for supervision has improved
and increased support supervision. Funds have beensecured from the GAVI Alliance for immunisation
supervision while funds have also been secured from TheGlobal Fund to Fight AIDS, Tuberculosis & Malaria, for TBsupervision.
Jinja district also received funding from the Uganda AIDSCommission and conducted training in M & E to improve
the skills of the health workers. The recent M & Etraining has increased the capacity of in-charges to lookat data and see where gaps exist, one DHMT membernoted.
Luwero district has been able to conduct regular supportsupervision with support from USAID-fundedStrengthening Decentralisation for Sustainability (SDS)
initiative. Health Sub District in-charges have also been
empowered to appraise their staff. By the time of thevisit, Luwero had developed a new supervision toolwhich is expected to capture more information than the
old tool.
For the three districts; the end is not yet near, butprogress made is impressive.
In Jinja, where the bundles consisted of strengthening theappraisal mechanism and strengthening support
supervision, resources have been identiied and allocatedto 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 wererecruited and mentored. Management skills have actuallyimproved; judging from the past when things were in a
mess at some facilities. Now you ind 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 isconducted. Those days we used to do appraisal just for
the sake of it, but now we do it with meaning, anothermember 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 implementingtheir bundles of human resources/health systems
strategies.
Members of District Health (Management) Teams fromLuwero, Jinja and Kabarole; the three districts where theImproving Health Workforce Performance (PERFORM)
project is implemented, on November 15 th 2013converged at Kolping Hotel in Kampala.
District teams during group discussions at the meeng
The Performer is a Publicaon of the Uganda team of the PERFORM Project ; Improving health workforce performance in Ghana,Tanzania and Uganda
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The Performer Issue 2: December 2013
The Performer is a Publicaon of the Uganda team of the PERFORM Project ; Improving health workforce performance in Ghana,Tanzania and Uganda
DHMT Experiences and Challenges in Using the Diary
In Luwero district, the open appraisal system was re-instated. Before PERFORM came our core problem wasabsenteeism 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 9 thposition up from 56thposition, 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 betweenthe 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 healthperformance management, engaging district leadership to support capacity building of health workforce in leadershipand management.
Documentation and Information Sharing within
the DHMTsDocumentation and information sharing is a key
element in the implementation of the PERFORMproject, for it facilitates relection and learning acrossteam members. Documentation in PERFORM is
mainly done through recording of key learning
details of events in diaries at each of the threeDHMTs.
District Experiences using the Diary so far For purposes of clarity, the composition of thedistrict teams differs across the three districts;
Luwero and Kabarole districts have District Health
Management Teams (expanded to include Health Subdistrict in-charges) while Jinja has a District HealthTeam (only includes oficers based at the District
Health Ofice) by Sept/Oct 2013 when we last visited.This composition has therefore impacted how thedairy has been used.
The Luwero diary is a dairy on the road; movingfrom one health sub district to another. Thistherefore means that at the time it is in one HSD (say
Nyimbwa), others are not able to access it untilsomeone at headquarters deliberately makes sure it
leaves Nyimbwa or when there is a meeting and theperson from Nyimbwa carries it along. In this mix
too, is the factor of time constraints on the part of thehealth workers. The implication is that even writingin the book may not happen. Although the teams
reported that it has improved sharing informationwithin the DHMT, its accessibility is still a major
challenge.
In Luwero, the travelling diary had been to KalagalaHSD for long, before it found its way to Nyimbwa. Theteam in Nyimbwa though didnt know how to ill 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 HealthOfice within easy access to the DHT members,
documenting is still a challenge. As we go out, mostof us when you come back you try to write. We havebeen working out of ofice most of the time (morning
to evening) and not getting time to enter this in thediary.
The Luwero diary has undergone metamorphosis to
accommodate reecon and learningSeveral people wait to use it at the same time; sometimespeople keep it in their ofices and you have to be keen tolook 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 thingsthat should go into the diary and enter them. They alsonoted that they have challenges with the format. Therelection column; we are not really sure all people would
understand what to put there, noted that DHO, RichardMugahi.
All is not lost however, despite all the challenges, the
diary is still appreciated. Me I have learnt somethingfrom that book. It doesnt target only meetings; it alsocaptures 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 membershave not embraced it because a lot has been done but notwritten in the diary. Some visitors came and saw it and
they liked it a lot, they thought it is a very good book. Thefact is that there are many things done but few arewritten is clear testimony that there is something wrong,
yet another added.
In all the three districts, there were suggestions forimprovement 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 thediary. Trying out Facebook to go hand-in-hand with the
book/diary in the district where the book takes long onits journey from one place to another.
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The Performer is a Publicaon of the Uganda team of the PERFORM Project ; Improving health workforce performance in Ghana,Tanzania and Uganda
Makerere University School of Public Health Successfully Hosts Third PERFORM
Consortium Meeting
The Performer Issue 2: 2013
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 havedecentralised management structures that offer
management teams greater decision-making spaceincluding in the area of human resources. PERFORM is
studying how management strengthening interventionscan be used, and under what conditions, to enhanceworkforce 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 context-
speciic 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 somecountries, the documentation of experiences and
relections 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
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 indings will add new
knowledge as to the effect of different country contexts
on these interventions, hopefully leading to insights intothe 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 MUSPH team with the European partners during
a group discussion. Back to camera is Dr. Sebastian
Olikira Baine the PI
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The Performer Issue 2: December 2013
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 toidentify and know those who were not working,
according to the discussion with the CountryResearch Team (CRT). The district team therefore
reported some improvements in conducting the
appraisal process, although some more support is
still needed.
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 areavailable 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 LukolaHealth Centre IIIs. The recognition was at a public
meeting (during a workshop) in front of everybody
and we believe this motivates.
Some members of the Jinja DHT during the support visit
meeng
District Support Visits Reveal Impressive Progress and Growing
EnthusiasmControlling Arrival and Departure at
the Health Facility Improves staff
AvailabilityIn the months of September and October, theCountry 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 USAID-
funded Strengthening Decentralisation for
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 Publicaon of the Uganda team of the PERFORM Project ; Improving health workforce performance in Ghana,Tanzania and Uganda
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From page 1Partnerships Forming...
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.
Kabarole PERFORM progress on a
Rollercoaster
The Kabarole team has formed ive supervisory
teams each of four members, with each team
supervising speciic 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 Ofice to know and
learn what happens at top management. They also
chair Monday morning meetings as a way of
building their management and leadership
potential.
The DHO has initiated mentorship of HSD in -
charges 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.
Luwero DHO, Dr. Joseph Okware with part of his
team
The Performer is a Publicaon of the Uganda team of the PERFORM Project ; Improving health workforce performance in Ghana,Tanzania and Uganda
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The Performer Issue 2: December 2013
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 matchwhat you are paying, said the DHO.
Whatever mentorship and support happens,
Some Tips on recording Reflections in the Diary
What does relection 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. Speciically, it was noted
that the area of relection is quite weak. In the
following article, are some tips on how to improve
our relection.
When we relect, 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 relect on our activities, we examine
them deeply and in detail as opposed to just
living them or doing them and walking away.
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
From page 5...Kabarole on Rollercoaster progress
Relection enables us learn from our
activities, actions and experiences from
which we learn. We can relect on a
meeting, an interaction, an event or an
entire project.
The great beneit of relecting 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
relection.
The Performer is a Publicaon of the Uganda team of the PERFORM Project ; Improving health workforce performance in Ghana,Tanzania and Uganda
Sources:http://www.alara.net.au/aral/actionresearch
http://cadres.pepperdine.edu/ccar/deine.html
http://www.alara.net.au/aral/actionresearchhttp://www.alara.net.au/aral/actionresearchhttp://cadres.pepperdine.edu/ccar/define.htmlhttp://cadres.pepperdine.edu/ccar/define.htmlhttp://cadres.pepperdine.edu/ccar/define.htmlhttp://www.alara.net.au/aral/actionresearch -
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Relection can focus on some or all of the elements in the table below:
Sample Questions for Relection Who was there? (descriptive) What did she say? (descriptive) What did I say? (descriptive) Why did I respond in that way? (analytical/relective) How did each of us feel as a result? (analytical/relective) What if I had chosen my words more carefully? (analytical/relective) So what? Would that have made any difference to the outcome? (relective/evaluative) Where can I go from here in my interactions with this person? (relective/evaluative)
Check list/Tips Start your relection as soon as you can. You will forget things with time and may lose valuable l
learning experience s or even marks as a result. Do some free writing on your experiences to get you started Remember that relective 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.
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)
The Performer is a Publicaon of the Uganda team of the PERFORM Project ; Improving health workforce performance in Ghana,Tanzania and Uganda
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The Performer Issue 2: December 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 Ssengooba3. Mr. Saul Kamukama4. 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
The Performer ce
The Performer is a Publicaon of the Uganda team of the PERFORM Project ; Improving health workforce performance in Ghana,Tanzania and Uganda
More information about PERFORM can be accessed on the consortium
website: http://www.performconsortium.com/
http://www.performconsortium.com/http://www.performconsortium.com/