Introduction

General

There is a worldwide shortage of health workers, particularly in the African and Mediterranean regions, against WHO recommended staffing levels to achieve Universal Health Coverage recommended by the World Health Organization (WHO) [1]. Making the most efficient use of the available workforce through improved health workforce performance is therefore important—both the collective and individual performance of the workforce (including skills mix, levels of absence, and quality and quantity of work output). This requires a level of literacy about the health workforce—in other words “the capacity to obtain, process and understand health workforce information and services needed to make appropriate health workforce decisions” ([2], p. 2).

The aim of this document review, based on the experience of the PERFORM2Scale project, was to assess the feasibility of designing potentially effective integrated workplans for health workforce performance improvement at district level.

Theoretical background

Improved health workforce performance management can be more easily achieved using the principles of Strategic Human Resource Management (SHRM) [3]—an important ingredient of ‘health workforce literacy’—right from the design stage. In addition to ensuring vertical integration (i.e. the human resource (HR) strategies clearly support organisational goals), SHRM advocates horizontal integration of HR strategies—or ‘bundles of strategies’ [4, 5], e.g. training supported by supervision and performance appraisal—to ensure maximum impact. Though the use of integration of HR strategies is advocated by the Global Health Workforce strategy 2030 [6] and in the recently updated guidelines for staffing rural and remote areas [7], the successful use of this approach has not been well documented in recent reports that cover health workforce strategy [1, 8, 9]. Furthermore, there is little evidence about if and how managers acquire these important skills for designing integrated HR strategies [10].

Supporting DHMTs to develop integrated HR strategies

The practical application of the concept of horizontal integration (or ‘coherence’ [11]), of HR strategies was incorporated into a district level management strengthening initiative (MSI) used as a pilot by the PERFORM consortium (2011–15) [12] and then scaled up by the PERFORM2Scale consortium (2017–2022) [13] in Ghana, Malawi and Uganda. In each country there are District Health Management Teams (DHMT) with similar functions and operating in varying decentralised contexts [14]. The MSI, which was facilitated by project staff from each country together with health service officials, is described in more detail in Box 1.

Methods

Research aim

The aim of the study was to assess the feasibility of designing potentially effective integrated workplans for health workforce performance improvement at district level through document review.

Study countries and districts selected

Ghana, Malawi and Uganda were selected as countries where management has or is currently being decentralised to the district level and where consequently the district health management teams are more likely to have sufficient ‘decision space’ to address any problems identified [19]. All three countries started the implementation of the MSI initially in three districts at approximately the same time, though the scale-up to new districts and adoption of subsequent MSI cycles proceeded at a different pace in each country (see Additional file 2).

Data collection and analysis

As part of the intervention described in Box 1 routine documentation of the programme included the collation of the problem trees and workplans developed during workshops and visits. This data collection took place between 2018 and 2021. The problem trees and the workplans were analysed using the framework provided in Table 2. Content analysis [20] was conducted for each workplan by two researchers (see Table 2) which also includes the scoring criteria. Generic planning was first reviewed in order to: categorise the type of problem statements; check the clarity of the links to the workplan; and check for any consideration of gender and inclusion of indicators. The strategies were analysed first using the four HR categories shown in Table 1. If this was not clear from the strategy column (B), the ‘activity’ column (C) (see Fig. 2) was reviewed. We have used the generic term ‘strategy’ for both levels of the ‘hierarchy of objectives’ [21] of the workplan, i.e. strategies and activities. The presence of any other health systems strategy in the workplan was then checked.

Table 2 Framework for reviewing the problem analysis and emergent workplans for each MSI
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Results

During the implementation of PERFORM2Scale, 43 workplans were developed across the three countries over two or three cycles (see Table 3). Several districts in Uganda and one in Malawi used the same problem in more than one cycle, but the workplans were modified in the second cycle—even if only slightly—and were therefore treated as different workplans. This number of workplans was developed despite the arrival of the COVID-19 pandemic in 2020 which led to some disruption to the schedule of the MSI workshops, support visits and delays to implementation of the workplans.

Table 3 Number of MSI workplans developed by country and district group
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The findings represent the decisions made by the DHMTs related to the problem analysis and subsequent design of a relevant workplan and the use of the guidance in the planning table for all 43 MSI cycles (see Table 2). Some examples, where relevant, are presented for illustration.

Type of core problem selected

Out of the 43 MSI cycles there were 21 (49%) problem statements which are based on ‘service delivery’ (SD) problems, e.g. ‘low case detection of neglected tropical disease (Yaws)’; 20 (46%) based on ‘human resource’ (HR) problems, e.g. ‘high-level absenteeism among health workers’; and two (5%) based on general management (GM) problems. The two GM problems—both from Malawi—included ‘Late data entry to DHS2 (the health information system)’ and ‘departmental heads do not compile and submit descriptive reports’.

Whereas the overall split between SD and HR problems is even, when disaggregated by country there is a clear difference between Ghana where all 13 (100%) problems were framed as relating to service delivery and between Malawi where 75% of the problems (9/12) were framed as relating to HR. In Uganda, there was a more even mix with 11 of the 18 (61%) problems being related to HR. Some switching by the DHMT after the first MSI cycle from SD to HR related problems in subsequent cycles (but not the other way around) was observed in Uganda. Some districts continued with the same problem (e.g. low tuberculosis cure rate in Cycles 1 and 2 in Luwero, Uganda; and Ntchisi and Salima districts in Malawi both worked on improving staff appraisal in both Cycles 1 and 2), though with improved workplans as the problem was not fully addressed in the first cycle. In Cycle 2, Yilo Krobo district (Ghana) continued working on the problem selected for Cycle 1 (Yaws case detection), but added other Neglected Tropical Diseases (NTDs) (leprosy and Buruli ulcer).

Clear link between core problem and workplans

There was a clear logical link between the core problem selected and the workplan eventually produced in all 43 MSI cycles, though not all factors identified as contributing to the problem were covered by the workplan. Some of the problem areas could not be addressed within the constraints of the MSI cycle (resources, time or authority) or may not have been high priority.

Consideration of gender

All but three (7%) workplans contained at least one reference to gender. This was mainly in relation to health staff and it was often simply noted that equal opportunity policies would be followed. However, there were some more specific factors noted such as the challenges for women using motorcycles for fieldwork in Luwero district, Uganda (Cycle 1). Nakaseke district (Uganda, Cycle 1) DHMT included strategies to improve fairness in absence management and to better disaggregate absence data by gender. Gender was also considered in service delivery elements of some plans such as differently tailored messages regarding antenatal care (ANC) attendance for males and females and the involvement of men in ANC services in Suhum district in Ghana in Cycle 1.

Presence of indicators in workplans

Almost all (42/43–98%) workplans included at least one indicator for monitoring and evaluation and many included an indicator for each strategy in the workplan. One example from Fantekwa district, Ghana (Cycle 1) demonstrated clear strategic thinking in relation to improving staff retention. It had an activity of ‘Identify and implement both financial and non-financial incentive packages that can be contained in the District Health Authority annual budget’ for which the expected change was ‘staff motivated to accept postings in rural areas’ (Column D in the workplan—see Fig. 2) and the indicator was ‘number of vacancies in selected facilities filled with staff’.

Use of HR strategy

All workplans—regardless of problem type (SD, HR or MD)—included one or more types of HR strategy (availability, direction, competencies and rewards/sanctions). In a few cases (6 in Ghana, 3 in Uganda and 2 in Malawi) it was necessary to review the workplans at activity level to make the categorisation. For example, Yilo DHMT (Ghana, Cycle 2) had included the activity of ‘Institute rewards for well-performing staff’ (categorised as ‘Rewards/Sanctions’) to support the broader strategy of ‘Use of health workers to search for NTD cases’ in order to address the problem of ‘Low NTDs case detection’.

On average nearly three out of the four categories of HR strategy/activity were included in the workplans (see Table 4 below), with a minimum of 2 HR categories in 15 of DHMT workplans and a maximum of 4 HR categories in 10 DHMT workplans. The inclusion of strategies related to ‘direction’ (42–97%) and ‘competencies’ (39–93%) was common in all intervention districts in the three study countries. The use of strategies related to ‘availability’ was common in Ghana at 92%; less common in Uganda at 39% and only 8% in Malawi. The use of strategies related to ‘rewards/sanctions’ was common in Ghana (85%) and less in Malawi and Uganda (both at 50%).

Table 4 Use of HR strategies by category and average per workplan
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An example of a multi-strategy workplan (including all four types of HR strategy) is found in Fantekwa District in Ghana for Cycle 1. The DHMT identified low out-patient department (OPD) attendance as the problem. Based on their problem analysis, they identified multiple strategies to include in their workplan which covered availability (lobbying for more enrolled nurses and improving retention through offering study leave and reposting staff to urban areas after serving two years in rural area; and improving attendance through regular supervision); improving direction through job description orientation and staff appraisal; improving competencies in “customer care”; and an award for the best performing staff member (reward).

In addition to the mix of categories of HR strategy, there were often multiple strategies within one category. For example, the workplan of Bunyangabu District (Uganda, Cycle 2) aimed to reduce malaria positivity rates through two complementary strategy/activities to improve ‘direction’: 1) ensuring that facility in-charges included malaria management in schedules of duties and performance plans of health workers; and 2) supervising and mentoring Village Health Teams (VHT) with a focus on malaria prevention). Two complementary strategies were also used to improve the ‘competencies’ of District Health Teams through the use of key malaria prevention guidelines and the provision of training for health assistants on key messages for sensitising VHTs on malaria prevention.

Use of health systems strategy

Most workplans (32/43—74%) included at least one HS strategy that complemented the HR strategy (see Table 5). For example, Fantekwa’s (Ghana) Cycle 1 workplan to increase OPD attendance (described above) includes the strengthening of community engagement (classed as an HS strategy) to increase demand. Salima DHMT (Malawi, Cycle 1) complemented several HR strategies (including clearer direction and on-job training) to improve supervision with the provision of mobile phones and better transport.

Table 5 Number of workplans including HS strategies by study country
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Overall, Ghana and Malawi MSI workplan had more HS strategies (12/13 and 9/12, respectively) while Uganda MSI workplans had a more even mix of both HR and HS strategies. Combining HR and HS strategies does make the workplan more complex, with Fantekwa DHMT’s workplan (Ghana, Cycle 2) including 14 different strategies, but most workplans were less ambitious.

Discussion

All DHMTs in each study country already had the competencies for making annual workplans, so it is reassuring that some of the basic elements of planning were evident in nearly all of the MSI workplans: the clear link between problem and workplans; some consideration of gender; and the use of some indicators for monitoring and evaluation of workplans.

Whereas the original PERFORM project was based on the premise that through better management of the workforce greater efficiencies would be achieved thus helping to address the global problem of workforce shortage [12], an important principle of action research (and, similarly, action learning), is that participants should have ownership of the problems they choose to address [12, 22,23,24]. For this reason, DHMTs were not necessarily required to address problems directly related to health workforce, though as mentioned above earlier experience indicated that regardless of the core problem being addressed the workplans required strategies related to workforce performance. It was unsurprising that about half of the problems selected related directly a service delivery, as the targets given by ministries of health to DHMTs are generally related to service delivery, such as immunisation coverage rates or tuberculosis cure rate.

Regardless of the type of problem selected, HR strategies were included in all workplans. This indicates that by carrying out a root cause analysis, DHMTs recognise that improving the management of the workforce is necessarily part of the solution to any problem they selected. This reinforces the assertion that HR is a central component of the health system [18, 25]. It is interesting to note that the DHMTs did not necessarily include HS strategies in the workplans to address workforce performance—7 HR problems in Uganda and 3 in Malawi included no HS strategies.

Having recognised the importance of including HR strategies, the DHMTs did not rely on single HR strategies such as training or supervision in their workplans to address the workforce-related problems. The DHMTs—particularly in Ghana—included a range of categories of HR strategies in their workplans which is a clear demonstration of the SHRM concept of ‘horizontal integration’, or ‘bundles’ of HR strategies—whether intended or not. The highest use of the four categories was ‘direction’ and ‘competence’. Strategies related to ‘availability’ and ‘reward/sanction’ are less likely to fall within the ‘decision space’ of the DHMTs [26,27,28] as these probably require external resources which DHMTs in Malawi and Uganda may have found more challenging. Although a full analysis of all strategies in the workplans was beyond the scope of this study, examples of multiple strategies within category were also identified. This further demonstrated that the DHMTs had acquired the skills from the MSI process to develop "bundles" of linked and coordinated SHRM interventions. The integration of strategies both between and within the four categories of HR strategy ‘will be more likely to achieve sustained improvements in organisational performance than single or uncoordinated interventions’ [4, p7]. However, the quality of the ‘bundles’ is more important than the quantity of strategies included [29] and Marchal and Kegels suggest that it is more important that the strategies are complementary and appropriate to need [30].

The evidence presented in this paper has demonstrated that it is possible for DHMTs to design workplans with integrated HR strategies in line with SHRM thinking using the MSI approach described. As shown at district level, improving health workforce performance using integrated HR strategies is just as important for solving wider service delivery problems. This is equally true at higher levels of the health system. This 'health workforce literacy' [31] will also help DHMT members who may get promoted whether they take higher level posts in HR management or other broader areas of management to have more impact on health workforce performance improvement. The SHRM concept of ‘horizontal integration’ strategies needs to be incorporated into health management related training to support the design and implementation of bundles of HR strategies. This concept is implicit in WHO’s recently published Human Resources for Health leadership and management course materials [32], but needs to be taught using practical examples.

Evaluation of the implementation and impact of these workplans at district level is ongoing, but this simple, scalable, structured approach can help district managers design relevant and coherent workplans to address workforce-related problems to support more effective service delivery. The approach could also be useful at higher levels of the health system and an analysis of levels of horizontal integration in national plans could be included in future reviews.

Policy implications

As DHMTs demonstrated the ability to link effective root cause analysis to problems they had prioritised and linking this analysis to strategy development, this kind of approach should be encouraged to improve service delivery in general at district level.

DHMTs also demonstrated the ability to develop quite complex workplans including quite a wide range of integrated HR and HS strategies. Given that all problems identified, even the service delivery ones, required HR strategies, more emphasis is needed in developing health workforce literacy at this level.

The process of problem analysis and HR strategy development following SHRM principles is also needed at higher levels of the health system. A similar approach could be used at higher levels of the health system resulting in both the development of more relevant and effective HR strategies as well as broadening health workforce literacy within the system.

Strengths and limitations

The strength of this study is that it presents a new way of analysing the degree of integration, following the SHRM approach, in the design of workplans for improving performance management across multiple districts in three countries and the range of strategies used. This approach could also be used for different areas of the health system.

As the study was based on a document review, several limitations of the study include: the lack of data on the interconnection between strategies in the workplans; on the learning by district managers either during the workplan development process or during the implementation period; and the impact of the workplans on workforce performance and service delivery.

Future research

In future more details could be collected on the interconnection between the different strategies in the workplans, the development of DHMTs’ planning skills as they go through multiple MSI cycles and the results of the implementation of the workplans could offer more knowledge about the effectiveness of the different strategies. More detail on the quality of both the considerations of gender and the indicators would be useful. In-depth qualitative data on the DHMTs’ perceptions and experience of the guidance and facilitation process of the MSIs would benefit future users of this approach. For such a study an independent evaluation might be more appropriate.

Conclusion

The study has shown that it is possible to give health managers in decentralised districts the necessary skills to design workplans with integrated HR strategies using an action research approach. If the workplans are implemented, this is likely to lead to improved health workforce performance at the district level, though further evaluation is needed. The process of analysing health workforce and service delivery problems using the MSI’s action research approach is likely to improve the level of ‘health workforce literacy’—and will potentially help managers at district level (and higher levels, if promoted) to have more impact on health workforce performance improvement within the health system.