Management of human resources for health in health districts in Uganda: A decision space

Five lessons from a mid-level health manager intervention to increase uptake of tuberculosis prevention therapy in Uganda: 'it is a completely different thing to implement what you know.'

BACKGROUND

Leadership skills are essential for middle-level healthcare manager efficacy. Capacity-building efforts may attempt behavioural change by filling 'knowledge gaps' while neglecting a sustainable application of that knowledge. Sustainable application of that knowledge, or implementation know-how, must resonate with local cultural patterns. When it is neglected, root issues like unclear decision-making space and local authority to interpret policy during implementation remain unaddressed. Particularly in decentralized healthcare systems, the impact can appear in implementation challenges, subjective decision-making, poor teamwork, and an absence of disseminating best practices.

OBJECTIVES

The SEARCH-IPT trial led a series of mini-collaborative meetings, which provided business leadership and management training for an intervention group of mid-level healthcare system managers in rural Eastern, East-Central, and Southwestern Uganda to see whether this would increase uptake of isoniazid-prevention therapy (IPT) for people living with HIV (PLHIV) in intervention districts. IPT is known to reduce active tuberculosis (TB), a leading cause of death among PLHIV, by 40-60%.

METHODS

We performed a thematic analysis of six focus-group discussions from this intervention (held in May 2019, January 2020, September 2021) and 23 key informant interviews with control group participants (between February and August 2019 and September and December 2020).

RESULTS

Analysis revealed five implementation skill sets District Health Officers (DHOs) and District Tuberculosis and Leprosy Supervisors (DTLSs) deployed to achieve sustainable implementation and realize their decision-making space. The five practices were as follows: data-based decision-making, root-cause analysis, quality assurance, evidence-based empowerment, and sharing best practices with colleagues.

CONCLUSION

These practices reached beyond outcome measures to address root problems around the DHO's range of authority and elicit buy-in from district health workers. For successful capacity building at the mid-manager level, focusing on core practices as part of competency is objectively implementable and measurable at the system level and does not rely on DHO self-assessments.

Strengthening anthrax outbreak response and preparedness: simulation and stakeholder education in Namisindwa district, Uganda

BACKGROUND

Anthrax is a zoonotic disease caused by Bacillus anthracis that poses a significant threat to both human health and livestock. Effective preparedness and response to anthrax outbreak at the district level is essential to mitigate the devastating impact of the disease to humans and animals. The current diseaae surveillance in animals and humans uses two different infrastructure systems with online platform supported by established diagnostic facilities. The differences in surveillance systems affect timely outbreak response especially for zoonotic diseases like anthrax. We therefore aimed to assess the feasibility of implementing a simulation exercise for a potential anthrax outbreak in a local government setting and to raise the suspicion index of different district stakeholders for a potential anthrax outbreak in Namisindwa District, Uganda.

METHODS

We conducted a field-based simulation exercise and a health education intervention using quantitative data collection methods. The study participants mainly members of the District Taskforce (DTF) were purposively selected given their role(s) in disease surveillance and response at the sub-national level. We combined 26 variables (all dichotomized) assessing knowledge on anthrax and knowledge on appropriate outbreak response measures into an additive composite index. We then dichotomized overall score based on the 80% blooms cutoff i.e. we considered those scoring at least 80% to have high knowledge, otherwise low. We then assessed the factors associated with knowledge using binary logistic regression with time as a proxy for the intervention effect. Odds ratios (ORs) and 95% Confidence intervals (95%CI) have been reported.

RESULTS

The overall district readiness score was 35.0% (24/69) and was deficient in the following domains: coordination and resource mobilization (5/16), surveillance (5/11), laboratory capacity (3/10), case management (4/7), risk communications (4/12), and control measures (4/13). The overall community readiness score was 7 out of 32 (22.0%). We noted poor scores of readiness in all domains except for case management (2/2). The knowledge training did not have an effect on the overall readiness score, but improved specific domains such as control measures. Instead tertiary education was the only independent predictor of higher knowledge on anthrax and how to respond to it (OR = 1.57, 95% CI = 1.07-2.31). Training did not have a significant association with overall knowledge improvement but had an effect on several individual knowledge aspects.

CONCLUSION

We found that the district's preparedness to respond to a potential anthrax outbreak was inadequate, especially in coordination and mobilisation, surveillance, case management, risk communication and control measures. The health education training intervention showed increased knowledge levels compared to the pre-test and post-test an indicator that the health education sessions could increase the index of suspicion. The low preparedness underscores the urgency to strengthen anthrax preparedness in the district and could have implications for other districts. We deduce that trainings of a similar nature conducted regularly and extensively would have better effects. This study's insights are valuable for improving anthrax readiness and safeguarding public and animal health in similar settings.

Using the integration of human resource management strategies at district level to improve workforce performance: analysis of workplan designs in three African countries

BACKGROUND

There is a worldwide shortage of health workers against WHO recommended staffing levels to achieve Universal Health Coverage. To improve the performance of the existing health workforce a set of integrated human resources (HR) strategies are needed to address the root causes of these shortages. The PERFORM2Scale project uses an action research approach to support district level management teams to develop appropriate workplans to address service delivery and workforce-related problems using a set of integrated human resources strategies. This paper provides evidence of the feasibility of supporting managers at district level to design appropriate integrated workplans to address these problems.

METHODS

The study used content analysis of documents including problem trees and 43 workplans developed by 28 district health management teams (DHMT) across three countries between 2018 and 2021 to identify how appropriate basic planning principles and the use of integrated human resource and health systems strategies were used in the design of the workplans developed. Four categories of HR strategies were used for the analysis (availability, direction, competencies, rewards and sanctions) and the relationship between HR and wider health systems strategies was also examined.

RESULTS

About half (49%) of the DHMTs selected service-delivery problems while others selected workforce performance (46%) or general management (5%) problems, yet all workplans addressed health workforce-related causes through integrated workplans. Most DHMTs used a combination of strategies for improving direction and competencies. The use of strategies to improve availability and the use of rewards and sanctions was more common amongst DHMTs in Ghana; this may be related to availability of decision-space in these areas. Other planning considerations such as link between problem and strategy, inclusion of gender and use of indicators were evident in the design of the workplans.

CONCLUSIONS

The study has demonstrated that, with appropriate support using an action research approach, DHMTs are able to design workplans which include integrated HR strategies. This process will help districts to address workforce and other service delivery problems as well as improving 'health workforce literacy' of DHMT members which will benefit the country more broadly if and when any of the team members is promoted.

Political economy analysis of subnational health management in Kenya, Malawi and Uganda

The need to bolster primary health care (PHC) to achieve the Sustainable Development Goal (SDG) targets for health is well recognized. In Eastern and Southern Africa, where governments have progressively decentralized health decision-making, health management is critical to PHC performance. While investments in health management capacity are important, so is improving the environment in which managers operate. Governance arrangements, management systems and power dynamics of actors can have a significant influence on health managers' ability to improve PHC access and quality. We conducted a problem-driven political economy analysis (PEA) in Kenya, Malawi and Uganda to explore local decision-making environments and how they affect management and governance practices for health. This PEA used document review and key informant interviews (N = 112) with government actors, development partners and civil societies in three districts or counties in each country (N = 9). We found that while decentralization should improve PHC by supporting better decisions in line with local priorities from community input, it has been accompanied by thick bureaucracy, path-dependent and underfunded budgets that result in trade-offs and unfulfilled plans, management support systems that are less aligned to local priorities, weak accountability between local government and development partners, uneven community engagement and insufficient public administration capacity to negotiate these challenges. Emergent findings suggest that coronavirus disease 2019 (COVID-19) not only resulted in greater pressures on health teams and budgets but also improved relations with central government related to better communication and flexible funding, offering some lessons. Without addressing the disconnection between the vision for decentralization and the reality of health managers mired in unhelpful processes and politics, delivering on PHC and universal health coverage goals and the SDG agenda will remain out of reach.

Using a theory of change in monitoring, evaluating and steering scale-up of a district-level health management strengthening intervention in Ghana, Malawi, and Uganda - lessons from the PERFORM2Scale consortium

Background

Since 2017, PERFORM2Scale, a research consortium with partners from seven countries in Africa and Europe, has steered the implementation and scale-up of a district-level health management strengthening intervention in Ghana, Malawi and Uganda. This article presents PERFORM2Scale’s theory of change (ToC) and reflections upon and adaptations of the ToC over time. The article aims to contribute to understanding the benefits and challenges of using a ToC-based approach for monitoring and evaluating the scale-up of health system strengthening interventions, because there is limited documentation of this in the literature.

Methods

The consortium held annual ToC reflections that entailed multiple participatory methods, including individual scoring exercises, country and consortium-wide group discussions and visualizations. The reflections were captured in detailed annual reports, on which this article is based.

Results

The PERFORM2Scale ToC describes how the management strengthening intervention, which targets district health management teams, was expected to improve health workforce performance and service delivery at scale, and which assumptions were instrumental to track over time. The annual ToC reflections proved valuable in gaining a nuanced understanding of how change did (and did not) happen. This helped in strategizing on actions to further steer the scale-up the intervention. It also led to adaptations of the ToC over time. Based on the annual reflections, these actions and adaptations related to: assessing the scalability of the intervention, documentation and dissemination of evidence about the effects of the intervention, understanding power relationships between key stakeholders, the importance of developing and monitoring a scale-up strategy and identification of opportunities to integrate (parts of) the intervention into existing structures and strategies.

Conclusions

PERFORM2Scale’s experience provides lessons for using ToCs to monitor and evaluate the scale-up of health system strengthening interventions. ToCs can help in establishing a common vision on intervention scale-up. ToC-based approaches should include a variety of stakeholders and require their continued commitment to reflection and learning on intervention implementation and scale-up. ToC-based approaches can help in adapting interventions as well as scale-up processes to be in tune with contextual changes and stakeholders involved, to potentially increase chances for successful scale-up.