The PERFORM Project

PERFORM2Scale is based on the success of the PERFORM project which was delivered in Ghana, Tanzania and Uganda in 2011-15.

The background to PERFORM

Health systems in Africa do not meet their full potential. Part of the reason is a lack of adequately-trained health care and related workers. However, we also need to focus on the existing workforce and help them to improve their performance and provide a better health service.

PERFORM sought to test a method for providing an adapted, cost-effective and sustainable way for researchers to support improvements in health worker performance within the health system. It did this through a management strengthening intervention.

What were PERFORM’s aims?

The overall aim was to identify ways of strengthening decentralised management to improve health workforce performance in sub-Saharan Africa.

The specific objectives were:

  • To support health managers to carry out a situation analysis on the health workforce, with a particular focus on performance, in the study districts.
  • To develop and test context-specific management strengthening processes, focused on improving workforce performance, which will:
    • identify areas of health workforce performance to be improved,
    • implement integrated HR and health systems strategies feasible within the existing context, to improve health workforce performance, and
    • monitor the implementation of the strategies and evaluate the intermediate processes and impact on health workforce performance, and the wider health system.
  • To conduct comparative analyses across districts and countries looking at:
    • the management strengthening intervention to support improved workforce performance, and
    • processes of implementing the integrated HR and health systems strategies and intended and unintended effects on health workforce performance and the wider health system.
  • To raise awareness and change attitudes of sub-national, national and international stakeholders.
  • To consolidate research capacity of partners on integrated approaches to workforce performance improvement and contribute to strengthening capacities of decentralised management of district health systems.
  • To establish and maintain effective partnerships amongst academia, civil society, policy-makers, and health managers in study countries and amongst partners.

How was PERFORM delivered?

The management strengthening intervention is which employs an action research cycle

PERFORM recognised that workforce performance improvement can be achieved better at management levels close to frontline workers. The team developed a problem-based management strengthening intervention for management teams at district level in three African countries, to improve health workforce performance and service delivery more generally.

The approach addressed real problems and used planning and management tools that managers were familiar with and for which they were likely to get future support. The intervention employed locally available tools and drew on the concepts of action research [link to resources section below] which are outlined in this diagram. District managers were supported in a situational analysis of their workforce problem and then the identification, implementation and evaluation of appropriate local strategies to respond to this.

What did PERFORM achieve?

The evaluation of the management strengthening intervention demonstrated its effectiveness in enabling the District Health Management Teams (DHMTs) in each context to solve workforce performance and other problems locally, improving service delivery and helping them become better managers.

DHMT members demonstrated improved management competencies for problem analysis, prioritisation and integrated human resource management and health systems strategy development. They learnt how to refine plans as more information became available and the importance of monitoring implementation. The intervention also produced changes in team behaviour and confidence.


PERFORM’s action research toolkit 

Resources including peer-reviewed papers, briefs, reports and videos

The PERFORM website 

PERFORM partners

Liverpool School of Tropical Medicine, UK

School of Public Health, University of Ghana

Institute of Development Studies, University of Dar es Salaam, Tanzania 

Makerere School of Public Health in Uganda 

Swiss Tropical and Public Health Institute 

Nuffield Centre for International Health and Development, UK 


The African partners were selected as each of these countries faces major problems of inadequate health workforce. They also have decentralised management structures that offer management teams greater decision-making opportunities, including in the area of human resources.