The PERFORM Project

PERFORM2Scale was 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.

Action Research Toolkit

PERFORM adopted and adapted an action research process to work on strengthening human resources for health policy and practice in Ghana, Tanzania, and Uganda. The toolkit explains the process that the team followed and to provide tools and tips to others who want to pursue a similar process or project. The full toolkit can be found here.

Introduction to how we used action research in PERFORM

Using an action research approach we supported health managers to carry out a situation analysis on the health system, with a particular focus on workforce performance, in nine study districts (three per country). They then identified the areas of health workforce performance to be improved, developed and to, implemented integrated human resource and health systems strategies feasible within the existing context to improve health workforce performance, and monitor the implementation of the strategies, evaluate the processes and impact on health workforce performance and the wider health system.

PERFORM researchers worked with district health managers in a process that led them through one or two cycles of action research. This enabled them to 1) Plan; 2) Act; 3) Observe; 4) Reflect.

Initial situational analysis

In this phase of the cycle researchers supported District Health Management Teams to conduct a situation analysis where they identified health workforce performance problems in their districts. They collected and analysed routine data such as staffing and health service information using a standard form, reviewed existing report and documents, and facilitated group discussion with District Health Management Teams to better understand their role and health workforce performance. From this they formulated problem statements related to health workforce performance.


In a series of facilitated meetings and workshops, the District Health Management Teams prioritised the problems and then analysed the root causes of these problems.

Based on the problem analysis, the district health management teams identified a mixture of human resource and health system strategies e.g. developing skills through a training workshop and repairing equipment so health workers can do better work.

These strategies needed to be:

  •     Possible to implement (i.e. within the District Health Management Team’s boundaries of budget and authority)
  •     Aligned to and embedded in annual priority/activity planning of districts
  •     Focused on improving health workforce performance in the district
  •     Likely to have a measurable and observable effect on workforce performance within 12-18 months
  •     Implemented within resources available to the district
  •     Reflected the data in the district report (i.e. based on evidence accumulated in the situation analysis).
  •     Likely to be effective in the given situation.


The strategies were implemented over a period of 18 months.


District Health Management Team diaries, visits by the research team, inter-district meetings were used to facilitate observation and reflection of the implementation of different strategies and their effects on workforce performance. In each district, qualitative and quantitative research methods were used to evaluate the intervention. Qualitative data collection and analysis: focus group discussions with District Health Management Team members, in depth interviews with District Health Management Team members, health facility managers and staff, and stakeholders were conducted. The recordings were transcribed verbatim, and analysed thematically with support from the NVivo software. Documents such as district annual workplans, budgets and reports, workshop reports and DHMT diaries were analysed thematically. Quantitative data collection and analysis: selected health systems and health services indicators were collated at the District Health Office from the Health Management Information System.


If the District found that one of the strategies they were implementing was not working – or affecting another strategy negatively (for example there is a risk that the upgrading training will have a negative impact on the strategy of reducing staff absence – especially if the number of staff in the facilities is already very low) they were encouraged to consider modifying it or even dropping it from the bundle. Modifying or dropping a strategy was not considered a failure. The purpose of the action research approach being used was not only to try to solve immediate problems, but also to learn, collectively as the District Health Management Team, what sort of strategies worked under what circumstances. More challenging – but even more useful – is to learn why certain strategies do or do not work in a particular situation.


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.