Action Research Toolkit
An Action Research Toolkit was developed as part of the original PERFORM project. Its purpose was to explain the process that was followed and to provide tools and tips for those who want to pursue a similar process or project. The full toolkit is below. An updated version of the toolkit is being tested in the PERFORM2Scale project and will eventually be made available.
The toolkit was divided into five sections: Introductory tools, Situation analysis tools, Planning tools, Observation tools and Reflection tools. They are all explained and available for download below.
This comparative analysis brief provides a quick overview of the outcomes of the perform project.
We also have briefs that give an overview of the work in Tanzania, Ghana and Uganda.
This brief provides a quick overview of the methodology.
This is our methods manual. It goes through the process that we followed, from start to finish. We also produced a manual for the DHMT members to guide them through the process and help with the design of the workplans.
Situation analysis tool
The first step is to agree and collect a minimum data set between all participating research sites. Depending on the focus of the project, this could include basic information on the health workforce, the composition of a District Health Management Team (DHMT), the local health system and local and national influences on DHMT performance. It is faster to collect, and more sustainable to use, existing (or secondary) data. Such sources include data routinely collected such as:
Health Management Information System; reports; plans; budgets; minutes of meetings etc.
Data collected by institutions such as the Ministry of Health, Ministry of Finance, Non-Governmental Organisations, development donors etc.
Where there are information gaps, it may be necessary to undertake primary data collection through key informant interviews or focus group discussions with DHMT members. Key informant interviews are used when it is important to gain insight into experiences, behaviours, attitudes, values of individuals. They vary in formality and structure. A focus group discussion is a moderated discussion that is used to explore the extent of shared beliefs, values and behaviours.
Data should be analysed within the action research team. The different roles and responsibilities in analysis should have been discussed at the beginning of the project, with flexibility allowed for these responsibilities to evolve over the course of a project. The whole team should then reflect on the issues emerging from these analyses. Some of these issues, for example, could include staff absenteeism rates and how decisions are made within the DHMT.
Once this analysis is conducted it is time to ask, “But why?” A list of follow-on questions should be compiled. As a result problematic areas of workforce performance can be identified and human resource/health system strategies selected to address them.
Tips on how to facilitate an introductory meeting with District Health Management Teams. If you are thinking of beginning an action research project with your District Health Management Team (DHMT) making a good impression at your first meeting and communicating clearly are crucial. Based on our experience here are some hints and tips which will ensure that your meeting goes as smoothly as possible.
Problem tree analysis. Problem tree analysis helps to find solutions by mapping out, in a structured way, the anatomy of cause and effect around an issue. Problem tree analysis should be used with the District Health Management team in advance of the first stakeholder meeting in order to get a clearer view of the human resources/health systems problems that are being faced.
Strengths, weaknesses, opportunities and threats exercise. The process of identifying strengths, weaknesses, opportunities and threats will allow the District Health Management Teams develop the team in a way that builds on their strengths and opportunities while managing and eliminating their weaknesses and threats.
The initial situation analysis lays the foundation of problem analysis. During the problem analysis, the research team asks questions of their collected data, such as:
- What are the areas that are in need of improvement or change?
- Are these problems specific to different cadres, gender or other criteria?
- What appears to be the root causes of these problems?
- What is the larger picture in which these problems and their causes seem to exist?
Are there links between the problems? There are various techniques that can be used to undertake problem analysis. Two such techniques are problem trees (see Appendix 11) These are used to develop a comprehensive list of problems, their root causes and relationships between seemingly different problems. Having identified the problems affecting workforce performance in a health district using tools like the Problem Tree analysis (included in Situation analysis tools) these need to be ranked in order of priority. In PERFORM this work was undertaken in collaboration with a wider stakeholder group in a series of two workshops.
There are a wide range of strategies that can be used to improve workforce performance, depending on the particular problem(s) to be addressed. The challenge is to identify strategies that are feasible to implement and likely to be effective in the short term within each unique local situation. Selected strategies should complement each other. When creating a bundle of strategies it is important to consider:
- Staff availability – what are the required cadres and specialists available in the district?
- Staff competencies – what skills does the available staff require to do their job?
- Staff direction – what tasks need to be performed to achieve the expected results?
- Rewards and sanctions – how can good performance be rewarded and what sanctions could be put in place to curb poor performance?
- The health system within which staff work – what system wide issues may be encouraging good performance or demotivating staff?
These guidelines for your first stakeholder workshop provide sample aims and objectives and a guide to how the two days could be structured.
This Power Point presentation provides a guide that you can adapt for your first stakeholder workshop.
Observation checklist for situation analysis presentation. In the months before the stakeholder workshop you will have worked with District Health Management Teams to conduct a situation analysis - identifying health workforce performance problems. This will include the collection and analysis of routine data such as staffing and health service information, reviewed existing report and documents, and facilitated group discussions with District Health Management Teams to better understand their role and health workforce performance. This will have led to the creation of problem statements related to health workforce performance. This document provides advice on how you can feed this information back to a wider stakeholder group.
Health workforce performance and the use of bundles of human resources/health systems strategies. This presentation leads stakeholders through what kind of strategies they might develop to address the problems that they are facing. It explains how the performance of the collective workforce is largely a result of management decisions and individual performance is, in part, a result of interactions between managers and/or supervisors and the individual health worker. It prompts stakeholder to consider the role of non-clinical staff such as managers and support staff. It includes a discussion of potential interventions to improve staffing levels and how research teams can better understand individual staff performance. Because it is unlikely that any one strategy will solve all the human resource and health system challenges that are being faced it talks about how a number of strategies can be combined.
Worksheet for listing and reviewing human resources/health systems strategies. This simple hand out enables stakeholders to list the potential problems that they will work on and the strategies that they will test in overcoming them.
Evaluation questionnaire. This tool allows stakeholders to provide feedback on your workshop.
These guidelines for your second stakeholder workshop lead you through the process of refining problem statements and problem trees, using reflective diaries, and ensuring ongoing support and communication throughout the research process.
This Power Point presentation provides introductory slides for the second stakeholder workshop.
Guidance for refining problem tree analysis. This can be used during small group work in the workshop to help participants improve and peer review their problem trees.
Developing bundles of human resources/health systems strategies. This Power Point presentation provides an overview of human resources/health systems bundles of strategies and this types of interventions that District Health Management Teams might consider. It then helps participants to develop and evaluate different bundles of interventions.
This table for planning bundles human resources/health systems strategies is to be used as a handout to guide small group work during the workshop.
Worksheet for reviewing bundles of human resources/health systems strategies to improve workforce performance. This tool enables workshop participants to review the bundles of strategies that are developed during the small group work.
Instructions for using District Health Management Team diaries. This handout can be taken away from the meetings as a guide to ensure that appropriate process data is collected throughout the research process.
Guidance for ongoing support and communication session. This is a very important session to ensure continued collaboration between research teams and District Health Management Teams in the project. This guidance for workshop facilitators provides some ideas for this session; please adapt as you feel appropriate.
It is important to evaluate the workshop. The form from the first workshop can be adapted for this.
Having selected the human resources/health system bundle, the research team is now in a position to plan implementation. Participating districts will likely have existing plans and targets, so first consider how these may be modified to address the prioritised problems. The plan is not necessarily a complex document. It can be as simple as a table noting the issues set out in bullet points:
- Identify the particular strategy you want to use
- Identify the activities needed to implement the strategy
- Develop targets based on expected improvements in performance when compared to the situation analysis. The targets should be time-bound
- Identify linkages to other strategies in a bundle
Strategies should always be developed within local budgets, integrated into local planning cycles and take account of authority constraints. Facilitators in the research team should focus on what is feasible for District Health Management Teams to undertake within a limited period of time. They should also ensure that the selected strategies are compatible with the regional and national human resources priorities and strategies. Second, District Health Management Teams will already have human resources/health systems strategies in place. These could also be included in a bundle or tweaked to be more effective. Strategies that are already in the routine plan will be funded so are more likely to be implemented. Do consider whether any new strategies may have negative unintended consequences on strategies already in place.
During this period of the project some strategies may be dropped - this is not a failure. Rather it is important is to understand why they were dropped. When a team reflects on why something changed, the District Health Management Team are in fact learning to develop appropriate strategies to improve workforce performance within their own unique district. Alternatively, new strategies may be added if, for example, a District Health Management Team identifies part of the overall problem that has not yet been addressed.
There are a range of documentation process that can be used but it is important to use a method that works most effectively given available resources (time, money, planning expertise, and willingness). This could be a learning history, or a diary or another format. Learning histories and diaries can be rich documents for research but if District Health Management Teams have no time or willingness to use them, they are useless. Second, when recording activities and reflection spirals, aim for a mix of quantitative and qualitative data because such a mix will help the action research team to comprehensively assess the change that took place.
This Power Point presentation provides more information on capturing progess and learning and the use of reflective diaries.
One way of observing the process of change in the project is to use a reflective diary. Guidance on how to use the diaries is provided in the Planning tools section of this toolkit. This is an example of a completed diary reflection.
The reflection period of the project is a time when the team can step back and take stock of whether, and to what extent, problems have been solved or have evolved over the period of the action research project.
A final situation analysis can create an endline to enable comparison with the initial situation analysis. By comparing initial and final situations, changes can be identified and measured. Just as with an initial situation analysis, you should aim to make best use of routinely collected data to simplify the collection process and minimize disruption to the daily work of the District Health Management Team. In principal, the final situation analysis should mirror the initial situation analysis. Use the same approach to both data collection and analysis and add further information as required, based on learning during the project.
An additional option is to include an external group as observers in the final situation analysis to gain an additional view of the changes during the project. This could be conducted by presenting results to a variety of stakeholders in a district or national workshop, or by inviting a group to observe the process of conducting a final situation analysis.
It is best to mirror the initial situation analysis, however the methods that you use need to be appropriate to the resources available: teams change; researchers with different skills sets leave and arrive; documentary information may not be available due to changes in personnel, organisational changes or disastrous events. Tools used in the initial situation analysis will inevitably need to be adapted somewhat to fit the new situation. In other words, some flexibility is required.
The human resources/health systems bundles will keep changing during the course of action research spirals and the baseline data collected during the initial situation analysis may not be relevant to the final bundle. When this happens, we suggest a meta-comparison such as comparing type of issue/problem addressed (easy versus complex), planned versus actual results and ensure that the justification for changes in the human resources/health systems bundles is clear and convincing. Finally, additional data may need to be collected to gain a useful picture of the final situation and to enable change to be measured.
This is an example of a Power Point presentation that we used to test our findings with stakeholders.