Introduction to the MSI

A circle of arrows with the words Plan, Act, Observe & Reflect

The full MSI toolkit containing this text and links to all associated documents can be found here.


The PERFORM project (2011-15) piloted a management strengthening intervention (MSI) and tested it with District Health Management Teams (DHMT) in Ghana, Uganda and Tanzania in groups of three districts (referred to as ‘District Groups’) in each country. The MSI was then slightly revised based on the PERFORM project experience and scaled up in 27 districts (also in District Groups of three) in Ghana, Uganda and Malawi from 2017-22 under the PERFORM2Scale project.  

The MSI is based on an action research approach (Figure 1) to enable the teams to analyse their own workforce performance- related problems and develop appropriate workplans (plan), implement the workplans (act), and learn about management from the experience (observe and reflect).  As the MSI was scaled up, the first district groups repeated MSI cycles (see Figure 2).

As PERFORM2Scale extended over five years, it was possible for the project to increase the number of MSI cycles supported, allowing each DHMT to deepen their learning and to increase the number of participating DHMTs (Figure 2) with up to three cycles achieved during the implementation period from mid-2018 to late 2021. There were some delays due to the COVID-19 pandemic. 

Three linked circles of arrows with the words Plan, Act, Observe & Reflect on each

The MSI principles were designed to ensure that the intervention would lead to management strengthening. Those principles included:

  • DHMTs themselves choose the problems to address, as this would increase ownership of the process and the workplans developed.
  • No extra resources for implementing the workplan were provided.
  • Not being too ambitious with workplans so that strategies were feasible.
  • Carrying out the MSI as a team.
  • Sharing experiences and learning across districts.
  • Strong facilitation skills to guide and support the DHMTs.

To facilitate the sharing of experiences and learning across districts groups, three adjacent districts were selected were selected for each group. In the process of scaling-up the MSI, new groups of districts were added during the programme. The selection of districts was done with government and in conjunction with the districts themselves.
In PERFORM and PERFORM2Scale the MSI was supported by national facilitators  in each country through meetings in each district, short workshops followed by joint meetings bringing the three DHMTs together, and follow-up support to each district. Problems selected in PERFORM2Scale included: service delivery problems, eg ‘low case detection of neglected tropical disease (Yaws)’, human resource (HR) problems, eg ‘high-level absenteeism among health workers’, and some general management problems related to reporting. They developed integrated strategies for inclusion in annual district plans, largely using available resources. 

The requirements for PERFORM2Scale to conduct the MSI included:

  • Agreements with national and local health authorities (this included sending out invitation letters for workshops etc and in some cases a memorandum of understand between the government and the implementing agencies)
  • Districts willing to participate in the MSI; these were selected in groups of three adjacent districts to facilitate meetings and workshops in one locality
  • Funding for workshops, meetings and visits
  • The facilitators were from the implementing agency  for the project (referred to as the Country Resource Team – or CRT) and Resource Team (RT) members from different levels of government.  In this main toolkit we now refer to them as ‘facilitators’, but in some of the unedited attachments they are still referred to as CRT and RT. Both CRTs and RTs made a major time investment, particularly once several district groups were running simultaneously.
  • Of the DHMT members, most were involved, but only three or four would attend the workshops. Some DHMTs appointed a ‘focal point’ to liaise with the CRT/RT.

MSI cycle 1

A circle of arrows with the words Plan, Act, Observe & Reflect surrounded by text describ9ng each stage

The MSI uses an action research cycle and includes four stages. Figure 3 shows these stages broken down into the key activities to be carried out. Figure 4 shows the activities with their durations. The text below now takes each of these activities, describes them in detail and provides links to relevant tools and guidance (for meetings, workshops and planning templates).

A timeline of stages and activities in each



+++ When planning the programme, the organisers should discuss whether the cycle should be aligned with +++
the regular planning and budget cycle and how long the period for implementing strategies should be.