Managers are health workers too

07 Apr 2021
An African man stands at a flipchart stand and talks to an interested group of African men and women

During World Health Worker Week the role of managers in supporting  their charges, and in being supported themselves, is considered  through testimonies from PERFORM2Scale participants.

When we consider health workers our first thought may be ‘frontline’ staff in PPE and uniforms directly interacting with patients. If we were not appreciative of their skill, dedication and empathy before COVID-19 then the pandemic has certainly driven home our reliance on these people and the debt we owe them. International calls to policymakers to listen to health workers and to better support and protect them are much needed.

However, the argument can be made that managers are also health workers: indeed, many will have been promoted from the ‘frontline’ at some stage. They are similarly committed to their profession, are also skilled – albeit in a different way – and care for those in their charge. Just as the drive towards universal health coverage is dependent on health workers, nurses and doctors in health facilities and the community, so it is reliant on the people behind the scenes who work to support their staff and get the most from the available resources.

Supporting behind-the-scenes health workers

PERFORM2Scale Country Research Teams in Ghana, Malawi and Uganda have worked to give members of the District Health Management Teams (DHMT) the tools to identify their own health workforce problems and address them in the way they think best. The aim is to make them better managers who can support their staff to do their best, resulting in improved service and better health outcomes. One Ministry of Health commissioner in Uganda described PERFORM2Scale as:

“It brings on board the real people on the ground who are implementing the service, the people in charge in the actual implementation - they are involved in the whole process. This automatically looked workable because there is a bottom-up approach… based on my experience of PERFORM2Scale it is working.”

A Regional Health Research Coordinator in Ghana agrees:

“What makes PERFORM2Scale stand out is that the project freely guides and allows intervention districts to use local evidence to solve their own workforce challenges which are specific to their districts.”

Managers are encouraged to use the ‘decision space’ that decentralised health systems have afforded them. As the 2021 World Health Worker Week call-to-action said, “Health workers know best what they need to be safer, healthier, and more prepared to end the COVID-19 pandemic, prevent future disease outbreaks, and ensure access to essential services for their communities”.

Listening to managers

Interviews with DHMT members and staff from regional and national government have revealed that staff are “finding their voices” through PERFORM2Scale.

Learning to make effective use of their decision space is repeatedly reported, both by Ministry of Health staff and DHMTs.

“You are trained to identify your own problems, to prioritise which problems you want to solve and then how you want to solve them. It is all within your own decision space.”

A manager from Wakiso district in Uganda commented that:

“The most important thing about PERFORM2Scale is that whatever interventions are put in place they are under our control, they are our decision space… It is one of the things that PERFORM2Scale has opened our eyes on, empowered us on…”

A Ministry of Health commissioner in Uganda agreed:

“What PERFORM2Scale has done is make DHMTs aware of the decision space that they weren’t aware about, that is within the decentralised mandate. What is also emerging is how once they are made aware of their mandates and decision space, is their ability to innovate around it.”

The value of work

Numerous workforce performance models highlight the intrinsic value of work – the satisfaction that comes from a job well done – and this is reported in PERFORM2Scale. A manager from Nakaseke district in Uganda commented that:

“PERFORM2Scale has improved my confidence… and also my job satisfaction – I’m more satisfied in my job than how I used to be. And it has developed my skills. I can now reflect on issues, analyse issues and problem solve more critically than I used to do before, so for me it has worked.”

PERFORM2Scale has also help bring extrinsic satisfaction to DHMTs in Malawi:

“We are seeing improvements in job satisfaction. Recently the director  recommended the promotion of some DHMT members because of their  commitment and good work which is increasing job satisfaction and motivation.”

Also, the key workforce performance model elements that enable health workers to translate their efforts into performance – clear direction from their managers (meetings, supervision, workplans etc), competencies (mentoring, self-learning and training) and materials – feature heavily in PERFORM2Scale. They provide focus for the workplans managers have created to address workforce issues and are reported as being vital by DHMT members. These factors were well represented in an interview with a doctor from Salima, Malawi. He talked about the steps his team took to address a lack of supportive supervision for health workers:

“Number one was to come up with a supervision plan. Number two was to come up with teams – the teams that would help us, that we have to conduct the supervisions... The third was to facilitate health centre interface meetings... Number four, was to develop and submit weekly plans – that is individual plans… Then to train supervisors in effective support supervision. The other one was to orientate the staff on their roles and responsibilities – that’s assigning each a job description that we were also missing in the HR personal files. And the last one was to come up with a specific transport system that was also lacking and also contributing to our poor performance in supportive supervisions.”

A Ugandan doctor agreed about the need for clear direction and how it flows from managers themselves:

“A more cohesive, common understanding of problems, working as a team for strategy development, has led to better management of and performance of lower cadres.”

As World Health Worker Week annually argues, listening to staff and allowing them to act on their ideas can have real impact. In Salima, Malawi a situation in which more than 50% of health facilities were unsupervised in 2017/18 saw a marked improvement thanks to PERFORM2Scale.  Action by DHMT staff led to greater staff efficiency and effectiveness, more job satisfaction and confidence, and better reporting and supervisory systems. In Yilo Krobo district in Ghana a very low rate of Yaws identification was turned around, leading to treatment of all identified cases and increased detection of other neglected tropical diseases. As the Regional Health Research Coordinator said:

“The case of Yilo Krobo is clear evidence that gathering people, helping them to realise their needs and finding solutions greatly helps in addressing problems.”

World Health Worker Week is sorely needed for us to show our support for and petition for the better treatment of health workers around the world – especially given the additional challenge of COVID-19. However, we also need to support them by finding ways to help their managers build the necessary skills to support workers on the ‘frontline’.  The progress made so far and the continued scaling up of the PERFORM2Scale management strengthening programme in three countries is doing just that.

Further information

There is more on the interviews and case studies mentioned here:

  • Yilo Krobo district, Ghana and its drive to improve Yaws detection are featured in this briefing paper, as is an interview with the Regional Health Research Coordinator
  • The Salima district, Malawi case study and interviews can be read in this briefing paper

The end-of-project webinar which revealed our main findings and heard from the people delivering PERFORM2Scale can be viewed here.