1. Dr Alvaro Alonso-Garbayo Second National Summit of Health and Population Scientists in Nepal ‘Health and Population Research for Achieving sustainable Development Goals in Nepal' April 10-12, 2016 Kathmandu, Nepal HRH for UHC PERFORM: Improving health workforce performance through action research

2. 2 Background Health workforce is essential to achieve SDGs and UHC; Achievement of all SDG targets proposed in Nepal depends on its workforce; HWF decisions need to be based on locally generated evidence; Action research has been used in other countries to strengthening management capacity at sub-national levels (e.g. Ghana, Tanzania, The Gambia); Resilient health systems require resilient health workforce (Nepal post-earthquake); Some issues identified during the development of HRH Strategic Plan 2011-2015 (still valid today) Shortage of HRH as a result of imbalances supply/demand Maldistribution particularly rural/remote areas; Poor performance including productivity, quality and availability; Fragmented approach to HR planning, management and development; HRH financial constraints

3. 3 Why the health workforce is important? Source: World Health Report 2006

4. 4 Shortage of HRH in the SEAR * (minimum thresholds: 23) Density of HRH (physicians, nurses and midwives/10,000 population)

5. 5 UHC and HRH: effective coverage Source: Campbell, J. et al 2013

6. 6 EFFECTIVE COVERAGE GAP UHC and HRH: effective coverage Source: adapted from Campbell, J. et al. 2013

7. 7 Improving health workforce performance in decentralised environments through action research: a case study in Uganda, Ghana and Tanzania

8. 8 Action research “Action research is a period of inquiry that describes, interprets and explains social situations while executing a change intervention aimed at improvement and involvement. It is problem focused, context-specific and future-oriented.” Subjects of research are transformed into active researchers and agents of change; Takes place in “real life” settings; Involves developing, implementing and reflecting on actions; Seeks to understand and improve the world by changing it; Those affected by problems collectively act and produce change as a means to new knowledge.

9. 9 What is PERFORM? Project Timescale Funder Start September 2011 Ends August 2015 4 year programme Focus: improving health workforce performance European Union (EU) Aim To understand how management strengthening can improve workforce performance in 3 districts in each country

10. 10 Who are the partners? PERFORM Consortium Ghana Leeds (UK) Liverpool (UK) SwitzerlandTanzaniaUganda College of Health Sciences, School of Public Health, Makerere University Liverpool School of Tropical Medicine School of Public Health, University of Ghana Nuffield Centre for International Health and Development, University of Leeds Institute of Development Studies, University of Dar-es-Salaam Swiss Tropical and Public Health Institute

11. 11 Background Global shortage of health workers; Deficit can be addressed by: training more new personnel; and improving performance of the existing workforce Complex factors affect workforce performance; Opportunities available where planning and management is decentralised; Action research is an appropriate approach to strengthening management to improve workforce performance.

12. 12 Study design PlanActObserveReflect

13. 13 Plan develop workforce improvement strategies, plan implementation and how to observe effectiveness Act implement workforce improvement strategies (HR/HS bundles) Observe the effects of the workforce improvement strategies Reflect on the effectiveness of the workforce improvement strategy Situation Analysis CRTs support DHMT to carry out a situation analysis on the health workforce (performance) in study districts AND IDENTIFY, PRIORITIZE AND SELECT PROBLEMS Overall Evaluation of Intervention Process and Impact  Record and reflect on the change process throughout AR cycles using learning histories.  Re-collect core data from situation analysis to identify within- district changes. Action Research Process

14. 14 Effects on health workforce performance Improved and increased staff supervision; Reductions in absenteeism; More staff appraised; Improved knowledge of existing workforce; Improved induction of new staff; Improved staff allocation according to workload; Increased awareness about the importance of HWF information and evidence at sub- national levels Results

15. 15 Results Effects on management strengthening Expansion of managers’ decision-space; Improved team work; Improved skills on in-depth problem analysis- finding root causes; Integrated planning, resourcing and monitoring of processes and effects of plans; Increased ownership Address problems within existing resource constraints; Entrepreneurial approaches; Recognised importance of data for monitoring progress and evaluation of effects;

16. 16 Key messages The PERFORM approach Can contribute to achievement of UHC through: Improved understanding of implementation issues at sub-national level Experiences of appropriate and sustainable management strengthening New knowledge of effective integrated health systems strategies for improving health workforce performance Improve workforce performance through management strengthening; Bridge the gap between research and practice; Support sustainability and ownership through solving real problems at district level; Enable sharing of practices and learning; Promote culture of partnership; Unlock innovation.

17. 17 Funding from the European Commission 7th Framework Programme Project website: www.performconsortium.com Material Technical reports, tools, manuals, etc. Publications in peer-reviewed journals Blogs, videos, voices & perspectives form DHMT