Human Resources for Health BioMed Central Commentary Improving retention and performance in civil society in Uganda

The Public Health Resource Network is an innovative distance-learning course in training, motivating, empowering and building a network of health personnel from government and civil society groups. Its aim is to build human resource capacity for strengthening decentralized health planning, especially at the district level, to improve accountability of health systems, elicit community participation for health, ensure equitable and accessible health facilities and to bring about convergence in programmes and services. The question confronting health systems in India is how best to reform, revitalize and resource primary health systems to deliver different levels of service aligned to local realities, ensuring universal coverage, equitable access, efficiency and effectiveness, through an empowered cadre of health personnel. To achieve these outcomes it is essential that health planning be decentralized. Districts vary widely according to the specific needs of their population, and even more so in terms of existing interventions and available resources. Strategies, therefore, have to be district-specific, not only because health needs vary, but also because people's perceptions and capacities to intervene and implement programmes vary. In centrally designed plans there is little scope for such adaptation and contextualization, and hence decentralized planning becomes crucial. To undertake these initiatives, there is a strong need for trained, motivated, empowered and networked health personnel. It is precisely at this level that a lack of technical knowledge and skills and the absence of a supportive network or adequate educational opportunities impede personnel from making improvements. The absence of in-service training and of training curricula that reflect field realities also adds to this, discouraging health workers from pursuing effective strategies. The Public Health Resource Network is thus an attempt to reach out to motivated though often isolated health workers. It interacts with, and works to empower, health personnel within the government health system as well as civil society, to meaningfully participate in and strengthen decentralized planning processes and outcomes. Structured as an innovative distance-learning course spread over 12 to 18 months of coursework and contact programmes, the Public Health Resource Network comprises 14 core modules and five optional courses. The technical content and contact programmes have been specifically developed to build perspectives and technical knowledge of participants and provide them with a variety of options that can be immediately put into practice within their work environments and everyday roles. The thematic areas of the course modules range from technical knowledge related to maternal and child health and communicable and noncommunicable diseases; programmatic and systemic knowledge related to health planning, convergence, health management and public-private partnerships; to perspective-building knowledge related to mainstreaming gender issues and community participation. Currently the Public Health Resource Network has been launched in four states of India--Chhattisgarh, Jharkhand, Bihar and Orissa--in its first phase, and reaches out to more than 500 participants with diverse backgrounds. The initiative has received valuable support from central and state government departments of health, state training institutes, the National Rural Health Mission--the current comprehensive health policy in the country--and leading civil society organizations.


Introduction
The Family Life Education Program (FLEP) of the Busoga Diocese of Uganda, a multi-service reproductive health agency that operates 40 rural clinics in five districts of Uganda was supported in part by the DISH II project, a project funded by the US Agency for International Development (USAID) [1]. FLEP provides community-based health services, including family planning, immunization, maternal health, nutrition, and HIV & AIDS counseling. At the end of the DISH II project, the services of FLEP were continued by the Planning and Development Department of Busoga Diocese.
When the program began to see an increase in staff turnover and a decrease in overall organizational performance, MSH was asked to help. The workplace climate was poor and people had stopped coming for services. FLEP's leaders decided it was time to examine their HRM system and practices.
In August 2001, the senior managers at FLEP used MSH's HRM Assessment Tool to examine the functioning of their HRM system. This tool provides users with a rapid way to identify the strengths and weaknesses of their HRM system and develop an action plan for improvement. The exercise, including the action plan, can be completed in one day.
The instrument consists of a matrix of 23 HRM components that fall into six broad areas of HRM: The tool also describes four stages of development for each component and provides blank spaces for users to write a brief statement, or indicator, to show how the organization fits into a particular stage of development.

Discussion
After the assessment, FLEP's management committee reviewed the results and determined the priorities for action. Their priorities were to: Longer-range priorities were likewise planned for staff training, strengthening of management and leadership at all levels of the organization, and annual reviews of salary policy. A survey measuring employee satisfaction was carried out in September 2001 to identify other areas for intervention. In addition, FLEP managers worked with MSH to develop a monitoring and evaluation plan using indicators that would track HR management and performance components.
MSH staff and the FLEP Human Resource Administrator met with two representatives of the FLEP board of directors and briefed them on the HRM assessment, priorities identified, proposed actions, and indicators to measure performance improvement. The board members agreed that the need to improve FLEP's HRM was urgent, and they fully supported the proposed HR plan and new management approach.

The Achievements of the Program
With MSH technical assistance, FLEP established a responsive HRM system. FLEP revised and updated its per-sonnel policy and procedures, and produced and distributed a new personnel manual to management and supervisory staff at the clinics. Personnel files were completed and job descriptions were updated. A senior management team was installed at headquarters. Operations were streamlined by reducing the number of zonal coordinators from eight to four and Volunteer Health Worker supervisors from seventeen to eight. Poor-performing staff were dismissed and the remaining staff were given fixed contracts until the end of the project, which gave them an increased sense of security. A performance appraisal process was instituted, and supervisors were trained in basic supervision skills and the use of appraisal forms and a supervisory checklist.
These measures did not require additional funding or resources. Rather they reflected the commitment of the leadership team to support health staff by increasing equity, accountability, and opportunity in the workplace.
When the staff satisfaction and organizational survey was conducted again, in June 2002, it revealed significant improvements in ten (83%) of the twelve indicators, including employee satisfaction and commitment (see Figure 1). Two indicators of staff satisfaction did not increase: staff benefits and accuracy of job description, items that required more resources to address. In just one year's time, the functioning of management systems and delivery of health services improved significantly (see Figure 2). While FLEP's transformation may not be typical of that of all nongovernmental organizations, MSH's experience offers important insights -not only into the linkages between strong internal leadership, strengthened management systems, better work climate, and improved health Improved employee satisfaction due to better human resource management Figure 1 Improved employee satisfaction due to better human resource management.
Increased utilization of services Figure 2 Increased utilization of services.
services, but also in the ability of an organization to persevere through difficult times.

Conclusion
The factors that contributed to this program's success were: ▪ a visionary leader who involved teams at all levels; ▪ establishing priorities based on assessment and root cause analysis; ▪ creating a climate of support for managers who were formerly isolated; ▪ establishing standards of performance and rewarding people for meeting or exceeding them; ▪ linking change to HRM systems.
The individuals leading this and similar transformations are not extraordinary. They are often doctors who have spent their careers working to improve health in their countries. What makes them effective in getting results is their commitment to addressing the human resource crisis and move from vision to action. In the process, they work to enable others to face challenges and achieve results, understanding that implementing change in human resources requires new ways of working.