Using a theory of change in monitoring, evaluating and steering scale-up of a district-level health management strengthening intervention in Ghana, Malawi, and Uganda – lessons from the PERFORM2Scale consortium

Abstract

Background Since 2017, PERFORM2Scale, a research consortium with partners from seven countries in Africa and Europe, has steered the implementation and scale-up of a district-level health management strengthening intervention in Ghana, Malawi and Uganda. This article presents PERFORM2Scale’s theory of change (ToC) and reflections upon and adaptations of the ToC over time. The article aims to contribute to understanding the benefits and challenges of using a ToC-based approach for monitoring and evaluating the scale-up of health system strengthening interventions, because there is limited documentation of this in the literature. Methods The consortium held annual ToC reflections that entailed multiple participatory methods, including individual scoring exercises, country and consortium-wide group discussions and visualizations. The reflections were captured in detailed annual reports, on which this article is based. Results The PERFORM2Scale ToC describes how the management strengthening intervention, which targets district health management teams, was expected to improve health workforce performance and service delivery at scale, and which assumptions were instrumental to track over time. The annual ToC reflections proved valuable in gaining a nuanced understanding of how change did (and did not) happen. This helped in strategizing on actions to further steer the scale-up the intervention. It also led to adaptations of the ToC over time. Based on the annual reflections, these actions and adaptations related to: assessing the scalability of the intervention, documentation and dissemination of evidence about the effects of the intervention, understanding power relationships between key stakeholders, the importance of developing and monitoring a scale-up strategy and identification of opportunities to integrate (parts of) the intervention into existing structures and strategies. Conclusions PERFORM2Scale’s experience provides lessons for using ToCs to monitor and evaluate the scale-up of health system strengthening interventions. ToCs can help in establishing a common vision on intervention scale-up. ToC-based approaches should include a variety of stakeholders and require their continued commitment to reflection and learning on intervention implementation and scale-up. ToC-based approaches can help in adapting interventions as well as scale-up processes to be in tune with contextual changes and stakeholders involved, to potentially increase chances for successful scale-up.

How capacity building of district health managers has been designed, delivered and evaluated in sub-Saharan Africa: a scoping review and best fit framework analysis

“…The emergent approach entails a dynamic, flexible or adaptable process that emerges from stakeholders’ interactions. We found that most CBP approaches were prescribed and collective,4 9 19 47 67 70 72 75–79 81 84 85 87 89–93 95–100 103 105 and prescribed and individual 17 68 69 71 73 80 82 83 86 94 101 102. The emergent and collective approach was marginal9 49 (figure 4).…”

“…Weak leadership and/or management were considered the major causes of poor health outcomes in low-income and middle-income countries 4 6 19 49 67–88. Frequently mentioned causes of weak leadership and/or management capacity were (1) inadequate professional profiles of health managers (often being clinicians without formal training on leadership and management)17 73 75 81 89 90 and (2) inadequate efficacy of leadership and management courses (usually classroom-based and knowledge-focused instead of practice-based and providing know-how to deal with real-life situations) 47 68 69 73 74…”

“…Most programmes assumed that strengthening the leadership and/or management knowledge, skills and practices of health managers would improve their leadership and/or management capacities. These improvements would, in turn, lead to improved health system performance and then better health outcomes 4 17 47 68 70 75–78 81–84 86 87 90–93. The CBPs were supposed to trigger health team members’ self-confidence to undertake good leadership and/or management practices which would, in turn, activate their job satisfaction, motivation and sense of ownership 68 91 93.…”

“…The included studies identified various features of the context within which the programme took place. The most cited was the decentralisation from national (or regional) to the district (or subdistrict) level 9 19 47 49 67 70–72 75 76 78 79 81 84 87 90 92 96–98 100. However, seven studies reported narrow decision space of DHMs regarding financial and human resources 4 49 70 78 87 90 97.…”

“…The most cited was the decentralisation from national (or regional) to the district (or subdistrict) level 9 19 47 49 67 70–72 75 76 78 79 81 84 87 90 92 96–98 100. However, seven studies reported narrow decision space of DHMs regarding financial and human resources 4 49 70 78 87 90 97. Three papers noted the persistence of a hierarchical organisational culture within the decentralisation setting 9 68 95.…”