Ghana is facing a health workforce crisis, with the mass exodus of experienced health workers (HWs) out of the country, and challenges in attracting and retaining HWs in deprived and hard-to-reach areas. Led by research teams from Liverpool School of Tropical Medicine (LSTM) and the University of Ghana School of Public Health (UGSPH), and funded by THET, our research aims to address this HW retention challenge. Through a participatory action research approach, we are supporting the design and implementation of community-based interventions to improve health workforce retention in three hard-to-reach districts in the Eastern Region of Ghana, namely Afram Plains North and South and Akwapim North.
“The participatory co-development of the staff retention intervention plan has generated deep sense of stakeholder ownership of the selected intervention strategies”
(DHMT member)
The project is rooted in the belief that developing an effective and efficient health workforce retention intervention through participatory action research requires strong collaboration and participatory decision making among district health managers and community members – particularly in resource constraint settings. Local managers, given their knowledge of their context-specific challenges, are well placed to contribute to the development of an effective staff retention intervention plan that is necessary for enhanced workforce job satisfaction, and its consequential improvement in staff performance and service delivery.
As part of the first phase of the participatory action research project, we conducted a situation analysis (SA) of the health workforce retention problems in the three study districts between February and March 2024. In the second phase, we held a participatory workshop to develop the staff retention intervention plan. This blog presents our approach and lessons from the participatory co-creation of the intervention plans.
Active participation and co-creation of retention interventions: our approach
“It is very very good that you are involving the communities, as well as the health staff in the intervention planning. Often projects and policies are planned at national level so it doesn’t solve the problem”
(Community member)
We conducted a three-day workshop in May 2024, whereby each district team worked together to conduct a root cause analysis of a key problem from the SA in each district, developed problem statements and interventions plans. Members of the District Health Management Teams (DHMTs), sub-district heads/in-charges, hospital managers and community representatives (i.e. Chiefs and District Assembly) attended. Whilst three community members were invited, only one was able to attend the workshop. The workshop was held in the district capital of Kwahu Afram Plains North, facilitated by the research team from UGSPH and LSTM. Checklists and guidelines developed by the research team aided the co-design and review process. A DHMT member noted that the guidelines and checklists were very useful as they “guided us to develop appropriate and well-focused plan”.
We used the following participatory co-creation steps:
- Firstly, SA findings of each district were presented by the research team, with feedback provided by districts. Presentations provided overviews of the key challenges, impacts and ways forward, identified through key informant interviews, focus group discussions and surveys during the situation analysis.
- Next, the district teams, working in groups, selected one key workforce retention problem that they wanted to address and conducted an in-depth problem tree analysis of this problem - identifying root causes and consequences of the selected problems.
- Each district team then presented their problem tree analysis and problem statements in a gallery walk, and received feedback from other districts and research team. Activities one to three took place on the first day of the workshop
- On day two, each of the three district teams came together to refine the problem tree analysis based on feedback from the gallery walk. The problem trees and statements served as starting points for the development of the interventions to improve workforce retention.
- We dedicated the rest of day two to developing the intervention (and bouquet of solution activities) through participatory and collaborative decision making. Guided by the research team, the district teams collectively brainstormed and developed the intervention plan. Based on the key areas for managing retention, the three district teams, developed interventions around the following areas: education, regulation, incentives, support and other health systems components. As part of the intervention plan, we also captured information on expected change, monitoring and evaluation indicators and genders issues for each of the selected activity. Throughout the process, facilitators encouraged equal participation from team members and managed power dynamics, with a particular focus on capturing the views of women.
- Next, each of the DHMTs costed their final intervention plans and presented at plenary on day three. Feedback from the research and district teams helped refine the interventions and implementation budgets.
Top tips for co-creation of HW retention interventions
Overall, the workshop was a success, and all districts began implementing their interventions in May. Following group reflection, our research team came up with the following lessons:
- Think through and prepare activities and materials that really promote active participation.
- Set up the venue so that all people can contribute to discussions and activities e.g. chairs around tables, wall space for posters.
- Kick off the workshop with an activity that gets everyone talking to each other.
- Factor in space and time for groups to view and comment on each other’s work - this enhances learning across different settings and contexts.
- Engaging community members is pivotal to developing an intervention package that has community trust and ownership and will have a better chance of being implemented and having a positive effect.
Written by Sam Amon, Research Fellow at the University of Ghana School of Public Health