EFFECTIVENESS OF TRAINING HEALTH UNIT MANAGEMENT COMMITTEES ON PERFORMANCE OF HEALTH CENTRES, IN EAST CENTRAL, UGANDA MUWANGUZI DAVID GANGU (MBCHB, MA HOSP. MNGT, MPH) Q97EA/CTY/37536/2017 DEPARTMENT OF HEALTH MANAGEMENT AND INFORMATICS A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE AWARD OF THE DEGREE OF DOCTOR OF PHILOSOPHY (HEALTH SERVICES MANAGEMENT AND INFORMATICS) IN THE SCHOOL OF PUBLIC HEALTH AND APPLIED HUMAN SCIENCES OF KENYATTA UNIVERSITY MAY, 2021 DECLARATION DEDICATION This work is dedicated to my father the Late Yovani Gangu. A poor un-educated person with gigantic and treasurable vision. AKNOWLEDGEMENT Since the Bible says all knowledge comes from God, I thank God for life and the knowledge given free of charge. I am grateful to Kenyatta University and in particular the School of Public Health; the Department of Health Informatics and Management; which accepted me, allowed me and enabled me to undertake this study. I am humbled for the guidance, kindness and advice from my supervisors: Dr Ochieng George Otieno of Kenyatta University; Dr Rucha Kenneth Kibara of Kenyatta University, and Professor John Francis Mugisha of Cavendish University. I acknowledge the various inputs and guidance at all stages of preparation and execution of this work I am Indebted to my fellow students in the PHD class of 2017 and especially Karim Muluya Mwebaza for all the timely support and encouragement accorded to me along this journey. Gratitude goes to the team that implemented the project and were able to produce results on time. I appreciate all in my family for the support given to me. TABLE OF CONTENTS DECLARATION ...................................................................................................... ii DEDICATION .......................................................................................................... iii AKNOWLEDGEMENT .......................................................................................... iv TABLE OF CONTENTS ......................................................................................... v LIST OF TABLES .................................................................................................... x LIST OF FIGURES .................................................................................................. xi ABBREVIATIONS AND ACRONYMS ............................................................... xii OPERATIONAL DEFINITION OF TERMS ..................................................... xiii ABSTRACT ............................................................................................................ xiv CHAPTER ONE: INTRODUCTION ..................................................................... 1 1.1 Background ....................................................................................................... 1 1.1.1 HUMC/Board Developments in Uganda ................................................... 8 1.2 Statement of the Problem ................................................................................. 9 1.3 Justification of the Study ................................................................................. 11 1.4 Research Questions ......................................................................................... 12 1.5 Hypotheses ...................................................................................................... 12 1.6 Objectives ........................................................................................................ 12 1.6.1 Main Objective .......................................................................................... 12 1.6.2 Specific Objectives .................................................................................... 13 1.7 Limitations and Delimitations ......................................................................... 13 1.8 Theoretical Framework ................................................................................... 14 1.9 The Conceptual Framework ............................................................................ 17 1.10 Significance of the Study ............................................................................... 19 CHAPTER TWO-LITERATURE REVIEW ....................................................... 21 2.0 Introduction ..................................................................................................... 21 2.1 Socio-Demographic Characteristics ................................................................ 23 2.2 The Performance of HCs, Incentives and Performance Management ............ 25 2.2.1 Employee Performance in Organisations .................................................. 26 2.2.2 Effects of HUMCs practice on the HC performance ................................ 29 2.2.3 Psychological Contract to explain performance ....................................... 32 2.2.4 Motivators to Improve Performance -Theoretical Perspectives ................ 34 2.3 Effect of Training of HUMCs on Performance ............................................... 37 2.3.1 Organization Responses to Trainings ........................................................ 38 2.3.2 Training Requirements in the Context of Health Centres ......................... 42 2.3.3 Health Manpower Training and Development for Health Facilities ......... 43 2.3.4 The Relevancy of Training ........................................................................ 44 2.3.5 Effectiveness and Efficiency of Coaching, Mentoring, as Training Methods .............................................................................................................. 52 2.3.6 Conferences as a Capacity Building Strategy ........................................... 53 2.3.7 Role Playing .............................................................................................. 53 2.3.8 Formal Training Courses and Development Programmes ........................ 54 2.4 Summary and Limitations of the Literature .................................................... 54 CHAPTER THREE-MATERIALS AND METHODS ........................................ 57 3.0 Introduction ..................................................................................................... 57 3.1 Research Design .............................................................................................. 57 3.1.1 Rational for this Study Design .................................................................. 58 3.1.2 Selection Criteria for Study Health Centres .............................................. 59 3.2 Study Variables ............................................................................................... 61 3.2.1 Dependent Variable ................................................................................... 61 3.2.2 Independent Variables ............................................................................... 61 3.2.3 Intervening Variable .................................................................................. 62 3.2.4 Training Methods ...................................................................................... 63 3.3 Study Area ....................................................................................................... 64 3.4 Target Population ............................................................................................ 67 3.4.1 Study Population ....................................................................................... 67 3.4.2 Inclusion Criteria for Participants ............................................................. 68 3.4.3 Exclusion Criteria for Participants ............................................................ 68 3.4.4 Sampling Procedure .................................................................................. 68 3.4.5 Sample Size Determination ....................................................................... 69 3.4.6 Determination of Sample size for Health Centres ..................................... 71 3.5 Study Description ............................................................................................ 72 3.5.1 Comparison ............................................................................................... 74 3.5.2 Study Procedures ....................................................................................... 75 3.5.2.1 Screening Procedure ............................................................................... 75 3.5.2.3 Follow-up Procedure .............................................................................. 75 3.6 Study Outcomes and Measurement ................................................................. 77 3.7 Construction of Research Instruments ............................................................. 78 3.7.1 Questionnaires ........................................................................................... 78 3.7.2 Interview Guides ....................................................................................... 78 3.7.3 Focused Group Discussions ...................................................................... 79 3.7.4 Secondary Data Extracted from the HMIS and DHIS2 ............................ 80 3.8 Training of Research Assistants ...................................................................... 80 3.8.1 Pre-testing of Research Instruments .......................................................... 81 3.8.2 Validity of Instruments ............................................................................. 81 3.8.3 Reliability .................................................................................................. 82 3.9 Data collection and Management Techniques ................................................. 83 3.9.1 Field Editing of Data ................................................................................. 83 3.10 Data Analysis ................................................................................................. 83 3.11 Logistical and Ethical Considerations ........................................................... 84 CHAPTER FOUR: RESULTS ............................................................................... 86 4.0 Introduction ..................................................................................................... 86 4.1 Response Rate ................................................................................................. 86 4.2 Social Demographic Characteristics ................................................................ 86 4.3 Performance of Health Centres ....................................................................... 88 4.3.1 Effect of Socio-demographic Characteristics on Performance of Health Centres ................................................................................................................ 89 4.3.2 Health centre Performance as Influenced by Socio-demographic Dynamics after the Intervention ......................................................................... 91 4.4 Ascertaining Performance of Health Centres in East Central Uganda ............ 95 4.4.1 The Different Players and Determinants for Health Centre Performance .......................................................................................................................... 101 4.4.2 Stimuli for Performance of HCs at District Level .................................. 102 4.4.3 The DHT and Health centre Meetings .................................................... 105 4.4.5 Motivation Mechanisms for Perfrormance of HCs ................................. 106 4.5 Effects of Training of HUMC Members on Performance of Hcs ................. 108 4.5.1 The HUMC Socio-demographic characteristics Coupled with Training Effect on Health Centre Performance .............................................................. 110 4.5.2 Relationship between Training of HUMCs and Performance of HCs .... 112 4.5.3 Performance Improvement as viewed by HUMC after Training ............ 113 4.5.4 The Changes in HC Performance as Potrayed by Health Workers after Training of HUMC Members ........................................................................... 115 4.5.5 The Relevance of Themes of HUMC Members Training and Performance of HCs .............................................................................................................. 116 4.5.6 Effectiveness of Training of HUMCs on Improving Performance of Health Centres .................................................................................................. 120 CHAPTER FIVE: DISCUSSION, SUMMARY, CONCLUSION AND RECOMMENDATIONS ...................................................................................... 124 5.1 Discussion ...................................................................................................... 124 5.1.1 Socio-demographic Characteristics of the Respondents ......................... 124 5.1.2 Ascertaining Performance of Health Centres .......................................... 128 5.1.3 Effects of Training HUMCs on Performance of HCs ............................. 132 5.2 Conclusions ................................................................................................... 139 5.2.1 Socio Demographics ............................................................................... 139 5.2.2 Performance of Health Centres ............................................................... 140 5.2.3 The Effect of Training of Members of HUMCs ..................................... 140 5.3 Recommendations ......................................................................................... 141 5.3.1 Socio Demographics ............................................................................... 141 5.3.2 Performance of Health Centres ............................................................... 141 5.3.3 Effect of Training of Members of HUMC on Performance .................... 141 5.3.4 Further Research ..................................................................................... 142 REFERENCES ...................................................................................................... 143 APPENDICES ........................................................................................................ 160 Appendix I: Consent Forms ................................................................................. 160 Appendix II: Questionnaires ................................................................................ 164 Appendix III-Interview Guides ........................................................................... 172 Appendix IV: Focus Group Discussion Guide .................................................... 184 Appendix V-Training Needs Assessment Pre and post training of HUMC ........ 185 Appendix VI: Training Instrument/Manual for HUMC Members ...................... 188 Appendix VII : Summary of intervention procedures ......................................... 247 Appendix VIII : Map of Uganda Showing Regions ............................................ 248 Appendix IX: Approval of Proposal by Kenyatta University Graduate School 249 Appendix X: Research Authorisation .................................................................. 250 Appendix XI : Kenyatta University Ethical Review ........................................... 251 Appendix XII: Nsambya Ethical Review Committee Approval ......................... 253 Appendix XIII: Clearance by Uganda National Council for Science and Technology .......................................................................................................... 255 LIST OF TABLES Table 3.1: Population Coverage by health centres ............................................... 65 Table 3.2: The health system in Uganda .............................................................. 66 Table 3.3: CronBach's Test Results ...................................................................... 82 Table 4.1: Socio-Demographic Characteristics of HUMC Members ................... 88 Table 4.2: Effects of Socio Demographic characteristics on HC performance before intervention ............................................................................. 90 Table 4.3: Effect of Socio-Demographic characteristics after training HUMC members ................................................................................................. 92 Table 4.4: Socio-demographic characteristics and HC performance in control arm ...................................................................................................... 94 Table 4.5: Baseline Performance of HCs in East-Central Uganda ....................... 96 Table 4.6: National Health sector Performance Trends ....................................... 97 Table 4.7: Performance Trends of HCs in EC Uganda ........................................ 97 Table 4.8: Summary of effects on performance of the indicators targeted in training HUMC members .................................................................. 98 Table 4.9: The Performance of HCs after training members of HUMCs ........... 109 Table 4.10: Summary of performance indicators before and after intervention compared ........................................................................................ 110 Table 4.11: HUMC Characteristics training and Performance of HCs .............. 112 Table 4.12: Relating Performance of HCs to training of HUMCs ..................... 113 Table 4.13: Changes in Perceptions of HUMCs after training ........................... 114 Table 4.14: Relevance of training themes to improving performance of HCs ... 117 Table 4.15: Mean Variable Changes-Baseline (2018) to Post Intervention (2019) .............................................................................................. 120 LIST OF FIGURES Figure 1.1: Conceptual Framework ...................................................................... 18 Figure 3.1: Study Flow Chart ............................................................................... 76 Figure 4.1: Performance Outcome ....................................................................... 89 ABBREVIATIONS AND ACRONYMS CAO Chief Administrative Officer DHIS- District Health Information System DHMT- District Health Management Team FBO- Finance Based Organization FGD- Focus Group Discussion HC Health Centre HCs Health Centres HCW- Health care workers HMDC Health Manpower Development Centre HMT Health Centre management HP- Health Policy HUMC- Health facility management committee HUMCs- Health facility management committees HSSP- Health Sector Strategic Plan IMF- International Monetary Fund IMR- Infant mortality rate KI- Key Informant KUERC Kenyatta University Ethics Review Council MOH- Ministry Of Health NGO- Non Governmental Organization PHC Primary Health Care PFP Private For profit PNFP Private Not for Profit PRA- Participatory Rural Appraisal UBOS Uganda Bureau of Statistics UDHS- Uganda Demographic and Health Survey SWAP- Sector wide Approach SWAPs- Sector wide Approaches SDG- Sustainable Development Goals SPSS- Statistical package for social scientists TPC Technical planning committee UNICEF- United Nations International Children‘s Emergency Fund US United States VHT- Village Health Team WHO- World Health Organisation OPERATIONAL DEFINITION OF TERMS Effectiveness : Refers to the level of quality with which a task or process is carried out that ultimately leads to higher overall business performance. In other words, does it do what it's supposed to do? In this case is there improvement in performance of health centres? Good performance : According to the Pareto principle of 80 /20 rule (Woodcock, 2010), if 80 percent of the outputs are attained, it is referred to as good performance. Eighty percent is the cut off level being used by Ministry of Health of Uganda. Health Centre : In this study refers to a place of treatment and health promotion services at the level of hospital. Health Unit Management Committee: Refers to a group of individuals selected from the community to participate in the running and management of health centres. Motivation : Refers to a reason or reasons for acting or behaving in a particular way for example liking to work or hating work. In this study it represented the impetus to work and anything that was driving the decisions to do work. Performance is : The action or process of carrying out, executing, discharging, conducting, effecting, or accomplishing, achieving, completing implementation of a task or function. Training refers : To specialized education aimed at giving the trainee a particular or specialized knowledge, skill and attitude which s/he must possess to effectively perform in a given position (Onasanya CMD 2005). ABSTRACT There has been poor performance of health sector in East Central Uganda leading to the Districts in East Central Uganda perpetually being at the tail end of the Uganda National District Performance League Table. Performance of the health sector is the sum total of the performance of individual health centres. Uganda embraced decentralization and Primary Health Care Concept that provide responsibility for managing performance of health centres at lower administrative levels. The performance driven management of health centres is completed by having in place competent and knowledgeable management committees. This study investigated the effectiveness of training of Health Unit Management Committees (HUMC) on performance of health centres in East Central Uganda. Specifically, the study assessed how the socio-demographic characteristics of members of the management committees were affecting performance of health centres. The study ascertained the performance levels of health centres and assessed the effect of training members of Health Unit Management Committees on performance of the health centres. The study was interventional employing the design of a randomised community trial. The study was done in East Central Uganda in 24 health centres. These were randomly selected into two study arms as intervention and control arms each arm with 12 health centres. Out of expected 288 members, only 280 members of Health Unit management Committees participated in the study. Data from monthly reports provided the records for assessment of individual health centre performance. The dependent variable was the performance of the health centres. The independent variables were the factors that influence performance of health centres including the social demographics of the HUMC members. The intervention was training of the Health Unit Management Committees. The study used both qualitative and quantitative data collection techniques. Data was analysed using Chi-Squares for the bi-variate analysis and pearson‘s correlations. Logistic regression was then employed for the multivariate analysis on factors that drive performance of health centres in view of training of HUMC members. The results showed that Good performance of health centres was dependent on ages of members of HUMCs (P-Value 0.005), occupation of HUMCs p- value 0.006, economic level p-value 0.05 and education level of these members (P- Value-0.003). The performance of individual health centres in East Central Uganda had been poor prior to training of Health Unit Management Committees. After training of members of health unit management committees in the intervention arm, performance improved and was better than those health centres in the control arm. The t-test statistic showed that training of HUMC improved performance of HC (p value 0.000), and this had the strongest association with improved performance with odds ratio of 164.22, age had odds ratio 38.56, education level had odds ratio 59.43, profession of member of HUMC odds ratio 26.16 and economic level at odds ratio 1.41. It was concluded that performance of health centres in East Central Uganda depended on social demographic characteristics, was poor prior to training of HUMCs and training of members of health unit management committees greatly improved performance of health centres. It was recommended that average aged members that are trainable be appointed members of HUMCs, Ministry of Health of Uganda increase resources to enhance performance of HCs and enforce HUMC involvement and participation in running HCs, and all members of HUMCs be trained by policy from the Ministry of Health. CHAPTER ONE: INTRODUCTION 1.1 Background Performance of the health sector is the sum total of the performance of the composite individual health centres. In East Central Uganda, the performance of the health sector was poor and the region‘s performance indicators were trailing other regions (MoH, 2018). Probably this was arising from poor management systems. Health centres are facilities where community visit to get their broken health repaired. It is in health centres that health performance indicators are compiled and computed to show the performance trends of the health care system in place. In Uganda, activity in health centres signifies either good performance of the health care system, or bad performance. Indeed if health centres are busy, then this is paradoxically taken to mean good performance of the health sector. The reverse is also true. This reflects how deep the Ugandan Health Services are entrenched in curative rather than preventive health. Globally, Primary health care, basic sanitation, and adequate nutrition form the bedrock of public health, yet billions of people in low and middle income countries (LMICs) lack access to these basic entitlements because of inadequate management systems (WHO 2008; Bhutta et al. 2011). Inaccessible health services, ineffective management at community level of care, inadequate sanitation, and poor nutrition continue to cause high rates of avoidable illness and death among the poor (Black et al. 2013; WHO 2015, Benova, Cumming, and Campbell 2014). The vast majority of the 280,000 maternal deaths in 2013 occurred in Low and Mid Income Countries (LMICs) and were rooted in a lack of basic health care, poorly managed health care systems, exacerbated unsanitary conditions and maternal under-nutrition (Kassebaum et al. 2014). Although decades of national and international policy and programs have enabled great improvements in public health and health sector management, there are still far too many gaps (WHO 2015). A vast range of inter-connected factors contribute to whether basic public health interventions reach the people who need them, including political issues of prioritization and governance, implementation issues of management and scalability, and community issues of engagement and trust in the health facilities (WHO 2015). In East-Central Uganda where performance of the health sector was poor, public health interventions were therefore not reaching the people prompting actions that could hopefully culminate in reversing such occurrences in the region. More than three decades in the world, organizations want to decrease growth of health care costs and also health organizations want to decrease health per capita by creating productivity increaments while preventing quality fall (Goldberg & Kosinski, 2011). One way for productivity increase in recent years for improvement of health system in the world is paying attention to new structure and widespread organizational changes (WHO, 2017, WHO, 2015). Some of such changes involve skilling committees or like as it occurred in Iran where reform was done by changing Committees number from 14 to 11 in 2011(Goldberg & Kosinski, 2011). For productivity improvement, presence of vital information is necessary. Hospitals bear high stress for productivity improvement by internal performance without sacrificing quality of care. One of the main reasons for stress increase is ignorance of current information about hospitals which is very useful source for processes and productivity reform (Adi, 2012, WHO, 2015). And now in hospitals, documenting the activities such as setting the agenda related to hospital committee sessions and sending a copy to higher levels for planning is much emphasized (Adi, 2012). Also, according to limited sources and control of health care costs, nowadays all beneficiaries search different strategies for productivity of work force one of which is innovations designed to increase trained work force at hospitals (Adi, 2012). Some hospital problems are related to budget deficit therefore managers should dominate on this problem by improving on policies and programs of hospital committees (Dischoeck et al, 2011, WHO, 2010). Hospital committees should be more active in planning such as participating in setting strategic and operational programs in hospitals but doing so requires the HUMCs to have the knowledge of that task. For many decades, community participation in health systems in East South African (ESA) countries has been a consistent element of health policies to support primary health care (Goodman et al, 2011). The adoption of PHC in all countries in the region means that public participation is central to the design and implementation of health systems. In the Alma Ata declaration, community participation implies that individuals, families and communities enjoy health as a right and a responsibility, locating participation in functions of systems in planning, service delivery, budget and other processes (Goodman et al, 2011m WHO 1978). How the community participates effectively is through skilled HUMCs. However, the Regional Network for Equity in Health in East and Southern Africa found in its regional equity analyses in 2007 and 2012 that although ESA countries have implemented various measures in the past three decades to mobilise communities for health, it had not yielded positive results (McCoy et al, 2012). One measure not yet assessed is whether trained community structures can add a positive effect and solve the problems. Health services have high legitimacy, but weak capabilities for social roles and community participation has been limited by inadequate resources coupled with lack of skills at community level, an organisational culture of top-down planning and limited reward for health workers‘ social roles and inadequate informed user participation (Mayor et al, 2012). However, some studies have also shown that these issues are amenable to change. Communication gaps between communities and health workers can be closed by changes in work organization and services and by involving client networks (Adi, 2012). One way that systems facilitate such social participation is through committees and boards at neighbourhood, primary care level and in hospitals (Adi, 2012). Well trained and knowledgeable Health Centre Committees (HCCs) involve representatives of communities and primary-care level health workers in planning, implementing and monitoring health services and activities (Bakker, Demerouti, 2013). Known by different names in different countries, Health Unit Management Committees are emerging as a common mechanism at community and primary- care level for communities to ensure that health systems access and use resources to address community needs, are responsive and accountable to communities, and create opportunities for social participation and co-determination in health systems, with positive impact on health outcomes (McCoy et al., 2012; EQUINET, 2012). Yet the majorities of these community structures are ignorant of the problems of the health care systems and lack skills to perform their roles (Sengooba, 2010). Uganda has had a rich health policy framework over the years (Sengooba, 2010). This policy framework among other things encompasses the national health policies (1999; 2010, 2020); the framework for Uganda National Minimum Health Care Package (UNMHCP); the Health Sector Strategic Plans (HSSP) I, II III, the Health Sector Quality Improvement Framework, and the Health Sector Strategic Investment Plan (HSSIP). The ultimate goal of this broader framework has always been to improve the quality of and access to healthcare and improve performance of the health sector. Over the years, Uganda‘s Ministry of Health appears to have focused more on increasing geographical and financial access to health services but little emphasis has been put on efficiency gains, how to effectively engage the communities and quality of health services provided (Waldman et al. 2011, Ministry of Health, 2018). Ensuring quality of care at health facilities might be regarded as a ‗systemic‘ issue necessitating a great deal of government interventions particularly on staffing, drugs and other medical supplies and infrastructural development. However, health facility management by drilled HUMCs and good administration could play an equally important role in ensuring the quality of health care service. Unfortunately, despite the existing rich national policy framework on general health sector governance issues, public health facility management and administration appears to be lacking sufficient attention, moreover, considering its critical element in the quality of care (Le Grand 2009). One critical aspect of quality of care and improvement is supervision, monitoring and inspection (SMI) system especially by HUMCs. But the HUMCs have to know what they are doing which has not been the case in East central Uganda. According to the Annual Health Sector Performance Report (AHSPR) (MoH, 2018), there is inadequate leadership at all levels to demand and enforce regular supervision, monitoring and ensuring follow up of the recommended actions (Kajungu et al. 2015, WHO, 2015). The established structures such as Regional Performance Monitoring Teams, District Health Teams, Hospital Boards and Health Unit Management Committees for monitoring health sector performance are not functioning optimally (Kajungu et al. 2015). Thus therefore the need to empower the community structres to do it probably now rather than later. Health centres are the epitome of health service provision in Uganda. Health centres are important structures being close to community they serve. All community benefits in terms of health care spring from health centres. They are the points of reference for prevention of ailments and curing ailments. Health centres are close to the community or rather within the community. They should therefore be entrenched in community rather than being white horses. Community should be having closer feeling and ties to these health centres. There must be a mechanism that brings community in the centre of operations of the health centres. The health sector reforms in Uganda tried to address this through the creation of Health Unit Management Committees (HUMC) (Ssengooba, 2010, MOH, 2014). The Health Sector Reforms prescribed that every health centre must have a Health Facility Management Committee. This was to enable the health centre to be owned and guided by the community. Even when HUMCs were introduced in Uganda, out-puts and out-comes from the HUMCs have not been clear. Their contribution has not been well harnessed and emphasized (Waldman et, al. 2011). It was taken for granted as though the Health Units Management Committees had been inducted and trained to execute their mandates. Bearing that view as being true, the effectiveness of that training has not been examined. Neither has the performance of health centres been analysed in respect to efforts put in by HUMCs. It is against this background that this study has been developed. The study took in context the question why despite health sector reforms in Uganda, the health indicators remained poor in East-Central Uganda. Community has not been utilizing health services and has not been interested in the health services being provided (Waldman, 2011). Uganda has been providing health services under PHC policy which calls for community participation. This may have not been happening in some health centres leading to poor performance of the health sector especially for East Central Uganda. Health service provision and health sector performance was thus poor presumably because of dismal community monitoring being done by unskilled HUMCs. 1.1.1 HUMC/Board Developments in Uganda HUMCs are the key link mechanism of the health system to the grassroots community. It links the community, the local government and the health facility. HUMCs are established at facilities at the different levels of care. HUMCs consist of representatives of the community within which the health facility is located. Ministry of Health guidelines require that the committee is chaired by ―a prominent educated public figure of high integrity and not holding any political position‖. Other members are chosen by the political leadership one from each of the major administrative units within the area served by the facility (MOH, 2014). The health workers of the facility are represented by two people on the committee; one health worker and the facility in-charge, who serves as the secretary to the committee. The lowest local government unit (Local Council I) is represented by its chairperson (MOH, 2014). The government of Uganda established HUMCs in 1998 (McCoy et al, 2012). Prior to this, in some facilities, almost similar community based or NGO supported community participatory mechanisms existed like the Parish Development Committees and Hospital Boards. The committee roles then, were strengthened through induction trainings provided through the Ministry of Health and Danish International Development Agency (DANIDA) Health Services Project (McCoy et al, 2012). However, the guidelines provide for limited period of service of two terms each term running for three years. In East Central Uganda, training ended with the first group of HUMCs. Even then, the effcetiveness of that training to stimulate improvement in performance was not analysed. The official roles of the HUMCs according to the Ministry of Health (2014) include; to oversee the general operations and management of the health centre, advise community on matters related to promotion of health, prevention of diseases, treatments in health centres and rehabilitation. Others are to represent and articulate community interests on matters pertaining to health in local development forums, facilitate feed back to community on matters pertaining to health centre, facilitate implementation of community decisions and ideas pertaining to the health of the community. HUMCs also mobilize resources towards development of health in their area, and contribute to development of the work-plan and budget and allocate/re- allocate resources. When there is available good governance with HUMCs doing their roles appropriately, the productivity of any health sector is bound to improve (WHO, 2010). It is natural that for HUMCs to have skills and be able to effectively do their work, they should be trained. The poor performance of health centres in East Central Uganda was probably due to ineffective supervision and monitoring by HUMCs which in turn was probably caused by lack of training. This intervention study of training of members of HUMCs was therefore developed and implemented to try and establish whether if the members of HUMC were trained, then this could improve the performance of HCs in East Central Uganda and improve on the poor health indicators in this region. 1.2 Statement of the Problem Despite the Government of Uganda improving on funding levels, improving human resources for health and infrastructure, performance of the Health Centres in East Central Uganda has been poor. There have been poor health performance indicators in East Central Uganda as a result. The average out-patient attendance rates are 80% in East-Central Uganda against 96% for the country, the immunization coverage was 66% well below the national average of 93% (MoH, 2018). Skilled deliveries were at 54% in East Central Uganda against the 80% national average (MoH, 2018). Consequently, the Infant Mortality Rate was high at 54/1000 live-births in East Central Uganda against 43/1000 for Uganda (UDHS, 2016), the Maternal Mortality Ratio was 346/100,000 live-births against 336 for Uganda (UDHS, 2016), the Neonatal Mortality Rate was 27/1000 live births against the national rate of 21/1000 live births (UDHS, 2016). These rates have been poorer than the national averages and attribute to status of health of the region remaining poor. The districts in East- Central Uganda trail others in socio-economic development (Kajungu et al., 2015). The services provided by the health centres in the region have not been utilised by the community leading to poor health indicators. The HUMCs that were expected to be linking community to services were not doing their roles probably due to inadequate knowledge about that responsibility (Sengooba, 2010). Yet Ministry of Health had developed a curriculum to be used in training HUMCs but it was not being used to implement trainings probably due to lack of evidence to support the worthiness of training of HUMCs. There was therefore dismal contribution being made by the community and this was suspected to be causing poor performance of HCs. The desire to establish whether training of the HUMCs could bolster or hinder committee functionality and provide evidence on the effectiveness of training HUMCs towards improvement and enhancing the performance of HCs was mooted in consequence. 1.3 Justification of the Study The performance of HCs in the study area was perpetually poor therefore the need to identify evidence based and cheap solutions to this problem. Indeed the Uganda Healthy Policy 2015-2024 emphasized strengthening cheap interventions, innovations and operations leading to improved performance of HCs (MOH, 2017). The aims of this study were within the broad aspect of improving performance of the HCs by empowering a cheaply available stakeholder with skills. Thereafter it was made possible with evidence to assess the contribution made by the intervention and also made it possible to advise management about a cheap undertaking that can lead to improving health service delivery. According to WHO (2015) user participation in health services management which is the hall mark of PHC was key to improving performance of health sector. Yet in East Central Uganda, there was inadequate utilization of health services due to unskilled representation in management. One way to make the users participate was to empower the HUMCs by training them. There was also limited literature on the subject of training HUMCs in the context of improving performance of HCs. The findings from this study contribute to a growing body of literature on HUMCs functions and health sector services monitoring and enhancing performance of health centres. The findings make three significant contributions to health systems research and public health work. First, they contribute to the broader literature on understanding the dynamics of socio-demographic characteristics of a section of the health workforce in relationship to performance of HCs and how these can be manipulated to improve productivity of HCs. Second, they contribute empirical evidence to inform policy discussions on the complex and adaptive nature of monitoring health service delivery and performance, and how best HUMCs can be engaged in running of HCs to improve performance. Thirdly, the finding from this study informs policy on the importance of training HUMCs to enhance productivity of the health centres in particular and the health sector in general. 1.4 Research Questions 1. What is the effect of socio-economic-demographic factors on performance of health centres in East Central Uganda? 2. What is the current performance of health centres in East Central Uganda? 3. What is the effect of training Health Units Management Committees on performance of health centers in East Central Uganda? 1.5 Hypotheses This study tested the following hypotheses: H1: Training members of HUMCs enhances performance of health centres H0: Training of HUMCs does not have any effect on performance of health centres 1.6 Objectives 1.6.1 Main Objective To investigate the effect of training of the members of HUMCs on the performance of health centres in East-Central Region of Uganda in order to inform policy on how to improve performance of these health centres. 1.6.2 Specific Objectives In order to address the research goal, this study was guided by the following three specific objectives: 1. To determine the effect of socio-economic-demographic factors on performance of HCs in the East Central Uganda. 2. To ascertain the current performance of HCs in the East Central Uganda. 3. To test the effect of training of HUMCs on the performance of the HCs in East Central Uganda. 1.7 Limitations and Delimitations The limitations are the characteristics of design or methodology that impact or influence the interpretation of findings of a research. They impact the validity of the study. They are here below blended with other hardships that were encountered in the process of this study and are generalised as challenges. The limitation in terms of time to allow observation of time tested effects and limited financial resources were encountered in the study. However, these were mitigated by coming up with a work plan and budget to guide the researcher in carrying out the study. Usage was also made of observable short period observable changes and comparisons with performance in periods before the study. There were also limitations related to respondents fearing to participate in the study, or giving false information, poor response rate, hoarding of information by the respondents, administrative bureaucracies in accessing the data/classified information. However, these were addressed by ensuring that the respondents understood the purpose of the study, and assuring the respondents of confidentiality of their opinions. Scarcity of records relating to the operations of HUMCs was encountered and was solved by relying on detailed information elicited during the probing at interviews and focused group discussions. Work schedules of the Medical Personnel and the ambiguous work schedules of HUMC members was going to lead to loss of interviews but this was overcome by planning interviews in time and observing time management processes by all players. The notion of difficults encountered in training of adults (adult learning) was a limitation on progress of training the HUMCs as it was also challenging in maintaining their zeal, but this was sorted by continuous explanations to respondents and reassurances and simplifying of the training materails. Also the approach of mixed methods of training ensured that participants were all the time actively participating and enjoying the sessions coupled with periods of energizers from them selves. The investigator‘s challenge of carrying out this research in Uganda with supervisors based far away in Kenya was mitigated by engaging one additional supervisor locally based in Uganda. 1.8 Theoretical Framework The theoretical framework given below endeavors to show that HUMCs exist in the East-Central region of Uganda and some work has been done before to allocate some roles to these committees especially in public health facilities. Three theoretical approaches, which have not been previously used in the context of effectiveness of training HUMCs and its contribution in improving monitoring and enhancing performance, these fortified the development of this theoretical framework: thus the market systems approach, complex adaptive systems, and individual motivation. The aim was to create a framework that investigated HUMCs practice in monitoring to enhance performance of health centres, widening the scope of the health system in which HUMCs operated, beyond those typically adopted by previously used economic theories (e.g. job complementarities theory, hours constraints theory) (Ssengooba, 2007)). An exploration of the effectiveness of training HUMCs in Monitoring to enhance performance in the health sector while employing elements of a health market system framework acknowledged that community empowerment and user appraisals within poorly defined and organized health service markets could be the new norm in most developing countries (Boulle, 2008). There was need to train HUMCs and mix the formal management structures with the ideas obtained from the trained consumers of the services to enhance performance and not merely leave free market forces to drive the performance of health centres as according to the Market Theory. Imparting skills to HUMC members had an expectation of having the committees empowered. This could offer opportunity to HUMC members to express themselves and the performance then is compared and contrasted with that in health centres where the committees have not been trained. This theory is underpinned by comparisons made in mixed services system in HCs where Government Health Facilities having HUMCs are compared with private health centres that may or may not accommodate HUMCs‖ (McCoy, 2012). Performance of health centres in mixed systems is assumed to be enhanced when one moves beyond the traditional understanding of the roles of government, its agencies and private sector (Brum, 2007) and explores new innovations that capture the roles played by trained HUMC in enhancing performance in health centres as was explored in this study. From the economic perspective, the principal consideration is the need to expand the production frontier to the optimal level of efficiency through appropriate incentives to the agents (Macha et al, 2011). Health provision is a complex industry with many tasks, some more measurable than others and some requiring more attention to quality than the speed of production or requiring team action rather than individual effort (Zia-ud-Din, 2017). The Maslow‘s individual needs theory points to existence of a tension among the incentives provided for performance of a particular task and the allocation of effort by agents on that task relative to other mandated tasks (kundabayanga, 2012). This is built on the theory of incentive. In general, the theory of incentives argues that when there are multiple tasks, incentives serves not only to allocate risk and to motivate hard work, but also to direct the allocation of the agents' attention among the various tasks (Zia-ud-Din, 2017). If volume of output is easy to measure but quality is not, then a system of incentives based on measures of service volume may lead health providers to increase their volume at the expense of quality. Yet some of the parameters for assessing performance are directed either at volume of out-puts rather than quality. On the other hand, community appreciation and utilization of services is a factor of quality. If responsive to the incentives theory, the provider (agent) would assign more effort to the elements that are measured compared to those that are not (Molyneux, 2012). The implication of this theory is that the recourse to volume than quality will end up driving clients away from services and lead to poor performance of HCs. This study addressed how to utilize measurable outputs to be able to solve the difficult to measure outputs in relation to quality of care by getting clients satisfaction measured remotely from training of HUMCs. The hallmark was to test productivity enhancement from team based incentives rather than individual Maslow‘s needs theory provisions. 1.9 The Conceptual Framework The conceptual framework was developed basing on the above cited theories. In the context of community monitoring and improving performance, it was the roles of trained HUMCs, the effects of these HUMCs and the zeal applied by HUMCs to enhance productivity in the health sector in East Central Region of Uganda that was of greatest interest. More specifically, the focus was on the interaction between trained HUMCs, then other community players, health workers and health managers in health facilities for improving performance of health centres. The HUMCs were trained and it was ascertained that HUMCs were playing their part to enable health unit performance or that whether irrespective of the training; HUMCs could not contribute to enhance performance of HCs. It was desired to establish whether HUMCs were essential in this health market system of East-Central Uganda and also identify techniques to improve HUMCs contributions to enhance performance of health centres. The various market system actors, such as central government, local governments, opinion leaders, leaders of religious bodies investors and users of services, illustrate the multiple perspectives from which HUMCs practicing research and evidence for policy has been important and guided the selection of participants for this study. The framework also highlights the fact that the working and factors that drive HUMCs functionality not only come from system policies but also arise from personal attributes like the knowledge level, awareness of roles, attitudes and demographics of an individual. 7Independent variableIntervening variableDependent variableModified from Trenno & Hantim 2005, Bloom Champion, 2009, Leowansea, 2013Social demographic factors (HUMC & HCWs) •Age •sex •Education•Marital status•Residence•Economic statusCurrent performance of HCs•Immunization •Deliveries •Availability of supplies•Frequency of HUMC meeting •OPD attendance •ANC attendanceHUMC training•Monitoring & Supervision •Awareness on their roles•Supplies management•Financial management •Human resource managementProvision of required leadership and managementPerformance of health centre•Good •Poor Conceptual Frame Work Figure 1.1 Conceptual Framework 1.10 Significance of the Study Health Unit Management Committees (HUMCs) have provided one vehicle for community participation and enhancing performance in health systems in many countries in the world (Goodman et al, 2011). However the potential for mechanisms such as HUMCs to meet their goals has been limited by lack of skills to perform their work (Ford, 2013). This has been inter-twined with the wider decentralization challenges such as insufficient transfer in practice of decision- making power to local levels for a range of functions, lack of clarity in responsibilities at local levels, and broader factors such as the prevailing political context, and inadequate access to financial resources (Kundabayanga, 2012). Relating performance of HCs to monitoring by knowledgeable users (HUMCs) has not been streamlined. HUMCs exist with the aim of ensuring that performance of HCs is good. (Tuwey, 2016). They are the community eyes and should be able to understand the system in place (Kundabayanga, 2012). Then they can be able to link users to providers and thereby ensure performance improves. The health sector in Uganda has undergone major reforms due to changing patterns of service delivery, government regulations, technological innovations, service quality improvements, and pressures to improve health care and health wages of workers (MOH, 2012). Yet little progress has been realized in improving the health status presumably due to faults in monitoring of service delivery (MOH, 2017). The economy is weak and seems not able to support monetary incentives in motivating HUMCs to perform their work too with energy and self-drive (Kundabayanga, 2012). Training of members of the health unit management committees was envisaged to be one way of motivating HUMCs to monitor and enhance performance of HCs. The training of the HUMCs on their roles ensured harmony and cordial relationship with staffs and ensured that performance assessment outputs improved. This drove improvement in performance of HCs. By having skilled HUMCs to bargain for better services was therefore the expectation that enabled improvement in performance of HCs. The study envisaged that providing training to HUMCs can enhance performance of the committees and therefore improve performance of the health centres. This was expected to lead to improvement of health indicators in the East Central Region of Uganda and eventually in the whole country. This study contributes to theory building and policy development on the concept of healthcare planning and management. The planning and management should be done by enlightened people and should reflect wider community participation through their management committees. Train ing HUMCs therefore improved their skills and enabled them to participate. This enabled improved performance of health centres. CHAPTER TWO-LITERATURE REVIEW 2.0 Introduction This chapter presents literature reviews from other related studies all over the world. The literature review provides the existing gaps and how these affect the performance of health centres as units and the individuals there in. The literature was analysed according to the specific objectives as follows: socio-demographic factors, performance of health centres, and effect of training. There is literature on performance of especially hospitals and also on the characteristics of HUMCs but scanty literature either on monitoring performance by trained and skilled HUMCs or on assessing effect of training in monitoring performance of health centres by HUMCs. Review of the available literature was done while reflecting on availability of HUMCs and performance of health centres. The concept of performance has a great link to governance especially in a health centre setting. This link has been well analyzed by World Health Organization (WHO) to give insight in this study as regards its objectives. Governance is one of the six core components or building blocks that World Health Organization (WHO) uses to describe health systems (WHO, 2010). The other components are: service delivery, health workforce, health information systems, access to essential medicines and financing (WHO, 2010). Governance overrides all the other building blocks which derive their effects from end products of governance (MOH, 2012). The health system consists of all organizations, people and actions whose primary interest is to promote, restore or maintain health. To have a strong Health system, there must be strengthening of the building blocks by addressing key constraints in each of building blocks (WHO, 2014) Strengthening health system governance involves establishing strategic policy frameworks and combined with effective oversight, coalition-building, appropriate regulations and incentives, and, transparent and effective accountability mechanisms (WHO, 2010.). Governance therefore provides the overall policy and regulation of the health system. This is a cross-cutting component that influences all the other five components, and ultimately the soundness or effectiveness of the health system. Among the ingredients for governance in Uganda is the contribution that is being made by HUMCs to drive performance of the health sector. United Nations Development Program (UNDP) developed five principles of good governance: legitimacy and voice, direction, performance, accountability, and fairness. Legitimacy and voice entails participation and consensus orientation; direction entails having a strategic vision; performance points to responsiveness, effectiveness and efficiency; accountability involves holding all players accountable and calls for transparency; while fairness deals with equity and inclusiveness, and rule of law (WHO, 2008). It is against these principles that a governance system will be measured as either facilitating or frustrating the strengthening of a health system. More or so after HUMCs will have been trained in these health centres. 2.1 Socio-Demographic Characteristics The composition of the HUMCs can affect their ability to deliver on their roles (J, (Haricharan, 2011). As Haricharan demonstrated already, a good mix in personal socio-demographic characteristics brings different skills and interests to the committee (Haricharan, 2011). The literature identifies various concerns as to whether or how socio-demographic dynamics of HUMC members enables or hinders them to represent or bring voice from various social groups in the community (Hipgrave and Hort, 2013). The literature also questions the representativeness of HUMCs in relation to the diverse component groups and differing interests in communities (Jeppsson and Okuonzi, 2000; Howard et al., 2002) such as whether they involve both influential people and disadvantaged people (Ngulube et al., 2004; Chatzimarkakis, 2010) and this question was explored in this study to fill the gap. Carl (2018) while discussing the composition of HUMCs in South Africa hinted on composition of committees while reflecting on gender balancing. The issue of influence of gender on performance of health centres was subject for analysis to close this gap in knowledge. In Carl‘s study they found out that at least one-third of the committee is drawn from women's groups or organisations, and others from community-level faith groups, youth groups and or from people living with disabilities. Other studies also aver that HUMCs are elected from and by people from surrounding villages and holding office for five years (Adam and de Savigny, 2012). The male-female ratios vary. Membership includes retired civil servants and pensioners with capacity to conduct health centre activities. Health workers are not expected to be members of the HUMC (Sengooba, 2010). It still remained relevant as was done in this study to test the effects of the socio-demographic factors of HUMC members in East Central Uganda Per-se when taken in context of performance of HCs and training HUMCs. Adi ( 2012) argues that there are three major factors affecting HUMC members influence on the design, delivery, and assessment of health services, and state capability to respond: The social, cultural, and economic power of the HUMC and clients group in question within community or society-its power to mobilise resources and public concern to support community interests and demands; The nature of the political system (the depth and procedural and substantive democracy, the configuration of executive/legislative/judicial power, the level of political participation), and the organisation of political participation. While the above studies pointed to the benefit in considering socio-demographic factors, Kavanugh concluded in his study that socio-demographic factors have no role in job satisfaction since demands and needs for survival are not essentially influenced by age, tribe or sex (Kavanaugh, 2006). His study was done in developed countrie therefore the need to cross check this finding in a developing country in East-Central Uganda. In Kavanaugh study, although mainly done while employing qualitative methodology, it cast light on why socio-demographic differences may not be essential when counting on factors deterring performance of organizations. This interventional study was essential to test the effect of socio-demographic characteristics on performance of HCs while employing an experimental study approach. Muathe (2013) threw support for the intervention study after discovering in the study in Kenya that it was more productive to employ female workers in ICT industry than male workers. HUMC performance outcomes include community bonding measures – social capital (McCoy, Hall, & Ridge, 2012), neighbourhood cohesion (Lagomarsino, Nachuk, et al. 2009), neighbourhood influence (Macha et al, 2011), community capacities or assets (Svensson, 2009) amongst others. Community and national level empowerment variables within the political, economic, legal, and human rights sectors include good governance, institutional performance improvement, and women‘s empowerment (Ngulube et al, 2004). Good governance includes accountability of politicians and managers through an information flow to the public, enhanced civil liberties, lower corruption, and increased responsiveness of an institution to public health needs and problems, and reciprocal relationships with a public empowered with greater access to transparent information and control over resources (Potts, 2009). Civil liberties and community participation, which facilitate transparency, for example, have improved development effectiveness, increased expenditures in schools and shaped health sector services, including increasing health centre attendance (Báez and Barron, 2006). 2.2 The Performance of HCs, Incentives and Performance Management Designing incentives for HUMCs to enable them contribute to the objectives of the organization is a grey area. Most partners do not buy in the idea of providing monetary incentives to the health workforce to stimulate performance (Molyneux, 2012). Therefore, the design of incentives needs to be well linked to all the desired outcomes as observed in (Mulumba, 2010). Contribution made by HUMCs may not be easy to measure. It may be difficult therefore to quantify the desirable incentives in terms of payments. Training them could be the best incentive in East Central Uganda to stimulate performance. The remainig question would be to establish the effectiveness of the training. 2.2.1 Employee Performance in Organisations Employee performance is normally looked at in terms of outcomes. However, it can also be looked at in terms of behaviour (Klassen, 2010). Klassen stated that employee's performance is measured against the performance standards set by the organization. There are a number of measures that can be taken into consideration when measuring performance for example using of productivity, efficiency, effectiveness, quality and profitability measures (Adi, 2012). Profitability is the ability to earn profits consistently over a period of time. It is expressed as the ratio of gross profit to sales or return on capital employed (Adi, 2012). Efficiency is the ability to produce the desired outcomes by using as minimal resources as possible while effectiveness is the ability of employees to meet the desired objectives or target (Soucat, 2013; Stoner, 1996). Productivity is expressed as a ratio of output to that of input (Soucat, 2013). It is a measure of how the individual, organization and industry converts input resources into goods and services. The measure of how much output is produced per unit of resources employed is called quality (Macha, 2011)). Quality is the characteristic of products or services that bear an ability to satisfy the stated or implied needs (Adi, 2012). It is increasingly achieving better products and services at a progressively more competitive price (Soucat, 2013). It is the responsibility of the company managers to ensure that the organizations strive to and thus achieve high performance levels (Soucat, 2013). This therefore implies that managers have to set the desired levels of performance for any periods in question (Soucat, 2013). This they can do by for example setting goals and standards against which individual performance can be measured (Soucat, 2013). Companies ensure that their employees are contributing to producing high quality products and/or services through the process of employee performance management (Adi, 2012). This management process encourages employees to get involved in planning for the company, and therefore participate by having a role in the entire process thus creating motivation for high performance levels. It is important to note that performance management includes activities that ensure that organizational goals are being consistently met in an effective and efficient manner. Performance management can focus on performance of the employees, a department, processes to build a product or service, etc. Earlier research on productivity of workers has showed that employees who are satisfied with their job will have higher job performance, and thus supreme job retention, than those who are not happy with their jobs (Soucat 2013). Further still, (Schaufeli, 2014) documented that employee performance is higher in happy and satisfied workers and the management finds it easy to motivate high performers to attain firm targets. Performance is the achievement of desired goals (Abor, 2015, Griffith and Alexander, 2002). High hospital performance should be based on professional competences in application of present knowledge, available technologies and resources; efficiency in the use of resources; minimal risk to the patient; satisfaction of the patient; and desirable health outcomes (Yuen, and Nga, 2012). Within the health care environment, high hospital performance should further address the responsiveness to community needs and demands, the integration of services in the overall delivery system, and commitment to health promotion (Gauld et al, 2011). High hospital performance should be assessed in relation to the availability of hospitals‘ services to all patients irrespective of physical, cultural, social, demographic and economic barriers (Dischoeck et al, 2011). Health centres are an important part of any health system. They provide complex curative care depending on their capacity that acts as a first referral, secondary or last referral level curative care facility. They also provide emergency care for the severely injured or the critically ill; they are centres for the transfer of knowledge and skills; they constitute an essential source of information and power; and they generally spend the major part of national health resources (El-Jardall et al. 2011). It is in their context as centres for transfer of skill that this study sought to examine the effectiveness of training HUMCs on performance of the health centres in the area of study. In the health sector, performance specifications can be based on service ―outcomes‖ such as abstinence from alcohol or drug addiction (Schaufeli, 2014, Shen, 2003; Lu and Ma, 2006) or based on volume of outputs such as patient visits, children immunised, maternal deliveries (Schaufeli 2014, Eichler and Levine, 2009; Soeters and Griffiths, 2003; WHO 2003; Akashi,Meessen, and Kashala, 2007, Sengooba, 2010). In some cases the measure of performance is on efficiency of resource utilisation such as reduction in the unit costs for care (Schaufeli, 2014, Ekochu, 2005; Dawson, Goddard et al. 2001; Dawson and Dargie, 2002; Smith, and Street, 2006; Jacobs and Dawson, 2003) while in other situations the measure is on the quality of services or productivity of the workers (Abor, 2015, Moody, 2004; Rosenthal et al, 2005; Mugisha, 2004). This study used performance indicators copied from those being applied by the Ministry of Health to assess and grade performance of HCs inorder to be able to find out the effectiveness of training HUMCs on performance of HCs. In Uganda the overall government health policy is to alleviate illness, reduce poverty and foster development. Performance in the health sector is tracked by its implementation of the minimum health care package (MOH, 2014). The package is a set of services that were judged to be cost-effective in reducing morbidity and mortality in Uganda (MOH, 2014). A set of indicators are used by the government to monitor performance of the sector some of which are: OPD utilisation, DPT3 immunisation coverage , Deliveries in health facilities, approved posts filled by trained health workers, urban and rural HIV sero-prevalence, and Standard Out-put Unit for hospitals (MOH, 2014). 2.2.2 Effects of HUMCs practice on the HC performance HUMC practice and impacts on health centre service delivery have been explored through theoretical and econometric models, which have identified a number of potential outcomes (Berman and Cuizon 2004; Machingura and Loewenson, 2013; Biglaiser and Ma 2007; Kiwanuka and Rutebemberwa, 2011). These effects range from positive – such as the retention of health professionals who might otherwise emigrate – to negative ones – such as public sector quality reduction and the diversion of patients, particularly healthier ones, to the private sector (Berman and Cuizon 2004; García and González 2006; Garcia and Gonzalez 2011). In a study of how retired officers earn their livelihood in Malawi, Muula and colleagues identified that working on boards is an important survival strategy (Paina 2011) meaning some members join HUMCs to earn a living than give a service. Loewenson et al 2004 found, in a study in Zimbabwe, that clinics with health committees generally had more staff, expanded programmes, and better drug availability. She suggested that health committees were instrumental in finding successful solutions to problems. Baez and Barron 2006 noted that community involvement in Malawi had resulted in a more responsive health service. There is also evidence suggesting that more equitable outcomes are achieved when communities are involved (Gryboscki et al, 2006). Lawn et al 2008 argue that community participation is the most neglected aspect in primary health care. Community participation provides an opportunity for community members and health care workers to become active partners in addressing local health needs. However such documentation is dismal and scanty for Uganda therefore the need to document the influence of these committees on performance especially for HCs in East Central Region of Uganda. In some instances, HUMCs may jeopardise performance (McCoy, 2012). McCoy infers in a systematic review that ―HFCs (Health Facility Committees) are therefore not a simple and ready-made solution to the problems of poor health services. But they can have a positive impact provided the committee members are trained on the targets and services are designed and implemented with care (McCoy., Hall & Ridge, 2012). Despite the potential impact, community participation is fraught with problems and in some cases both ineffective and limited. A number of studies suggest that health committees in South Africa are not functioning optimally (Boulle et al, 2008; Padarath and Friedman, 2008; Glattstein- Young, 2010). Numerous factors impact on their functioning. These include lack of political commitment, limited resources, limited capacity and skills, attitudes of health workers, lack of clarity of the role and mandate of committees, limited co- operation from health services, and lack of support. As can be noted, these studies are focusing more on functions leaving little room to explore fruits of the positioning of HUMCs in monitoring for enhancing performance. Some studies emphasise problems around an agreement on what community participation entails. Padarath and Friedman 2008, as well as Glattstein- Young 2010, found divergent views on community participation between health workers and health committee members. Most health committees were involved with solving problems between the facility and community, with health education being the second most popular activity. Glattstei n-Young (2010) found that service providers generally felt that health committees were not sufficiently visible in the clinic and were too complaints-focused, rather than assisting the facility to improve performance on a day-to-day basis with ‗rude and unruly‘ patients. Ssengooba (2007) defines active and informed participation as including participation in the following: identifying overall health strategy, decision-making, prioritisation, and setting the agenda for discussion. This includes being involved in policy choices, implementation and monitoring and evaluation. For (Ellis, 2008), being part of the decision-making process is also crucial to genuine or meaningful participation. These three authors argue that power-sharing between community members and health managers or officials, is essential to meaningful participation. But much of their work was derived from qualitative methodology and did not invoke interventional model that has been used to provide more insight in training of HUMCs to enhance community monitoring for productivity in health services in this study. 2.2.3 Psychological Contract to explain performance A psychological contract has been advanced as a product of the attitude and perceptions of the worker that motivates the individual to perform (Abor, 2015, Hopkins, 2007, Vroom, 1964). It also attempts to remedy the criticism of the expectancy theory which assumes that individuals are capable of calculating all the odds and always act in accordance with their motivation calculus. Psychological contract has been defined by Rousseau et al as the individual employee's subjective perceptions of the mutual obligations between employer and employee (Rousseau, 2014). Given bounded employee rationality, this contract reflects incomplete and sometimes distorted understanding of the employee-employer relations (Bulut & Culha, 2010). The psychological contract guides the day-to-day employee behavior in ways that cannot necessarily be discerned from a written job contract. How the psychological contract links back to employee performance is what (Bulut & Culha, 2010) has identified as causes, content and consequences on the employee. Inputs into the contract or causes include organizational culture, human resource practices, prior experience, expectations, and worker's job-alternatives. The state of the contract or its content has three main affective components: Sense of fairness, trust and fulfillment of workers expectations. Consequences include key attitudes such as job satisfaction, job security, organizational commitment and motivation. If this contract is violated, negative attitudes such as resentment, anger, mistrust and betrayal may arise. These may cause negative work behaviors ranging from low commitment, reduced effort or higher absenteeism, sabotage and worker exit (Jewer & McKay, 2012, Hopkins, 2007). In stable contexts, an existing psychological contract is likely to be reaffirmed by positive customs, practices and norms in relation to employer and employee understandings of the basis of the exchange. As such, the psychological contract serves as the internal glue arising from external incentives structures that helps to explain the commitment to relational contractual relations and sustained productivity (Klassen, 2010). It is important to note that the "psychological contract" approach is an integrating concept that knit together the theoretic elements of motivation-hygiene and expectancy theories into cognitive mental schemes that guide the day-to-day motivation for productive organizational life and commitment (Björkman 2010). Although presented as an individual-level concept, individuals share their schemes and cognitive constructs with others in the organization through formal and informal ways to generate a general mood, culture or norm for organizational commitment and productivity. Whether there are gaps in psychological contracts among stakeholders for performance of HCs in East Central Uganda becomes an ideal area for further research especially when HUMCs have been trained and are skilled enough to be able to appreciate the contract. 2.2.4 Motivators to Improve Performance -Theoretical Perspectives It becomes a mouth watering issue to cast a torch on how health workers and the health system can respond to training of their HUMCs. Before the training of HUMCs, the question at hand was: what can become after this component is empowered enough? Available were some theories from which to predict what was likely till proven either in pro or cons by the findings. Although agency-based economic theories explain why incentives are needed for performance improvements, they have weak operational explanations as to how these incentives lead to performance improvements (Goodman, 2011). Human resource management practitioners rightly concerned with sustained employee productivity and continued employee commitment to the organization find little practical assistance from agency-based theories (Johns, 2010). Operational mechanisms of how external incentives lead to performance improvement at the front line (health centre level) have been a central concern of the field of organizational psychology (Björkman, 2010). In equal measure, perspectives from organizational sociology and anthropology have provided contrasting approaches such as Human Relations, Organizational Contingency, Leadership and Governance and others - to deal with the issues of performance, efficiency and labour force commitment. Process theories of motivation have been advanced to explain the causal factors for labour productivity and organizational performance. Process theories refer to a system of ideas or statements that account for or explain a group of facts or phenomena related to the implementation of activities - how they should be planned, organized, and scheduled in order to be effective (El-Jardall, Saleh, Ataya and Jamal, 2011). Process theories vary in scope and application areas. Processes theories range from those seeking to explain the performance of organizations and work-team, to those dealing with the motivation, perceptions, organizational resources and support systems, and those that deal with how financial incentives influence performance. Motivation and Performance at the Individual Level although they have a long history in the business sector, recently, attention has turned to the psychosocial dimensions of labour productivity in the health sector (Klassen, 2010, Knyphausen- Aufseß, 1997). At the level of an individual worker within an organizational environment, two interrelated psychosocial streams are identified in the literature (Collier, & Green and Kim, 2011) as sources of motivation and productivity: The "will do" component relates to the extent to which a worker will adopt organizational goals and this is said to depend on intrinsic and extrinsic rewards from the work. The "can do" component depends on the extent the worker mobilizes personal resources/skills to achieve goals and depends on perception of competency, availability of resources and work environment. The Will do: This shows Commitment to Organizational Goals. Several process- based theories have been advanced to understand an individual's intrinsic and extrinsic motivation for work. These include those that seek to identify the factors essential for individual's motivation (content theories) such as Maslow's hierarchy of needs, McGregor's X and Y theories and Herzberg theory (Tumushabe, 2010). These theories identify various "needs" essential for the worker motivation, satisfaction and continued commitment to work. The needs arising from these theories range from basic ones such as food and shelter to higher ones such as recognition, growth and sense of accomplishment. Other needs relate to relationships with others and a sense of belonging. However in the context of human resource management as an explicit concern for sustained health centre performance, Herzberg's motivation-hygiene theory offers more explanatory potential (Chen, 2014). It identifies the short and long term factors as well as personal and environmental factors for employee motivation. In brief, motivation-hygiene theory posits that two factors i. e. motivators and satisfiers have different causal elements. The satisfiers relate to what a person does while the dis- satisfiers relate to the situation in which the person does his/her work. For example, supervision, interpersonal relations, organizational rules, working conditions and salary are short-term satisfiers rather than motivators. The absence of hygiene factors can create job dissatisfaction, but their presence does not necessarily motivate or create satisfaction. The motivators are related to elements that enrich a person's job; such as achievement, recognition, the work itself, responsibility, and advancement. These motivators are associated with long- term positive effects in job performance while the hygiene factors produce only short-term changes in job attitudes and performance that may fluctuate over time (Machingura, 2011 Herzberg et al, 1959). In particular, the use of financial rewards such as salary and bonuses are classified as hygiene factors with transient effects on productivity. The two factor theory has found broad application especially in managing and motivating knowledge-based productivity where tasks involve broad discretionary space from the employee. This situation is similar to health centre practice and care where decision making is delegated to health professionals (McCoy et.al. 2012). When HUMCs are introduced in the mix, the drive to performance assumes another dimension that need testing. Equally the need to test effectiveness of training of any component group of members and how this could be driver for productivity. 2.3 Effect of Training of HUMCs on Performance The response to training is influenced by performance governance relationships of upstream agencies and their resource inputs and support to the entities (Alexander and Lee, 2006). For health centres and training the HUMCs, these agencies include the Ministry Of Health, Districts and other projects seeking to achieve specific performance objectives from the hospitals. Performance surveillance and productivity are shown to interact at the levels of the health centres – where managers and clinical staff will make the decisions regarding the strategies to attain targets and how to motivate the workers (Ssengooba, 2010). Given their vital roles in performance governance, HUMCs represent a structural institution within hospitals whose function is vital if only they are skilled and empowered to contribute (Adam and de-Savigny, 2012). Contextual variables such as changes in upstream resources, relationships, market structure, and internal dynamics such as remuneration, institutional rules and the work environment within hospital organisations are also important drivers of performance (Ssengooba, 2010). Internal to the hospital, improved productivity requires a relationship between the HUMCs and the hospital managers (executives) as well as a motivated and supported workforce (Abor, 2015, Christianson, 2007). The empowerment of HUMCs as key contributors to the hospital performance are related to the, performance audit, feedback and emolument payments to workforce – all predicted to influence the hospital‘s strategies to improve service outputs (Dawson and Goddard et al,. 2001, Ssengooba, 2010). The training of workforce is not the only intervention that can work to improve hospital performance (Ssengooba, 2010). Other down-stream interventions such as prompt payment of salary, performance league (rankings) and the working environment are key interventions that influence the service outputs (Ssengooba, 2010). Training and imparting of skills to HUMC to be able to understand their roles in performance tmprovement underpinned this study. 2.3.1 Organization Responses to Trainings The health centre as an organisation may or may not respond to the training given to members of HUMC. The agency framework and model of revenue and costs of production predict that the agent would respond if the contract provides sufficient revenue to meet their reservation utility or cover the marginal costs of producing more services (Eldridge and Palmer, 2009, Ssengooba, 2010). If the risk (marginal costs of effort) of performance targets is judged to be worth the costs of training availed to members of HUMC, economic rationality would commit the authorities to provide policy and guidance to health centres to train their HUMCs. Since organisations are not single-minded, and may not have capacity to assess and monitor their reservation utility or marginal costs, the approach to organisational rewards and worker commitment to productivity is embedded in the environmental factors within the organisation and not limited to single items in the mix (Ssengooba, 2010, Franco and Bennett et al,. 2004). Organisational governance, such as rules and aspirations of the different constituencies, influences the psychological contract, strategic decision-making and goal transmission within the organisation (Machingura, 2011, Franco and Bennett et al,. 2004). The perceptions of health workers towards their organisation, leaders and leadership style may affect motivation and performance (Machingura, 2011, Franco and Bennett et al,. 2004). In particular, the degree of information sharing, consultation or participatory decision- making among managers and professional staff may influence the choice of selected performance innovations, psychological contract, all of which were reflected upon during the intervention of training of members of HUMCs in this study and how crucial it was about finding out the importance of training of members of HUMC to improve performance of HCs. Governance relationships among stakeholders i.e. the hospital Boards, core managers and professional staff would provide an environmental context that may facilitate or hinder the capacity of the hospitals to positively respond to training of HUMCs. Organisational theories suggest that organisational objectives can be manipulated by a package of process-based interventions that motivate people‘s productivity and job commitment at the same time providing a satisfactory work environment (Ssengooba, 2010). In this respect, cultural engineering (clan control) suggested by Ouchi (1980) – i.e. the specification of behavioural norms, procedures and processes, provide alternative control mechanism for organisational performance that is distinct from money-metric incentives (Campbell and Catherine, 2014, Oxman and Fretheim, 2008). Expectancy theory also provides process-based conditions that the training of HUMC study must fulfill if health centres are to respond. For example, communication that links the health centres‘ effort to the accomplishment of the service target is essential but not sufficient (Ssengooba, 2010). Additional communication requires that the measurements of outcomes will be fair, relevant and unambiguous (Ssengooba, 2010). Institutional arrangements such as rules and structures for facilitating HUMCs to do their work need to inspire trust that the training of HUMC as a practice will ―stay-the-course‖ and ―measure-up to the bargain‖. In this respect, health centres may choose response behaviours (innovations) that are tailored to the perceived stability /transience rather than those that lead to improved organizational performance which was the subject of assessment for this study. Thus, expectancy theory suggests that an individual considers the outcomes associated with various levels of his/her performance and elects to pursue the effort level that generates the greatest reward (Ssengooba, 2010). The conscious or subconscious calculus for effort behavior called "motivational force" is a product of three beliefs referred to as expectancy, instrumentality and valence (Oyaya, 2010): "Expectancy is the belief that one's effort will result in the attainment of the desired performance. This depends on skills gained from being trained, goal difficulty and perceived control over outcome. For example, the resources required, the skills and support available to the workers affect their expectancy. "Instrumentality - the belief that if one does attain performance goals, a reward will be received depending on trust and control mechanisms for the reward to be given (for example how, when and why rewards are distributed). This requires policies or formal organizational structures and rules that link the reward to expected performance. This also encompasses an objective and reliable means of measuring the expected performance (Nkundabayanga, 2012). "Valance encompasses the value that the individual personally places on the rewards. This is a function of his/her needs, goals and values. For example what value does a worker attach to the bonus, salary, promotion or recognition for task accomplishment? And therefore what value will the workers attach to training of HUMCs or even what value will members of HUMCs attach to their training to be able to stimulate performance improvement? The implications of expectancy theory for the training of HUMCs in East-Central Uganda are that management must ensure that employees are aware of the links between their effort and the required task (service targets), the accomplishment of the task should lead to a promised reward and the reward must be of sufficient value compared to the level of effort or need of the worker (Campbell and Catherine, 2014, Sengooba et al, 2007). "Without the knowledge of the [performance] score, the motivation calculus will soon dry up (Abor, 2015, Hopkins, 2007). In addition, the concept rests on "beliefs" which operate at the cognitive level of the worker to form what others have called a psychological contract (Abor, 2015). How managerial interaction and commuincation between members of HUMCs and staff has been affecting performance of health centres needed to be assessed and get HUMCs trained about it. And its effect on performance after the intervention to be established since there was not adequate literature to answer questions in this area. Training HUMCs in management of the HC and in communicating and assessing the effectiveness of that training on performance in HCs was therefore timely especially for East Central Uganda. 2.3.2 Training Requirements in the Context of Health Centres In an attempt to address the changing knowledge requirements, the Ministry of Health (MOH) conducted a training needs assessment in 2010 (MOH, 2017). This report highlighted the inadequate skills in leadership and management among health care workers and managers. It recommended a skills-building course to address the knowledge and skills gap. A lack of managerial and leadership skills among most health care workers and managers poses a major challenge to effective health care service delivery (MOH, 2017). Inadequate managerial skills would not only affect the quality of service delivery but would also reduce the utilization of services. In addition, the same report indicated that the existing training programmes for health care workers do not adequately address the managerial skills needed, and health care workers themselves expressed interest in acquiring the skills identified (MOH, 2017). The assessment was done for the training given to health care workers. It did not cover HUMC members as important components of the health systems. 2.3.3 Health Manpower Training and Development for Health Facilities The need for continuous capacity building for the health sector has seen the ministries of health in developing countries like Uganda effectively, responding to the increasing need for continuous professional development of health care workers and managers. The MOH in Uganda established the Health Manpower Development Centre (HMDC) in 1984 as a national in-service training centre. The centre is mandated to develop evidence-based training courses for professional development and health services management (MOH, 2017) for health workers only and none for HUMCs. Before innovating and having the HMDC, paper-based distance teaching and learning was used to train health care workers and managers. Over the years, however, this approach proved costly and unsustainable following reduced donor support (Ministry of Health, 2017) and left a gap of inability to continuously train stakeholders. The paper-based distance learning courses also included classroom sessions, for which participants were required to attend the HMDC. In addition to high costs, classroom sessions contributed to staff absenteeism thus low performances. Classroom sessions were tailored to the qualified HCWs and little or no effort was directed to training of HUMCs at the HMDC. To overcome these kinds of problems, the HMDC decided to develop a blended online training programme (MOH, 2017). The existing course on leadership and management for lower-level health care facilities (readily available and already used in face-to-face trainings) was transformed for delivery through e-learning (MOH, 2017). This online training covers only qualified health care workers and does not capture the HUMCs. Other courses are currently still being developed (e.g. clinical instructors and mentors, gender and human rights, and anti-corruption in health care services). More online courses are planned for the future (MOH, 2017). However the degree to which HUMC members have benefited from this training structure is both limited in documentation and actualisation. Designs for training of HUMCs cannot be traced in the literature surrounding operations of HMDC. The effectiveness and efficiency for training of members of the health committee can also not be traced in literature and how to best do it taking into consideration that HUMC members are rotational office bearers. 2.3.4 The Relevancy of Training Goldstein defined training as the systematic acquisition and development of the knowledge, skills, and attitudes required by employees to adequately perform a task or job or to improve performance in the job environment (Dhamodharan et al., 2010). This implies that for any organization to succeed in achieving the objectives of its training program, the design and implementation must be planned and systematic, tailored towards enhancing performance and productivity. Training consists of planned programs designed to improve performance at the individual, group and/or organizational levels (Dhamodharan et al., 2010). This raised optimism that if the stakeholders were trained in East-central Uganda, especially members of HUMCs and their health workers, performance of the health centres should therefore improve. Onasanya defines training as a form of specialized education aimed at giving the trainee a particular or specialized knowledge, skill and attitude which he/she must possess to effectively perform in a given position (Swanson and. Cattaneo, 2012, Onasanya, 2005). Training has been an important variable in increasing organizational productivity (Grip and Saverman, 2010). Training is a fundamental and effectual instrument in successful accomplishment of the firm's goals and objectives, resulting in higher productivity (Adi, 2012, Stanca, 2008). Training builds a team that is effective, efficient and well motivating, thereby enhancing the confidence and self-esteem of stakeholders (Grip and Saverman, 2010). The employees‘ knowledge and skills are thus developed to adapt to new technologies and other organizational changes and task requirements. The benefits of training are innumerable (Adi, 2012, Colombo and Stanca, 2008). Colombo et.al also state that one of the potent factors militating against the good performance of organizations and workers is inadequate training (Colombo et.al, 2008). A stakeholder may have the ability and determination, with the appropriate equipment and managerial support yet such person may be underproductive (Adi, 2012). The missing factor in most cases according to Adeniji is the lack of adequate skills, and knowledge, which are acquired through training (Ssengoba, 2010, Adeniji, 2002). Adeniji further stated that training reduces employee turnover and promotes goal congruency, while lack of training increases absenteeism rate, low output, poor quality and results in high unit cost (Ssengoba, 2010, Adeniji, 2002). Often times, organizations embark on training and imparting skills in stakeholders so as to enhance productivity and overall performance of the organizations. This is due to the recognition of the important role of training and manpower development in attainment of organizational goals (Adi, 2012). On the whole, human resources management theory predicts that the performance of an organization is necessarily based on innovative labour force, technology, quality management, and customer satisfaction (Dhamodharan et al., 2010). But also this theory sees training as a tool in the hands of human resources managers to activate and empower the productive base of an organization (Dhamodharan et al., 2010). Stakeholder training and manpower development is very vital to job productivity and organization performance since the formal educational system does not adequately provide specific job skills for a position in a particular organization. Thus there is no particular module in formal education that primes HUMCs in the role of monitoring health service delivery in Uganda. Yet this is the job that they should perform and show results to both their arms of supervision (community and government). While, few individuals (HUMC Members) may be having the requisite education and skills, knowledge, abilities and competencies needed to fit into a specific job function, some others require extensive training to acquire the necessary skills to be able to fit in a specific job function and also make significant contribution to the organization‘s performance (Dhamodharan et al., 2010). Training of stakeholders in an organization creates a workforce that is effective, efficient and well motivated, thereby enhancing the confidence and self-esteem of stakeholders (Grip, 2010)). The employees‘ knowledge and skills are thus developed to adapt to new technologies and other organizational changes and task requirements (Hipgrave, 2013). Training serves as a motivating force in improving the efficiency and productivity of the workers and many organizations have seen it as a veritable tool to enhance their organizational performance (Aguinis & Kraiger, 2009). Training and development aim at developing competences such as technical, human, conceptual and managerial for the furtherance of individual and organization growth (Bulut, & Culha, 2010). The functions of training include increased productivity, improved quality of work; improved skills, knowledge, understanding and attitude; enhanced use of tools and machine. It also leads to reduced waste, accidents, turnover, lateness, absenteeism and other overhead costs. Training leads to, elimination of obsolesce in skills, technologies, methods, products, capital management among others (Burroughs et al, 2011). The objectives of training a worker are to be better equipped to adjust to the changes in the nature of his/her work, to widen the trainee‘s understanding of the society in which he/she lives and develop him/her as a confident person, and to afford the staff the opportunity of changing their schedules of duties and to be able to perform equally well on them (Campbell and Coff, 2012). Human resources are the most valuable assets of the organization and, thus, expenditures on training should be regarded as ‗investment in people‘ and, therefore, the most valuable investment of all (Birdi et al, 2007). Brum is of the opinion that, those organizations that invest resources in workers‘ training stand the chance of gaining a lot (Brum, 2007). Definitely, the organization stands a better chance of increased productivity in their various enterprises than those who do not invest in the development of their workers. It is also evident that organizations reap much more benefits than the workers themselves (Brum, 2007). Staff training and development is a work activity that can make a very significant contribution to the overall effectiveness and profitability of an organization (Bulut & Culha, 2010). Orientation and induction training programme for instance provide new employees the general information that they need about the organization‘s policies, procedures, practices and rules that will affect them and also about the jobs, they are to perform as obtained in accurate and comprehensive job description (Campbell et al, 2012). Training provided to workers help the organization to function at an optimum level of productivity which is a direct effort of all employees (Ching-Yah et al, 2007). Training brings about change in behaviour with terminal objectives to achieve the goals of the organization through optimal use of manpower (Dhamodharan et al., 2010). Training helps in the coordination of men and material (Dhamodharan et al., 2010). During the training programme, employees are taught company expectations and objectives (Coetzee et al., 2009). They are shown the ladder through which they can attain their own objectives (Coetzee et al, 2009). This gives rise to goal congruence and consequently, everyone pulls in the same direction thereby making coordination easy. Other purposes of training are for safety considerations, the handling of equipment, facility and materials from the less risky to the very hazardous and the prevention of the cost of accidents and idle resources (Ching-Yah et al, 2007). With training and development, errors are reduced and efficiency is increased because employees are already well-equipped with the ways of the work (Ching-Yah et al, 2007). Lack of training causes increase in rate of absenteeism, low output, poor quality and results in high unit costs (Collier et al, 2011). Many employees have failed in organizations because of lack of basic training (Okpara, 2008) In light with the present research during the development of organizations, employee training plays a vital role in improving performance as well as increasing productivity (Campbell, & Kryscynski, 2012). This in turn leads to placing organizations in the better positions to face competition and stay at the top. This therefore implies an existence of a significant difference between the organizations that train their employees and organizations that do not (Abor, 2015). Existing literature presents evidence of an existence of obvious effects of training and development on employee performance. Some studies have proceeded by looking at performance in terms of employee performance in particular (Soucat, 2013). Others have extended to a general outlook of organizational performance (Klassen, 2010). In one way or another, the two are related in the sense that employee performance is a function of organizational performance since employee performance influences general organizational performance. In relation to the above, (Soucat, 2013, Vroom, 1964)) note that employee competencies change through effective training programs. It therefore not only improves the overall performance of the employees to effectively perform their current jobs but also enhances the knowledge, skills and attitude of the workers necessary for the future job, thus contributing to superior organizational performance. Training has been proved to generate performance improvement related benefits for the employee as well as for the organization by positively influencing employee performance through the development of employee knowledge, skills, ability, competencies and behaviour (Haricharan, 2011). Moreover, other studies for example one by (Hopkins, 2007), elaborate on training as a means of dealing with skill deficits and performance gaps as a way of improving employee performance. According to (Klassen, 2010), bridging the performance gap refers to implementing a relevant training intervention for the sake of developing particular skills and abilities of the employees and enhancing employee performance. He further elaborated the concept by stating that training facilitates organization to recognize that its workers are not performing well and acknowledges that their knowledge, skills and attitudes needs to be moulded according to the firm needs. It is always so that employees possess a certain amount of knowledge related to different jobs. However, it is important to note that this is not enough and employees need to constantly adapt to new requirements of job performance. In other words, organizations need to have continuous policies of training and retaining of employees and thus not to wait for occurrences of skill and performance gaps (Haricharan, 2011). According to (McCoy, Hall, & Ridge, 2012), employee competencies change through effective training programs. Dissatisfaction complaints, absenteeism and turnover can be greatly reduced when employees are so well trained that can experience the direct satisfaction associated with the sense of achievement and knowledge that they are developing their inherent capabilities (Oyaya, 2010)). Most of the benefits derived from training are easily attained when training is planned. This means that the organization, trainers and trainees are prepared for the training well in advance. According to (Abor, 2015), planned training is the deliberate intervention aimed at achieving the learning necessary for improved job performance. Planned training according to Kenney and Reid consists of the following steps; identifying and defining training needs, define the objectives of the training, plan training programs to meet the needs and objectives by using right combination for training techniques and locations. Also decide who provides the training, evaluatethe training and later amend and extend training as necessary. Weaver, S. J.; and others identify some negative impacts of training on firm performance, and they outline possible reasons for their finding (Weaver, et al. 2010). According to them, where firms offer more training, they may be doing so in an inadequate manner, either because they train in the wrong areas or because they do not follow up on the training to ensure good results (Weaver, et al. 2010). They argue further that it is clear that the link between training and productivity is a complex one, and there may be many external variables which interplay to determine the nature of the impact that investment in training has on business performance (Weaver, et al. 2010). Despite the importance of training in employee productivity and organizational performance, training programs are not sufficiently supported in East-Central Uganda. Potential supporters for training consider the money they will spend on training programs as waste rather than investment. The ambiguity in the existing evidence made it imperative to provide further empirical evidence on the effect of training and manpower development on HUMC productivity and health centre performance in East-Central Uganda. This study underpinned the importance to consider observation of the above mentioned requirements and be able to assess effectiveness of training HUMCs on performance of HCs. 2.3.5 Effectiveness and Efficiency of Coaching, Mentoring, as Training Methods This involves having the more experienced employees coach the less experienced employees (Haricharan, 2011). It is argued that mentoring offers a wide range of advantages for development of the responsibility and relationship building (Haricharan, 2011). The practice is often applied to newly recruited graduates in the organization. New workers are attached to senior colleagues who might be their immediate managers or another senior manager to be mentored. This however does not imply that older employees are excluded from this training and development method but it is mainly emphasized for the newly employed persons within the organization (Campbell and Coff, 2012). This involves getting new employees familiarized and trained on the new job within an organization. During this process, they are exposed to different undertakings for example the nature of their new work, how to take on their identified tasks and responsibilities and what is generally expected of the employees by the organization. They are further given a general overview of the organizational working environment including for example working systems, technology, and office layout, briefed about the existing organizational culture, health and safety issues, working conditions, processes and procedures. This study endeavoured to explore ways of making coaching and mentorship a continuous training process to not only fit new employees but also work for improving performance of HUMCs as a planned routine measure. 2.3.6 Conferences as a Capacity Building Strategy As a training and development method, it involves presentations by more than one person to a wide audience. It is more cost effective as a group of employees are trained on a particular topic all at the same time in large audiences. This method is however disadvantageous because it is not easy to ensure that all individual trainees understand the topic at hand as a whole. Not all trainees follow at the same pace during the training sessions. Indeed focus may go to particular trainees who may seem to understand faster than others and thus leading to under training other individuals (Campbell and Coff, 2012). It is also rather expensive to do training by conferences and may not be feasible in resource constrained health centres in East Central Uganda. 2.3.7 Role Playing Involves training and development techniques that attempt to capture and bring forth decision making situations to the employee being trained. In other words, the method allows employees to act out work scenarios. It involves the presentation of problems and solutions for example in an organization setting for discussion. (Kacmar, 2016). Trainees are provided with some information related to the description of the roles, concerns, objectives, responsibilities, emotions, and many more. Following is provision of a general description of the situation and the problem they face. The trainees are there after required to act out their roles. This method is more effective when carried out under stress-free or alternatively minimal-stress environments so as to facilitate easier learning. It is a very effective form of training method for a wide ranges of employees for example those in sales or customer service area, management and support employees (Campbell and Coff, 2012). 2.3.8 Formal Training Courses and Development Programmes In formal trainings, courses and programmes carried out are usually defined, widely known and preset. The programmes have been defined whereby the contents, durations and all the details about the training are clear to both the organization and the personnel to be trained. Unlike informal trainings and programmes, formal training and programmes can be planned earlier and also plan for their evaluation. Employees may undertake these courses and programmes while completely off work for a certain duration of time or alternatively be present for work on a part-time basis. These programmes can be held within the organization (in-house) or off the job. Off the job is argued to be more effective since employees are away from work place and their concentration is fully at training (Adeniji, 2002). Depending on the knowledge needed, organization‘s structure and policies, the trainers too may be coming within the corporation or outside the organization. 2.4 Summary and Limitations of the Literature The rise in the significance of health system performance in international health policy circles has been accompanied by a growth in the body of literature providing various frameworks for examining and understanding this concept. (Adi, 2012). The literature provides rich background information, bringing out common themes and patterns (with considerable overlaps) relating to community roles and functions but little on effectiveness of training HUMCs in improving HC performance and its application to health service research. Within HUMCs, most studies have focused on professional managers as the main monitoring and performance boosting mechanism for training, with very little information on other mechanisms. The HUMCs training as area of study has not been explored to detail thus leaving enormous gaps in literature for filling up. Available literature is only in their composition and formation, and there is not much variation across health care levels (Collier, & Green and Kim, 2011). Most committees consist of community representatives, health facilities staff representatives, and representatives of local administration (MoH, 2014). But the appeal to select community representatives and political representatives could be with many other objectives besides the goal of improving performance of health centres. The literature provides a mixed score card regarding committee effectiveness as a mechanism for enhancing performance. The various exploration study projects described in the literature show that committees can be effective in enhancing primary care delivery in many ways such as: by mobilizing the community to contribute to the management of their facilities and to identify priority areas; by overseeing facility development projects; amongst a few other activities (Ford,. 2013). These issues are dependent on: whether HUMC members understand their roles and authority. HUMCs monitor and control resources; they monitor staff attitude and perceptions. The HUMCs interpret local political dynamics; and blend it to health system and socio-cultural contexts within which the committees operate for better services to their communities. Little, however, has been known about the availability of skills by HUMCs to monitor and enhance performance of HCs. Also little has been explored about the process in achieving productivity from the health systems in East Central Uganda after training of the HUMCs. The reviewed literature highlights several key gaps concerning the functioning and impact of training HUMCs in enhancing performance of HCs. There was very little empirical data to match the growing national and international interest in this area. It was important, therefore to carry out this study for HCs in East-Central Uganda in order to close the revealed gaps and be able to embrace monitoring of performance of HCs by HUMCs. This study transcended the available literature that focused entirely on either monitoring of services only by qualified health managers, or on availability of committees in HCs or the health care workers‘ perspectives on committees, and therefore provides analysis of the contribution of trained HUMC in monitoring HCs to enhance performance in these HCs. It provides the ingredients probably missing in empowering the HUMCs to be able to do good work. CHAPTER THREE-MATERIALS AND METHODS 3.0 Introduction This chapter entails and provides information about planning for data collection, analysis, and interpretation. It covers the following; research design, variables, study setting, study population(inclusion and exclusion criteria for participants), study description (selection of study health centres), the intervention (training of HUMC), sample size determination, sampling techniques, validity and reliability, data collection and study instruments, data management, data analysis, and ethical considerations. 3.1 Research Design The design was a 2 arm cluster randomized community trial. There was an intervention cluster of health centres and control cluster of health centres that formed the units of randomization. The interventional study design was used to explain how training of HUMCs triggers improved performance of health centres. The unit of analysis in the study was the response of the performance of health centres to training of the members of HUMC. Clinical out puts like (OPD attendances, deliveries in health facilities, immunization coverage), perceptions, behaviours, practices and decision processes were the basis for assessing the response. The analysis sub-units embedded in this randomized community trial included the interaction between hospital actors i.e. HUMC members, managers and clinical staff in relation to prerequisites for health centre performance improvement. These relationships i.e. nature of strategic control (leadership and governance), performance monitoring and supervision, feedback mechanisms, how HUMC members were fitting in the mix, and technical assistance provided by the trainers of HUMC members shed light on the mechanisms that training elicited and provided the causal pathways to explain the response to the training. 3.1.1 Rational for this Study Design The randomized community trial study methodology was considered suitable for addressing the study objectives and satisfactorily enabled achievement of the objectives. The study objectives sought to understand a social phenomenon ―system reaction to training of members of HUMCs‖ at an organic entity (the health centre) that can be referred to as a social system. The health centre has a number of actors, a culture for interactions, rules and professionals and personal interpretation of experience. As such, when the health centre system was subjected to the training of its HUMC as a structural intervention, the experience and interpretation of the actors provided the basis for understanding the impact that training had on the performance of health centre as compared to a matched control whose members of HUMC were not trained. The strength of the community trial borrowing from the case-control study methodology was the depth of study it enabled for the phenomenon to be better understood. Machin‘s definition of community trial illustrates its appropriateness to this study. The experimental study is an empirical enquiry that: investigates a contemporary phenomenon within its real life context; when-the boundaries between phenomenon and context are not clearly evident, and in which multiple sources of evidence are used (Machin, 2010). In this study the boundaries between health centre performance, individual performance of health care workers and individual HUMC member performance were not clearly distinguished and allorted. The community trial study also depended on the careful selection of the object for the study as a way to make broader generalization from very small number of pre and post study cases examined. Community trials remain the only design appropriate for the evaluation of lifestyle interventions that cannot be allocated to individuals. A community trial entails the researcher to 1) carefully assess the secular trends for their outcomes and be confident that they can demonstrate an intervention effect against those trends; 2) be confident that they have effective programs that can be delivered to a sufficiently large fraction of their target population; 3) avoid differences between study conditions in levels and trends for their outcomes through random allocation of a sufficient number of communities to each condition; 4) develop good estimates of community-level standard errors prior to launching future trials; and 5) take steps to ensure that power will be sufficient to test the hypotheses of interest (Machin, 2010, Murray, 1995). 3.1.2 Selection Criteria for Study Health Centres Twelve health centres were selected for in-depth intervention study in the experimental arm and twelve health centres were selected in the control arm for this study on training of HUMCs to stimulate productivity of the health centres. The selection of the health centres was random and was guided by the desire of seeking validity of and generalizability in the community trial study approach. The study covered health facilities at the level of hospital. The study questions in this research were indeed best addressed at hospital as opposed to smaller health facilities. The major reasons for seeking to study the effectiveness of training HUMCs on performance of HCs at hospital-level was that hospitals represented complex organisations and findings from these hospitals provoked greater theoretical and operational generalization to guide policy and practice for performance enhancement in HCs of the Uganda‘s Health System. Furthermore, hospitals, as opposed to smaller health centres, have several organisational structures such as departments, skilled managers, and diverse mix (cadres) of workforce that were essential for the exploration of the theoretical propositions and conceptual framework for this study. A baseline to assess health centre performances, skills and knowledge in reviewing and monitoring capacities by HUMCs in the intervention and control arms of the study was conducted. The HUMC members in the intervention arm with limited skills and knowledge were subjected to intensive training for period of two weeks per each session. Six training sessions were held each at easily accessible training sites each site having two hospital sets of HUMC members (24 HUMCs participants trained per site). Each training centre had a trainer from Ministry of Health of Uganda and one officer from the host district training committee and one Research Assistants. After the initial 2 weeks training which ended within the first month of intervention period, then all HCs in the intervention arm were followed up with close mentorship and coaching sessions to the members of HUMC that were being provided with continuous apprenticeship learning sessions. Follow up was done monthly after the initial training in all twelve intervention sites and then assessment of performance was carried out six months in all centres in the intervention and control arms after the training to ascertain the improvement in performance in the intervention health centres that were compared with those in the control. This enabled explaining the impact and outcomes. 3.2 Study Variables The study variables that formed the basis for this Randomized Community trial are explored and explained below. The variables tested the effectiveness of training of the Health Unit Management Committees on performance of HCs. This underpinned HUMC effectiveness in supervision, monitoring and managing the health facilities to ensure improvement in performance in regard to the Ministry of Health performance indicators. 3.2.1 Dependent Variable This is defined as the variable that is the effect or is the result or outcome of another variable (also referred to as outcome variable or effect variable) (Adi, 2012). The dependent variable was the performance of health centres with a dichotomous out- come of whether good/enhanced or bad/not enhanced. It was determined in terms of User awareness of services (OPD attendance), the adequacy and appropriateness of the measures of performance in terms of the indicator variances (Immunisation rates and skilled deliveries) and accessibility of the health facility to the community members that each health facility serviced (Availability of supplies and governance issues). The assessment of impact of training of the health unit management committee on performance of HCs was therefore based on improvement in the performance indicators. 3.2.2 Independent Variables This is the cause variable or the one that identifies forces or conditions that act on something else (Adi, 2012). The independent variable is "independent of" prior causes that act on it and it comes before other variable in time (Adi, 2012). The independent variable exerts influence on the main out-come of interest to the research. The independent variables that this experimental study was built on formed the basis for which the health unit management committee‘s roles and responsibility as regards HC performance was being influenced. They related to the Factors that influenced performance of health centres. They were a bed rock for determining the characteristics of the dependent variable and the results of the study evolved around there. This study considered the socio-demographic characteristics like age, sex, education level, profession and economic prowess as independent variables. In the qualitative aspects of the study, attitude of members of HUMC and the general motivation factors in HCs were looked at as important independent variables. The study considered other factor that influenced performance of HCs as Independent variables for instance the health care workers‘ attitudes and motivation to perform and the roles of managers of health centres to motivate stakeholders to perform. The HUMC roles of Supervision, Monitoring roles contributed in predicting the dependent variable of performance of HCs. HUMC Skills to monitor, availability of effective communication, availability and use of Guidelines and policies, were considered as remote important independent variables to explore the dependent variable. 3.2.3 Intervening Variable The intervening variable that this trial was built on was training of HUMCs. It was underpinned by how the training of HUMCs influenced the outcomes in terms of enhancing performance of HCs. Its aim was to evaluate whether the capacities of the HUMC were built in order to be able to enable improved performance of HC. The components that were used in the intervention included; 3.2.4 Training Methods In the intervention Health Facilities the training components identified were set on training workshop for members of these health unit management committees. The HUMC members were trained in the different skills to enhance their roles as managers of the health facilities. This was expected to improve the overall performance of the health facilities which was the specific target indicators for this trial or intervention. The training consisted of a mixture of adult learning methodologies, including short lectures, questions and answers, small group discussions, plenary presentations, video shows and role plays. In the course of training, participants from the same HUMC developed their own action plan together, which was presented to the class and discussed. The action plan was meant to enable participants to analyse their health centre and district health care systems, prioritize certain problems for corrective interventions and redirect available resources to address these problems. Participants particularly reviewed and assessed the values, goals and objectives for relevance, critical problems to be addressed and the primary strategic options that might lead to accomplishment of the objectives. There was constructive feedback session in which other participants and the facilitators gave their inputs on the action plans. This was aimed at achieving a refined and well discussed action plan/project for each health centre. At the end of the course, each HUMC team was required to implement their action plan when they returned to work. Finally, the participants were requested to agree and develop the process milestones, monitoring and evaluation plans and the management structure for implementation of this Community and Health Centre Performance Improvement Project. Weekly mentorships and follow ups were also provided to HUMC members in the intervention arm to give them further support and training to ensure the correct application of their chosen projects were being realised. 3.3 Study Area The study was conducted in randomly sampled health facilities in the East Central Region of Uganda. Uganda is a low developed country in Africa. It is boardered by Kenya in the East, South Sudan in the North, Democratic Republic of Congo in the West, Rwanda and Tanzania in the south. Uganda is land locked country. The East-Central Region of Uganda shares borders with Kenya and Part of Southern Sudan and Northern Tanzania. The East Central Uganda is a composition of 16 districts (UBOS, 2016). It sits on an area of 15,242.8 square metres with a population of 9,042,422 people (UBOS, 2016). The people in the villages and towns have options between farming and producing food for consumption or doing some petty trading and or working in public offices. The proportion of the population in Uganda that lives within 5kms of a health facility is 78% up from 49% in 2000 and in Eastern Central Region of Uganda; it is 72% (MOH, 2012). The table below shows the distribution of the populations as being served by the health centres in the region. Table 3.1 Population Coverage by health centres District Population Hospitals HC III HC II Jinja 468,256 8 13 18 Kaliro 236,927 1 4 14 Kamuli 490,255 4 11 16 Luuka 241,453 1 6 8 Mayuge 479,172 2 5 11 Namayingo 223,229 1 3 10 Namutumba 253,260 1 7 10 Iganga 506,388 3 12 25 Buyende 320,468 1 8 17 Busia 325,527 4 11 16 Bugiri 360,076 4 10 12 Tororo 526,378 7 14 19 Buikwe 436,406 6 12 21 Pallisa 386,074 3 5 13 Kayunga 370,210 4 11 19 Butaleja 245,873 2 9 16 Total 5,869,952 52 141 245 Source: UBOS 2016 Health service provision in Uganda is organised in form of health centres as explained below. Table 3.2. The health system in Uganda Level Status Purpose HC I Village Health Teams (VHTs)-Village To mobilise community towards promotion of health andprevention of diseases. Has no HUMC HC II Out Patients Treatment Posts with only Nurses to offer care-Parish level Give out patienttreatment to mild illnesses in community. Has 8 members of HUMC HC III Sub-county Level-With Clinical Officers to manage The lowest level complete health centre with wards for admission of patients and a maternity wing Has 8 Members of HUMC HC IV County Level-HC With Doctors and other staff. Can perform operations/surgeries to patients. Has 12 members of HUMC HC V District Level- Hospital With 10 Doctors and other staff. Can perform operations/surgeries to patients. Has 12 members of HUMC Regional Referral Hospital Serves Regions For specialised and general services. For referrals. National Referral Serves the whole Country For training and specialised care. Rehabilitation In East-Central Uganda, there are 438 health centres of different levels with 52 hospitals, 101 public HC IIIs, 40 PNFP HC IIIs, 153 public HC IIs and 92 PNFP HC IIs (MOH, 2012). The majority of these formal structures are the basis for health services delivery/consumption in the communities that they cover. The Global Information system (GIS) is used to give the coordinates of each hospital, health facility and any other structures like clinics. Management committees (HUMC) exist in all public and PNFP health facilities and few or none in private (UDHS, 2016). The Uganda-East Central Region access to health care facilities has challenges of infrastructure, inadequate medicines and other health supplies, shortage of human resources in some health centres, low salaries, lack of accommodation at health facilities and other factors that constrain access to quality service delivery especially in the rural areas where the majority of the population lives. Analysis of correlation of these challenges in the event of training of HUMCs to enable effective Health Unit Management Committee monitoring to enhance performance has not been done before. 3.4 Target Population The target population included all health centres both public and private in East Central Region of Uganda whose total number is 438, the members of HUMCs in these centres estimated to be 5,256 (438HCs x12members) in number, all health workers in East Central Region of Uganda estimated to be 50,650, the managers of health centres totaling to 1,314 (438HCs x 3managers per HC), and the estimated 240 members of Districts Health Management Team (15members x 16 districts). The target population also included the people living in these districts and the immediate surrounding area served either through direct admission or referrals from lower health centers; as patients. 3.4.1 Study Population The study population included (HCS) hospitals in all the districts of East Central Uganda from which a sample of 24 that was randomly drawn. The subjects of the study included sampled participants selected from the Members of HUMCs, Managers of District Health Services, and the Managers of Hospitals in the region. 3.4.2 Inclusion Criteria for Participants Participants for the study included purposively sampled respondents from the District Health Teams, the District Administrators for the baseline in both the intervention and control arms. Included also were members of the HUMC that must have served for at least 6 months before commencement of the study. It also included sampled health center managers in those selected health centers who were willing to participate. 3.4.3 Exclusion Criteria for Participants Member of the HUMC who were not in good state of mind or were sickly, these were excluded. Also those members that had served for less than six months were excluded in the study. Also any member of HUMC in the region who had been sampled but did not want to participate in the study for any personal reason was excluded. 3.4.4 Sampling Procedure For the study area, the East Central Region of Uganda was purposively selected for the study. Purposive sampling is where the sample is arbitrarily selected because of characteristics, which they possess, are deemed important for the research (Palys & Atchison, 2008, Grellety, 2016). This was because the East Central Region of Uganda had been having most districts grouped among the districts with poor performance in the Districts Performance League Table released by the Ministry of Health of Uganda every year. For example twelve of the last twenty districts in the table of district performance for financial year 2016/17 were from the East Central Uganda (MOH, 2017). Health centres that were selected for the study were those at the level of hospital that carry out admission of patients. Therefore a sampling frame of 52 health centres was drawn from all health facilities in the East-Central Region of Uganda that offer in- patient services and were found to be at level of hospital. A sample frame is the set of items that have a chance to be selected given the sampling approach that is chosen (Grellety, 2016, Fowler, 1993). Selection of the 24 health centres to participate in the study was done after all the 52 hospitals in the sampling frame had been coded with three digit numerals beginning from 001. The selection was made using the random number table using the table to draw the first coded health centre and continuing until all 24 required health centres had been drawn. The coding followed alphabetical nomenclature taking into account the first letter for the name of the health centre. This excluded selection bias since the naming of these centres was done randomly and independently of each other. Hospitals coded with odd numbers were placed in intervention arm and those coded with even numbers were placed in the control arm of the study. 3.4.5 Sample Size Determination Even if it were possible, it is not necessary to collect data from everyone in a community in order to get valid findings. In research, only a sample (that is, a subset) of a population is selected for any given study. The study‘s research objectives and the characteristics of the study population (such as size and diversity) determine which and how many people to select (Natasha, 2005, Grellety, 2016) The samples were determined by the information power of this study. Information power indicates that the more information the sample holds, relevant for the actual study, the lower amount of participants is needed. (O‘Reilly, 2013) This is dependent on; a) the aim of the study, (b) sample specificity, (c) use of established theory, (d) quality of dialogue, and (e) analysis strategy. In this model as applied by the study, these elements of information and their relevant dimensions were related to information power. Phenomenological research generally deals with people: perceptions or meanings; attitudes and beliefs; feelings and emotions. In this context of this study it was perceptions on performance of the Health centres and the influence applied by members of the Health Unit Management Committees that was viewed as phenomenological study material. Taking the study in phenomenological context, each study site was considered as being heterogonous because of their social cultural diversity. There were 438 health centres each having 12 members of HUMC. This gave a total of 5,256 members of HUMC. Out of the 438 health centres, 386 were at lower level and 52 were at hospital level. This study focussed on health centres at the level of hospitals. Since each hospital had 12 members of HUMC, this gave a total of 624 eligible participants (12x52). From the 52 hospitals 12 intervention study sites and 12 control study sites were selected. This gave (12x24) thus 288 respondents from HUMC with chance to be trained and interviewed, 64 Key Interview respondents from DHT members (four members of DHMT from each of the 16 East Central Districts of Uganda) 72 KI respondents from hospital management (3 hospital leaders from each of the 24 health centres) and 20 Community leaders (5 from each of the 4 randomly selected districts in the region). 3.4.6 Determination of Sample size for Health Centres James Schlesslman (1982) states that in case-control studies the number of subjects to be selected in case-control study depends on the specified values below 1. Estimated exposure rate (proportion exposed) among controls = P0 2. A hypothesized relative risk (estimate by odd ratio) associated with exposure that would have sufficient biological/public health importance to warrant its detection R which is assumed to be 2. 3. Zα = Standard normal value corresponding to the required level of significance for 0.05 = 1.96 4. Zß = Standard normal value corresponding to required power of study for 80% = 0.84 5. n = number of the required sample size of the case 6. The desired level of significance for this study α was 5% 7. The desired power of this study ß was 80% 8. = The probability of success among the unexposed group 0P 9. = The probability of success among the Intervention group 1P 10. C= 1 (the number of controls per case) For every case sampled, 1 control was taken so the ratio was of 1:1, cases: controls respectively Using the formula n= (1+1/C) P1 Q1 (Zά + Zß) 2 / (P1 – P0) 2 P1 = (P1 + CP0)/ (1 + C), but Q1= 1- P1 P1 = P0 R/ [1 + P0 (R – 1)] C= 1 (the number of controls per case) P0 = 46.3% (Carl May, 2018: Implementation of grip strength measurement in medicine for older people wards as part of routine admission assessment: identifying facilitators and barriers using a theory-led intervention NewCastle, UK) P1 = 79% (Carl May, 2018: Implementation of grip strength measurement in medicine for older people wards as part of routine admission assessment: identifying facilitators and barriers using a theory-led intervention NewCastle, UK) By substituting the figures into the equation; n = 1 x 1 x 0.79 x 0.21 (1,96 + 0.84)2 / (0.79-0.463)2 = n = 1 x 0.79 x 0.21 x 7.84 / 0.107 = n = 1.300656 / 0.107 = n = 12 Therefore 12 intervention health centres and 12 control health centres were used for this study. 3.5 Study Description The study was undertaken in East Central Uganda in the 24 randomly selected health centres. 12 health centres were in the intervention and the other 12 health centres in the control arm. The HUMC members from each health facility were studied and the performance in selected indicators verified. HUMC members in the experimental arm benefited from the intervention while the other HUMC members in health facilities in the control arm acted as markers to compare the impact of the intervention on performance of the health centres. The selection was done to ensure that there was limited contamination between the intervention health centres and the control group. HUMC members from the selected health centres either in intervention or control arm were consented. There was provision of training in order to empower the HUMC to be able to support the health centres to improve performance indicators in the areas of; ANC attendance, medical Supplies availability, facility based delivery increase, OPD attendance, Immunization coverage (DPT3), ways of curtailing absenteeism by health workers and frequency of management committee meetings A review of the baseline indicators for the whole study area was done focusing on the sampled health centres both in intervention and control arm. Based on the identified capacity need, the interventions focused on providing appropriate skills and build the capacity for the HUMC members from the health centres in the intervention arm. Interventions included training the members of HUMCs in: support supervision and monitoring, awareness of roles of HUMCs, supplies management, financial management and human resources management. The HUMC members in the intervention arm were expected to perform their functions with more efficiencies and effectiveness for 6 months after the training period. Subsequently an impact evaluation was conducted to assess the effectiveness of training HUMCs on performance of HCs. The performance of health facilities in the intervention arm was compared with those in the control arm to be able to ascertain the level of improvement in performance that the intervention had contributed. Baseline data was collected from all health centres at the beginning of field activities in July 2018. After the base line data collection on the performance levels of all the health facilities in the study sites and the capacity levels of the HUMC in the sites in the intervention had been assessed, then training to fill the gaps was commenced. Therefore in the intervention arm, the team of HUMC were supported and equipped with different skills knowledge and capacity based on each of the HUMC members needs from the assessment at baseline. Follow ups and mentorships done to HUMC members in intervention arm were done by research assistants on daily basis for the first month after study then weekly in the subsequent five months that followed. Members of HUMCs that had acquired these skills but were not adequately implementing what they had been trained or asked to do were re-orientated. Trainers also conducted weekly review meetings with HUMC members to check on their knowledge and skills on performance monitoring and scrutinizing documents to identify performance gaps for filling. Trainers, and the HUMC mentors from districts outside the study area that were performing well carried out mentorship and coaching of the HUMC members to especially those who needed peer and professional mentorship and coaching once per month for a participant HUMC member during the course of the intervention. 3.5.1 Comparison Consenting HUMC in the control arm were monitored at similar time intervals as done to those in the intervention arm as a way of blinding. Members of HUMCs in the control arm had their capacity not tampered with. Both the intervention and control study arms performance was assessed at the beginning in July 2018 and at the end in January 2019. This enabled the study team to assess and compare the performance indicators of the health facilities. The impact made due to the intervention on performance of HCs in the intervention arm when compared to those in the control was then documented. 3.5.2 Study Procedures 3.5.2.1 Screening Procedure Members of the health Unit management Committee (HUMCs) were identified by the study team from the study health centres by either direct contact with them or telephone call. The research teams then notified the training team about the readiness to undertake a baseline to identify the specific capacity needs for each HUMC member. 3.5.2.2 Enrolment Procedure Consent for the HUMC to participate in the study was taken by Research Assistants. In addition, eligible respondents were given their informed consent for the study. Those who declined were exited and their data was not captured or included. Once included, the HUMC members, the leaders of health centres and the sampled district leaders remained in the study until 6 Months of the intervention and participated in post intervention assessment 3.5.2.3 Follow-up Procedure Participating HUMCs were followed up and their capacity was continuously built through mentorship, coaching support supervision and training sessions. Once a health centre HUMC had chosen an intervention to improve a performance theme or areas, the research team endeavored to check progress on the performance indicator during the intervention and at post intervention test. The research team also conducted a formal end-of study assessment of the performance at the end of 6 months of the intervention within the health centre where the HUMC existed. Intervention (Capacity Building) CONTROL CLUSTERS 12Hospitals (n=12) Members of the HUMC ALLOCATE INTERVENTION CLUSTERS (12 Hosp) (n=12) RECRUIT ALL HUMC MEMBERS CONSECUTIVELY FOR 1 MONTH INTERVENTION CLUSTERS (n≥144) CONTROL CLUSTERS (n≥144) Baseline Skills and HC performance Month 1 training thrroughmentorship coaching& support supervision Month 6 measure outcomes Month 3 implimention of performance improvement strategy Month 6 measure impact FOLLOW UP AT 9 MONTHS PRIMARY OUTCOME  Better performance indicators for General hospital  Better performance of HUMCs  Data forms Standard HUMC practices Figure 3.1 Study Flow Chart Overall Study Timeline The study duration was over a period of 10 months with 1month of set up, 6 months of intervention and evaluation and 3 months of closure. During the study 140 participants were recruited amongst HUMCs from the intervention HCs and the same number of 140 members of HUMC from the control arm. This recruitment period was carefully chosen so as to limit the study area to that in which high quality recruitment and follow-up could be maintained. 3.6 Study Outcomes and Measurement The outcomes have been assessed by measuring the 6 selected performance indicators for health centres. These indicator performance levels per health centres were determined at baseline and at the different interim visits. The tool used to assess was the National Health Facility performance assessment tool commonly called the District Health Information system-DHIS2 (MoH, 2016). 1mprovement in the health centre performance indicators in the selected intervention health centres was assessed at the same time interval as any improvement or stagnation in the control arm. Also assessed was the improvement in monitoring by HUMCs at different periods in time and frequency of HUMC meetings. This analysis was compared between the intervention arm and the control for purposes of ascertaining the impact of the intervention compared to the other control sites. 3.7 Construction of Research Instruments The influential mechanisms of the intervention of training HUMCs to improve performance of HCs were synthesised from four main data sources; 1) the quantitative questionnaire served to HUMCs,. 2) Observations and guidance provided during HUMC meetings in health facilities in the intervention arm. In the meetings, the rationale, methodology and preparation for the intervention of training were explained to the stakeholders thus District Leaders (Chief Administrative Officer and District Health Officer), Hospital Management Teams and the members of HUMC 3) Participant observations were made at initially daily schedules during the first month, then weekly and later monthly performance feedback meetings during October, November, December 2018 and January 2019; 4) from administrative records i.e. monthly progress reports, quarterly reports, annual performance reports and other documents related to the performance of health centres. Annual reports of the case study hospitals for the years 2013 to 2017 were reviewed. The fifth data source was interviews with members of the Hospital Management Teams (HMT) and the District Health Management Teams (DHMT). 3.7.1 Questionnaires Quantitative Data was collected using questionnaires (Appendix II) with the assistance of six research assistants (RAs). Semi-Structured Questionnaires was the main data collection tool targeting the main respondents (members of HUMCs). 3.7.2 Interview Guides Interview Guides (Appendix III) was employed to get information from district managers, health centre manager and sampled leaders of health facilities. The DHMTs and HMTs were asked how they were relating with HUMCs and how the hospitals were being managed to stimulate performance. Interview questions also dwelt on how the district specific performance targets were selected and what influenced their choices. The interviews with the DHMT and HMT aimed to describe their reactions to performance feedback, rewards and sanctions and to enablers/constraints in achieving the performance targets. At the end of the intervention In-depth interviews were done with the DHMT and HMTs in the intervention arm health facilities for verification of performance targets. The respondents were asked about the changes they had observed as a result of experiences they encountered during training of their HUMCs and there after. 3.7.3 Focused Group Discussions Using Focus Group Discussion Guide (Appendix IV) the focus group discussions were conducted with members of HUMCs and health care workers/managers of hospitals and community members (users) in order to obtain additional information for the study. There were six FGDs with 12 members in each group. One FGD was conducted with community members/users in intervention arm. One FGD was conducted with community members/users in the control arm. One FGD conducted with HUMC members in intervention arm. One FGD conducted with HUMC members in control arm. One focus group discussions was held with health workers in the intervention arm and then one FGD with health workers in the HCs in control arm. 3.7.4 Secondary Data Extracted from the HMIS and DHIS2 The research team analysed information from performance management reports and also from the routine data collected in the HMIS or DHIS2 of the Ministry of Health. This was secondary data obtained from the HMIS tools at the health facilities and district. This data was analysed according to themes in the section for performance assessment of the different health centres. 3.8 Training of Research Assistants Research assistant were required to know details of the study in order to be confident especially in probing the respondents and filling answers in the questionnaires. A total of six RAs received five days intensive training on the contents of the questionnaires and techniques for achieving scientific validity and trustworthiness of the data. They were drilled on how to establish a rapport with the respondents while maintaining the neutrality essential to obtaining the most accurate data possible. Specific topics covered included introduction to research, background and aims of the study, basic communication skills, how to introduce the work, informed consent, giving constructive feedback, data collection, mapping, expected problems and their solutions, how to complete the questionnaire and other basic field work information plus the required ethical considerations. The training was participatory, consisting of role-playing and practice sessions aimed at ensuring that the RAs fully understood their roles and ensured that they were able to complete the data collection tools without any difficulties. The researcher not only supervised the RAs throughout the research period but also carried out a substantial number of interviews as a quality control mechanism. 3.8.1 Pre-testing of Research Instruments Tools were pre-tested in the nearby health centres in one of the district that was not in the study area (Mukono-District). The pretest sample size was predetermined by investigator to be 90 respondents detailed as follows: 18 HUMC members, member for the district health Teams (5), middle level managers were 22, health centre staff were 18, staff from non-government facilities were 6 and health centre administration staff 3. 4 hospitals were purposevely selected to be able to pretest the tools and these were Nagalama Health Centre IV, Nkokonjeru Health Centre IV, Mukono HC IV and Seeta HC IV. The objective of this was to ensure that the questionnaires could bring out the exact information required by the researcher. 3.8.2 Validity of Instruments Validity means efforts to do with how accurately the data obtained in the study represents the variables of the study. To ascertain content validity the instruments were thoroughly discussed with experts in the subject matter but more especially with the supervisors. The Data collection instruments were designed in such a way that the issues that they were seeking information about were those that had been considered relevant to the study objectives and as such, were able to guarantee their validity. The researcher discussed the interviewer administered questionnaire with the research assistants for clarity before time of real interviews. According to Teijlingen van et al. (2001), pilot testing is important in the research process because it reveals vague questions and unclear instructions in the instrument. It also captures important comments and suggestions from the respondents that will enable the researcher to improve efficiency of the instrument, adjust strategies and approaches to maximize the response rate. The sampling techniques adopted also ensured randomization and representativeness to cater for internal and external validity. 3.8.3 Reliability Reliability is a measure of the degree to which research instruments yield consistence results or data after repeated trials. Reliability is inversely proportional to random errors and high validity ratios reduce error due to random sampling techniques (DeVon HA et al., 2007). The degree of validity attained ensures a level of consistence to the tools so that even when applied to more than one respondent and for more than once, they are able to retain their reliability. The reliability of measured values was ensured by using internal and external quality control strategies. As applied by Grellety E, Golden MH (2016), the Cronbach‘s alpha estimation was used to test the reliability of research tools and instruments and this Cronbach‘s alpha was calculated using SPSS Software. Reliability tests on each of the items were conducted under the guidance of thresh-hold of above 0.70 set by Nunnally (1978). Details of reliability results are presented in table 3.3 as shown below: Table 1.3 CronBach's Test Results NO. Variable No. of Items Cronbach Results Average Pre Post 1 Social Demographic Characteristics 7 0.76 0.90 0.83 2 Current Performance of HCs 5 0.85 0.85 0.85 3 Effectiveness of training 12 0.79 0.83 0.81 3.9 Data collection and Management Techniques The data was collected on daily basis during the period of the study by RAs and the principal researcher from 9 am to 5 pm. The research team checked data carefully to make sure all the filled tools were available and were neatly arranged for filing. After each day of data collection, filled in questionnaires were edited again, and checked for completeness by the principal researcher. The responses were coded with numbers to ease quantification and analysis. The coded data was entered in the computer using SPSS 25 software, for storage and for analysis later. The file of filled data tools was kept in a locked cupboard for safety 3.9.1 Field Editing of Data Data from questionnaires was edited after collecting tools whereas data from interview guides was recorded and written concurrently while carrying out interviews with key respondents. Appliances like audio recorders were employed to capture data in details after which it was transcribed and coded for analysis. 3.10 Data Analysis Quantitative data was analysed according to research objectives and emerging themes using SPSS 25 computer package. After recording the responses to the questionnaires, interviews and observation, the researcher categorised and coded the responses. The descriptive statistics (frequencies, percentages, means and standard deviations) was computed using SPSS 25 for the quantitative data. Chi squares test was applied to analyse the bivalet associations. Paired t tests of independence were used to determine the statistical significance of the different multiple variables. The p-value set at 0.05 was used to determine the statistical significance of the associations between independent and dependent variables at 95 percent confidence intervals. Logistic regression model was used to ascertain the statistical relationship between independent variables and the performance of health centres and also identifying the predictors for performance. Thematic analysis was done for the qualitative data generated by a master sheet analysis tool. The sub themes based on the study objectives simplified cleaning and coding of statements of respondents. Relevant quotations were identified and used to support each theme/sub theme during the reporting process. Use of a computer based qualitative data analysis software atlas Ti 7 allowed in-depth analysis of each of the main categories of data. The analysis facilitated teams to be able to describe the range of the HUMC member‘s skills, training and health centre performance. During analysis, each category was considered for further assignment into subcategories. Using these subcategories gave more insight into the details of the mentors‘ and trainers‘ activities in each category. 3.11 Logistical and Ethical Considerations Informed consent was on all occasions obtained from the respondents and the study only proceeded with those that endorsed the consent form in the affirmative (Appendix I). All information collected was handled with utmost confidentiality using only codes mostly rather than names of individuals. Approval of the Proposal was obtained from the Dean of the School of Graduate Studies (Appendix IX) who also issued a research Authorisation letter (Appendix X). Ethical approval was sought from Kenyatta University Ethics Review Committee (KUERC) before proceeding to Uganda for further clearances (Appendix XI). After obtaining clearance from Nsambya Hospital IRB (Appendix XII) and the Uganda National Council for Science and Technology (Appendix XIII), the researcher then proceeded to data collection. Permission was first granted from the districts and from individual health facilities research ethics committees before participants could be engaged into the study process. Each individual participant signed a consent form after detailed explanations about the study and having accepted to participate. CHAPTER FOUR: RESULTS 4.0 Introduction This chapter provides the results as analysed from data obtained from the respondents. The findings presented in this chapter avail answers to research questions originated from the three objectives of this study which were: First, the study sought to determine the effect of socio-demographic characteristics of members of the health unit management committees on performance of health centres in East Central Uganda. Secondly the study was aimed at ascertaining the current performance of HCs in the East Central Uganda. Thirdly this study tested the effect of training members of HUMCs on the performance of the HCs in East Central Uganda. 4.1 Response Rate A total of 280 HUMC respondents against a target of 288 (members of HUMC) participated in quantitative studies, collected from 24 health centres at the level of hospitals; 12 of these in the intervention arm and 12 health centres in the control arm. This was a response rate of 97%. All 64 targeted DHTs, district administrators and hospital managers for KII (4 per District Health Team and 3 per hospital- Response rate 100%), were interviewed. The findings were collected from July 2018 to January 2019. 4.2 Social Demographic Characteristics From the Table 4.1 In relation to age, the mean age of respondents was 43 years with a standard deviation of 9 years. Ages of HUMC members ranged between 18years to over 60 years. The majority of respondents thus 162 out of 280 (57.1%) was in age bracket of 35-60 years. They were further distributed as follows: sixty percent or 84 of them in intervebtion arm and fifty five percent or 78 in control arm. The respondents in the age bracket 18-34 years constituted 113 out of 280 or (40.7%). Respondents in ages above 60 years (elderly) were 5 out of 280 or (1.8%) and these are old people considered to be out of pace. Most respondents thus 184 out of 280 (65.7%) were males while females constituted (34.3%) 96 out of 280. The majority-162 out of 280 (57.8%) of respondents were married, 92 out of 280 (32.8%) were single, 6.4%-18/280 were widows while widowers were least 8/280 (2.8%). The study results showed that most respondents had a diploma thus 163 out of 280 (58.2%), 44 out of 280 (15.7%) had a high school certificate, 34 out of 280 (12.1%) had Bachelor‘s degree, while only 29 out of 280 (10.4%) had masters degree. As regards economic ability of members of HUMCs, the results indicate that the majority 210 out of 280 (75%) of respondents were neither among rich people nor among poor people, 48 out of 280 (17.1%) were in ‗below poverty‘ economic level bracket, while only 22 out of 280 (7.8%) were in ‗above poverty‘line economic bracket. The distribution of sampled members of HUMC by profession showed that the majority 141 out of 280 (50.1%) were politicians. The next profession in numbers were the nurses 42 out of 280 respondents which was 15%. The religious leaders were 35 out of 280 which was 12.5%. The Allied Health Profession were 21 out of 280 (7.5%). Doctors were 19 out 280 (6.8%) and professionals in other unspecified categories constituted 7.9% (22 out of 280 respondents). Table 2.1 Socio-Demographic Characteristics of HUMC Members Variable Performance of Health centres pre-intervention Control HCs Intervention HCs Frequency (N=140) Percentage Frequency (N=140) Percentage Age 18-34 35-60 Above 60 54 84 2 38.6 60 1.4 59 78 3 42.1 55.7 2.2 Gender Female Male 46 94 32.9 67.1 50 90 35.7 64.3 Marital Status Single Married Widow Widower 36 94 8 2 25.7 67.1 5.7 1.5 56 68 10 6 40 48.6 7.1 5.3 Education Levels High school Diploma Degree Masters 25 83 19 13 17.9 59.3 13.6 9.2 19 80 25 16 13.6 57.2 17.9 11.3 Economic Levels Below poverty line Neutral Above poverty line 24 104 12 17.1 74.3 8.6 24 106 10 17.1 75.7 7.2 Occupation Doctors Allied Nurse Religious leaders Politicians Others 5 9 10 18 89 9 3.6 6.4 7.1 12.9 63.6 6.4 14 12 32 17 52 13 10 8.6 22.9 12.1 37.1 9.3 4.3 Performance of Health Centres From figure 4.1, it show the performance of health centres in East Central Uganda before and after intervention in both the control and intevention arms. Performance outcome after training of members of HUMC Figure 4.1 Performance Outcome 4.3.1 Effect of Socio-demographic Characteristics on Performance of Health Centres From table 4.2, the results for the education level of respondents with Chi-square 12.623 and P-value of 0.031 showed a significant relationship between the level of education of a member of the HUMC and the performance of health centres at baseline. Age of respondents with chi-square of 0.771 and p-value of 0.101 at 5% confidence level, p-value of 0.228 for gender, P-value of 0.787 for marital status, P-value of 0.753 for economic level and P-value of 0.656 for occupation; these showed non- significant relationship between these social demographic charactersitcs of respondents and performance of HCs at baseline. Table 4.2 Effects of Socio Demographic characteristics on HC performance before intervention Variable Performance of Health centres pre- intervention Chi-square Tests Good performancing HCs Poor performancing HCs X2 df P Value Frequency % Frequency % Age 18-34 35-60 Above 60 34 50 2 12.1 17.9 0.7 80 111 3 28.5 39.3 1.4 0.771 2 0.101 Gender Female Male 32 54 11.4 19.3 64 130 22.9 46.4 0.635 1 0.228 Marital Status Single Married Widow Widower 36 38 8 2 12.9 27.1 2.8 0.7 56 120 10 6 20 42.9 3.5 2.1 0.578 3 0.787 Education Levels High school Diploma Degree Masters 14 56 10 4 5 20 3.5 1.4 30 122 24 16 10.7 43.6 8.7 5.7 12.623 3 0.031 Economic Levels Below poverty line Neutral Above poverty line 12 66 6 4.3 23.6 2.1 36 140 16 12.9 50 5.7 0.567 2 0.753 Occupation Doctors Allied Nurse Religious leaders Politicians Others 5 9 10 8 50 2 1.9 3.2 3.5 2.8 17.8 0.7 14 12 32 27 87 20 5 4.3 11.4 9.6 31.1 7.1 0.183 5 0.656 We would be performing well if only members selected for the HUMC were having medical background. But these politicians who simply pick their ignorant friends for positions on the HUMC cannot help us to deliver as expected. (Med superintendent-KI) Interactions with HUMC members during focus group discussion enlisted the young HUMC members blaming the older ones as the ones responsible for any poor performances in the area. These old men and women look tired and therefore should be retired from responsibilities of HC affairs. They do not have energy to move things. They are living in the past. They are often lazy and not ready to take up any responsibility. These expired items should be removed. (HUMC-FGD) 4.3.2 Health centre Performance as Influenced by Socio-demographic Dynamics after the Intervention From table 4.3, the analysis of performance of the health centres in the intervention arm when tabulated with social demographic variables after training of members of the HUMCs showed significant relationships between performance of the health centres and age; P-value 0.001, gender P-value 0.028, Marital status P-value 0.017, education level even became stronger at P value 0.0000, and economic level of respondnet at P value 0.015. Only occupation of respondents showed non significant relationshp with performance of health centres (p=0.956) in the intervention arm after members of HUMC had been trained. Table 4.3 Effect of Socio-Demographic characteristics after training HUMC members Variable Performance of Health centres pre- intervention Fisher Exact Test Good performancing HCs Poor performancing HCs OR CI P- Value Frequency % Frequency % Age 18-34 35-60 Above 60 51 63 2 36.4 45 1.4 4 15 1 2.8 10.7 0.7 6.59 3.19- 25.52 0.001 Gender Female Male 47 69 33.6 49.3 6 14 4.3 10 4.43 0.01 -0.49 0.028 Marital Status Single Married Widow Widower 46 60 8 2 32.9 42.7 5.7 1.4 5 12 1 2 3.6 8.6 0.7 1.4 2.49 1.09 -4.67 0.017 Education Levels High school Diploma Degree Masters 14 58 10 4 10 41.4 7.1 2.8 3 14 2 1 2.1 10 1.4 0.7 32.62 2.49 -35.33 0.000 Economic Levels Below poverty line Neutral Above poverty line 20 90 6 14.3 64.3 4.3 6 10 4 4.3 7.1 2.8 0.41 0.47 – 0.99 0.956 Occupation Doctors Allied Nurse Religious leaders Politicians Others 5 9 30 18 52 2 3.6 6.4 21.4 12.9 37.1 1.4 1 2 6 6 3 2 0.7 1.4 4.3 4.3 2.1 1.4 5.67 1.47 – 13.24 0.015 From table 4.4, the analysis of performance of the health centres in the control arm when tabulated with social demographic variables remained showing non-significant relationships between performance of the health centres and age; P-value 0.224, gender P-value 0.600, Marital status P-value 0.561, economic level of respondnet at P value 0.616 and profession of respondnet 0.911. Education level of respondents remained significant at P value 0.032 in the control arm having been 0.031 at baseline. Table 4.4 Socio-demographic characteristics and HC performance in control arm Variable Performance of Health centres pre- intervention Fisher Exact Test Good performancing HCs Poor performancing HCs OR CI P- Value Frequency % Frequency % Age 18-34 35-60 Above 60 10 32 1 7.1 22.8 0.7 38 58 1 27.1 41.4 0.7 0.26 0.04-0.73 0.224 Gender Female Male 21 30 15 21.4 44 45 31.4 32,1 0.75 0.15-0.99 0.600 Marital Status Single Married Widow Widower 18 20 4 2 12.9 14.3 2.8 1.4 22 62 8 4 15.7 44.3 5.7 2.8 0.93 0.08-1.06 0.561 Education Levels High school Diploma Degree Masters 7 24 5 2 5 17.1 3.6 1.4 16 68 11 7 11.4 48.6 7.9 5 13.42 4.60-22.11 0.032 Economic Levels Below poverty line Neutral Above poverty line 6 34 3 4.3 24.3 2.1 18 71 8 12.9 50.7 5.7 0.86 0.33-0.79 0.616 Occupation Doctors Allied Nurse Religious leaders Politicians Others 4 4 6 5 18 2 2.8 2.8 4.3 3.6 12.9 1.4 6 7 13 19 46 10 4.3 5 9.3 13.6 32.9 7.1 0.69 0.43-1.11 0.911 4.4 Ascertaining Performance of Health Centres in East Central Uganda From table 4.5, the performance of health centres is displayed. The performance was deemed to be good if the average score was 80% and above but was taken to be poor if the average performance was below 80%. According to the results in table 4.5, eighteen health centres out of the twenty four (75%) the prformance was below 80% and was deemed poor and only 25% of health centres thus six out of twenty four had good perfomance at baseline. Table 4.5 Baseline Performance of HCs in East-Central Uganda Code NO NAME Baseline Immunisation Coverage Number/Target (%) Baseline Health Facility Deliveries Number/Target (%) Baseline OPD Utilisation Number/Target Number/Target (%) Average of the percentage score (%) 001 Bugiri Hospital 141/252 (56) 400/909 (44) 13500/15090 (90) 63 002 Kakira Hospital 212/416 (51) 362/1097 (33) 16630/16806 (99) 61 003 Iganga Hospital 160/199 (80) 388/467 (83) 18570/20180 (92) 85 004 Buwenge Hosp 230/274 (84) 304/354 (86) 15643/17381 (90) 87 005 Kamuli Hospital 99/247 (40) 360/581 (62) 9270/15450 (60) 54 006 New Hope Hospital 275/320 (88) 374/473 (79) 18106/18860 (96) 88 007 Buluba Hosp 230/255 (90) 502/539 (93) 7544/8200 (92) 92 008 Namayingo Hosp 84/255 (33) 298/573 (52) 13600/17215 (79) 54 009 Kayunga Hospital 228/242 (94) 369/415 (89) 14789/16806 (88) 90 010 Kidera Hospital 86/154 (56) 494/1029 (48) 12145/16412 (74) 59 011 Kiyunga Hosp 73/174 (42) 90/250 (36) 20102/25128 (80) 52 012 Kawolo Hosp 192/259 (74) 250/455 (55) 10099/11743 (86) 71 013 Nsinze Hosp 66/178 (37) 94/336 (28) 8165/11664 (70) 45 014 Bumanya Hosp 236/375 (63) 196/595 (33) 19232/21855 (88) 61 015 Namwendwa Hosp 612/1302 (47) 451/867 (52) 21466/23851 (90) 63 016 Nankoma osp 461/886 (52) 366/1356 (27) 12154/13504 (90) 56 017 Bugono Hosp 397/1280 (31) 420/1750 (24) 13540/14879 (91) 49 018 Mpummudde Hosp 628/897 (70) 360/1385 (26) 21322/25065 (85) 60 019 Busesa Hosp 987/1175 (84) 768/883 (87) 19883/22092 (90) 87 020 Nankandulo Hosp 390/813 (48) 370/1423 (26) 12111/15139 (80) 51 021 Mayuge Hosp 411/839 (49) 433/984 (44) 13285/16213 (82) 58 022 Kigandaalo Hosp 367/734 (50) 371/1124 (33) 12245/13456 (91) 58 023 Bugembe Hosp 406/1068 (38) 420/1024 (41) 15246/15718 (97) 58 024 Ikumbya Hosp 229/558 (41) 200/571 (35) 10564/17607 (60) 45 From the table 4.6, it is shown the performance of the health sector at national level for the five previous financial years. Table 4.6 National Health sector Performance Trends Indicator 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 OPD Utilization 95% 98% 100% 97% 100% 100% Immunization coverage (DPT3) 80% 83% 90% 94% 94% 97% Delivery at Health Facility 68% 71% 84% 88% 85% 88% Availability of supplies 80% 80% 81% 83% 83% 83% From the Table 4.7, it is shown the performance in East Central Uganda for the last five financial years. The performance of HCs in EC Uganda was far below the national proportions. Table 4.7 Performance Trends of HCs in EC Uganda Indicator 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 Baseline Values OPD Utilization 75% 68% 75% 78% 80% 80% 80% Immunization coverage (DPT3) 60% 73% 70% 65% 60% 63% 66% Delivery at Health Facility 25% 33% 38% 38% 41% 54% 54% Availability of supplies 60% 60% 64% 63% 63% 63% 63% From the table 4.8, the surmarised performances in the two arms show an improvement in trends in the intervention arm as compared to stagnation in the control arm. For the intervention arm there was positive effect of training HUMCs on the performance of the respective HUMCs. Table 4.8 Summary of effects on performance of the indicators targeted in training HUMC members Indicators Performance/Month in percentages Intervention Arm Control Arm Before study (6months) During study (6months) Before study (6months) During study (6months) J F M A M J J A S O N D J F M A M J J A S O N D New OPD attendance 60 61 70 69 66 65 97 99 107 110 99 106 64 73 70 63 59 65 68 66 68 70 54 60 OPD reattendance 70 68 72 58 64 75 99 96 97 120 126 113 68 65 61 53 79 72 69 74 69 80 68 69 Deliveries 44 51 39 55 50 49 88 90 87 92 96 99 46 44 49 46 46 51 44 48 49 44 50 45 ANC1 91 90 88 90 89 93 102 104 100 110 99 112 93 94 93 91 89 82 80 91 79 81 74 78 ANC4 36 41 47 48 46 59 71 79 87 89 86 90 41 46 39 51 46 49 45 48 44 47 48 45 DPT3 78 70 73 72 73 79 92 96 104 100 101 120 99 74 70 73 76 73 71 69 72 67 63 70 Measles 60 65 59 58 60 74 91 90 94 96 99 94 59 65 60 63 67 62 60 66 69 61 58 70 Magt Meeting 0 0 1 0 0 0 0 1 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 Supplies 50 46 63 59 48 52 78 82 88 81 93 92 46 44 51 45 43 44 45 56 51 45 44 48 Graphical presentation of performance trends before and after intervention The graphs below show that performance levels were low but shot up after training of members of HUMC. Graph showing performance trends for OPD attendance Graph showing performance trends for immunization services DPT3 Graph showing performance trends for deliveries of mothers Graph showing the trends in availability and management of supplies Responses drawn from analysing and discussing the Annual Health sector Performance Report of Uganda Ministry of Health for the year 2017, showed that East Central Uganda was bedeviled with many performance challenges. “We have many gaps that do not allow us to deliver services well. For example in this district there is problem of inadequate man power and health worker shortage, low salaries, sub-optimal functioning of the infrastructure, inadequate drugs budgets and problematic procurement processes of medical goods. National level procurement of drugs and other medical products regardless of the needs at the HCs is contraining us and is leading us to a situation of helplessness and therefore causing under-performance‖ (DHO) 4.4.1 The Different Players and Determinants for Health Centre Performance It was observed that multiple players in command each had an approach to ensure that there was achievement of the desired performance in their own realms of authority which was ultimately being reflected through the output indicators for performance of the health centres at the lowest level of authority. “Performance is determined for us from many angles, like the World Health Organisation that lays the global requirements, then down to continemntal contexts and national level. At national level we have the performance guidelines and finincial manegement guildelines within which to operate and these do not allow any freedom to manipulate to be able to improve. We have also individual staff performance guidelines and recruitment guidelines that help us to ensure staff produce out-puts expected of them. But the challenge we face is the inability to implement the guidelines usually due to lack of skills amongst the implementers and inadequate funding” (CAO). From the performance reports of different health centres and discussions held with health care workers, there was observation of existance of guidance for health centres to be able to perform from the national level. HUMCs were however observed not to be contributing to this performance scenario. “ We make our plans and follow them. Although funding for these plans is not realistic. Nevertheless our current plan draws from the National Health Sector Strategic and Development Plan 2015/16 to 2019/20 of Uganda penciled in from the World Health Organisation priorities. This plan set its objectives among others as; Strengthen Management of National Health systems, Improve access to quality hospital services (HCs), Ensure universal access to Uganda National Minimum Health Care Package, Review relevant laws and acts, Ensure adequate and appropriate human resource, Increase motivation, productivity, performance, integrity and ethical behaviour of the human resource. Our objectives are aligned to these objectives” (KII-Medical Superintendent) 4.4.2 Stimuli for Performance of HCs at District Level There was found in place the decentralization policy. Power and authority was devolved to lower government levels that is the district level and sub-county level. It was at these levels that implementation of programmes and the decisions to run health centres were abound. Efforts contributed at these levels varied from place to place. Each district had the overall mandate and remained answerable for the performance of its health sector. “We have been subjected to performance assessments and monitoring of implementation of essential national programmes by the Office of the Prime Minister of Uganda. Every finincial year in the month of october these guys come and do the Local Government National Performance Assessments and its assessment tool that ranks districts overall performance. The sad news is that results are shared to public and put in news papers for all to see It is during the time of results that son of man makes all wishes. Nevertheless it encourages us in management positions to incrrease monitoring and supervision geared at improving staff performance” (KII-CAO) In the health sector, they have been having a Districts Performance League Table. The ―performance‖ measures included in the league table have been made simplified by the ease of data availability at the district level in the DHIS II system. The individual district performance after analysis of data from DHIS II was being disseminated at the Annual National Health Assembly where stakeholders in the running of health services have been invited. Districts in the first fifteen positions have been rewarded and the districts in the last fifteen positions have been named on their shame list. Views expressed during the interviews with some DHOs in the region indicated that bad performance on the league table was not hell after all but a blessing in disguise. It was a major factor for attracting partners to support the district and an attraction for more resources. “A bad position on the district league table is not death. It is not Hell. It is a sour pill whose effects of sourness are felt only during the National Health Assembly when the district is named on the shame list. It is for that period only. After that, you get partners flowing in to help you recover by providing resources to enable you run activities. The healing effects of that pill then are experienced for longer period than its sourness. So no need to lose sleep but rather let performance decline and be rewarded with more resources to run services.” It is de- motivating sometimes to do well” (KII-DHO). Never the less some DHT members felt very much inspired to improve performance of HCs in the region so that they could have a better position on the league table. This was mainly because of the pressure that was being exerted by the political leaders. Because of these pressures, DHOs and their health systems were forced to up their efforts. These are the extracts from some of the DHOs: “The league table rankings has ignited excitement and driven performance efforts among the DHOs and politicians at the district level. The league table position (rank) for districts had ignited some performance related queries from district political leaders. Political leaders had started to ask why their districts were in tail end and what could be done to alleviate the situation. “This (league) table is brought in a Political Leaders‟ Forum… You get them (District Council) Chairman asking “what has happened to our district to be (ranked) down”. Of course no one wants to be at the tail end. (KII-DHO) 4.4.3 The DHT and Health centre Meetings Attempts to address performance gaps were traced in the minutes and recordings of meetings of some DHTs and HCs. Meetings at district level were the quarterly and annual performance review meetings where the quarterly or annual performance was shared with stakeholders to inform the planning for the next period in time. As for HCs, the performance review meetings were being held monthly with stakeholders at that level also to inform the next planning period. In these meetings it was observed that members of HUMCs were not being invited and their views were not being captured prior to this study, a situation that also persisted in the control arm of the study. As a result of not sharing performance with community structures, indicators for performance of HCs and performance targets were not being given due attention. No wonder the performance was poor. “Either there are no meetings here or we are not being invited for the meetings. We are completely left in darkness and have no platform to voice our concerns. I wonder how the health centre is being managed. I even do not know how my people are getting services from here” (FGD- HUMC Members). Frequency of meetings at health centre level was found to be irregular and in some health centres non-existent. After training of members of HUMCs in health centres in the intervention arm, it was observed that the quality and frequency of minutes improved as compared to the HCs in the control arm. Members of HUMCs were being invited at performance review meeting in the intervention arm while they were not being invited in HCs in the control arm. This involvement of trained HUMC members contributed to improved performance in HCs in the intervention arm. 4.4.5 Motivation Mechanisms for Perfrormance of HCs The districts in East-Central Uganda have a rewards and sanctions committee each. The committee is responsible for setting parameters on which they base to guide their decisions whether to reward or sanction a public officer. In their work, the rewards and sanctions committees are further guided by rewards and sanctions frame work issued by the Ministry of public service. “The objectives set out in the frame work are not those ones used to rank districts in the national Performance League table of the Ministry of Health. But some of the effects of what is done by committees in implementing the rewards and sanctions framework do trickle into products for the improving of performance of the HCs. The rewards and sanctions committee deliberations focus on individual public servants especially focusing on code of conduct” (KII-DHO). The rewards and sanctions committees were more focused on sanctions and never at all on rewarding performance. This was in total disregard to the theory of incentives as drivers of performance. ”We are not scertain about the parameters on which to base the rewards and be able to stimulate performance enhancement. For example I do not undestand whether I reward performance basing on quantity of outputs or on quality of care provided to patients. Assessment in either direction is not clearly spelt out for us. Therefore we encounter the complication of separating issues of quantifiable out-puts against issues of quality‖ (KII- CAO). The result was failure by all districts in East-Central Uganda to identify parameters for rewarding good performance. In addition to the lack of the parameters for rewarding performance, there was also the challenge of the unpredictability of resources to support the occurrences that would follow the decisions whether to sanction or reward performance. This was well explained by one Chief Administrative Officer (CAO) during Key Informant interview thus ―If it required suspension of officer then it would create human resource gap and compromise performance further. If it meant availing a reward then the question of funds to purchase the reward arose. This made the whole process un tenable for the health centres.‖ (KII-CAO). 4.5 Effects of Training of HUMC Members on Performance of Hcs From table 4.9, the results show improved performance in health centres in the intervention arm as compared to the ontrol arm. All health centres in the intervention arm showed improved average scores from those at the base line. Ten of the twelve HCs in the intrvention arm scored the average performance pass mark of 80% and two still remained in poor performance of score less than 80% (Kiyunga Hospital and Mayuge Hospital). But there was great improvement from the scores at baseline in these two Hcs also. Two out of the twelve health centres in the control arm had the pass mark average score of 80% that is 80% for Buwenge Hospital and 86% for Bumanya Hospital. Table 4.9 The Performance of HCs after training members of HUMCs Code NO NAME Exit Immunisation Coverage Number/Target (%) Exit Health Facility Deliveries Number/Target (%) Exit OPD Utilisation Number/Target (%) Average of the scores(%) INTERVENTION ARM HEALTH CENTRES 001 Bugiri Hospital 247/252 (98) 818/909 (90) 18108/15090 (120) 102 003 Iganga Hospital 187/199 (94) 755/909 (83) 27848/20180 (138) 105 005 Kamuli Hospital 217/247 (88) 500/581 (86) 23175/15450 (150) 108 007 Buluba Hosp 235/255 (92) 491/539 (91) 10660/8200 (130) 104 009 Kayunga Hospital 218/242 (90) 382/415 (92) 18151/16806 (108) 96 011 Kiyunga Hosp 108/174 (62) 198/250 (79) 23369/25128 (93) 78 013 Nsinze Hosp 148/178 (83) 232/336 (69) 11664/11664 (100) 84 015 Namwendwa Hosp 1250/1302 (96) 772/867 (89) 26236/23851 (110) 98 017 Bugono Hosp 1165/1280 (91) 1470/1750 (84) 18599/14879 (125) 100 019 Busesa Hosp 987/1175 (84) 768/883 (87) 30929/22092 (140) 103 021 Mayuge Hosp 596/839 (71) 728/984 (74) 13295/16213 (82) 76 023 Bugembe Hosp 940/1068 (88) 932/1024 (91) 15247/15718 (97) 92 CONTROL ARM HEALTH CENTRES 002 Kakira Hospital 216/416 (52) 455/1057 (43) 13304/16630 (85) 60 004 Buwenge Hosp 225/274 (82) 297/354 (84) 13035/17381 (75) 80 006 New Hope Hospital 157/320 (49) 260/473 (55) 15465/18860 (82) 62 008 Namayingo Hosp 117/255 (46) 252/573 (44) 13560/17215 (79) 56 010 Kidera Hospital 80/154 (52) 525/1029 (51) 13130/16412 (80) 61 012 Kawolo Hosp 186/259 (72) 218/455 (48) 9629/11743 (82) 67 014 Bumanya Sub Hosp 311/375 (83) 524/595 (88) 19233/21855 (88) 86 016 Nankoma Hosp 461/886 (52) 637/1356 (47) 12154/13504 (90) 63 018 Mpummudde Hosp 628/897 (70) 637/1385 (46) 20553/25065 (82) 66 020 Nankandulo Hosp 423/813 (52) 797/1423 (56) 11203/15139 (74) 60 022 Kigandaalo Hosp 352/734 (48) 483/1124 (43) 10227/13456 (76) 55 024 Ikumbya Hosp 273/558 (49) 257/571 (45) 12149/17697 (69) 54 From the table 4.10, the summary reflects improved performance of the health centres especially for the indicators where the members of HUMC were trained on their management. In the intervention arm after training HUMC the achieved percentage levels are better when compared with those in the control arm health centres some of which reflected no improvement at all or a decline in the monitored indicators. Table 4.10 Summary of performance indicators before and after intervention compared NO Indicators Intervention arm Control arm (%) Baseline Post interv. Baseline Post interv. 1 OPD attendance New 55% 109% 58% 74% Reattendance 53% 100% 60% 59% 2 Immunisation DPT3 80% 95% 80% 78% Measles 60% 85% 72% 76% 3 Deliveries Total 55% 84% 54% 58% Live births 95% 99% 92% 91% Maternal deaths 3 1 2 2 4 ANC attendance ANC1 98% 100% 96% 94% ANC4 60% 80% 59% 61% 5 Quarterly HU Management meetings 1 2 1 0 4.5.1 The HUMC Socio-demographic characteristics Coupled with Training Effect on Health Centre Performance From the Table 4.11, there was a significant relationship between performance of HCs and the some socio-demographic characteristics of HUMC members that had been trained thus leading to good performance of the health centres. A HUMC member who had been trained was 6.802 times more likely to ensure good performance of the HC compared to one who had not been trained (P=0.006; CI= 1.682-11.433). There was a significant relationship between HUMC member age and good performance of the health centre. A member who aged 35-50 years (prime of life) was 3.346 times more likely to ensure good performance of the HC compared to one who was aged/elderly (P=0.001; CI= 2.374-5.211). There was a significant relationship between HUMC members that were exposed and been educated up to high school level to good performance of the health centres. A HUMC member who had attained education to high schhool was 9.166 times more likely to ensure good performance of the HC compared to one who had not attained high school standard of education (P=0.001; CI= 6.813-16.488). There was a significant relationship between the profession of HUMC member doing the work to good performance of the health centres. A professional member was 1.152 times more likely to ensure good performance of the HC compared to the un-professional member (P=0.045; CI= 0.038-3.741). Table 4.11 HUMC Characteristics training and Performance of HCs Fisher’s Exact test 95% CI for OR Variable Good Performance Poor Performance P- Value OR Lower Upper Training Trained 116 (67.2%) 20 (32.8%) 0.006 6.802 1.682 11.433 Not trained 24 (29.1%) 120 (70.9%) Age 18-34 years 24 (17.1%) 41 (29.3%) 35-60 years 113 (80.7%) 97 (69.3%) 0.001 3.346 2.374 5.211 >60 years 3 (2.1%) 2 (1.4%) Profession Medical 99 (70.7) 40 (30.3%) 0.045 1.152 0.038 3.741 Other 41 (29.3) 100 (71.4%) Marital Status Married 103 (73.6%) 101 (72.1%) 0.944 1.022 0.619 1.268 Not married 37 (26.4%) 39 (27.9%) Education level Masters 3 (2.1%) 5 (3.6%) Bachelors 8 (5.7%) 7 (5%) Diploma 66 (47.1%) 41 (29.3%) 0.001 9.166 6.813 16.488 High School 39 (27.9%) 45 (32.1%) Primary 24 (17.1%) 42 (30) Economic Level Below 46 (32.9%) 41 (29.3%) Neutral 70 (50%) 65 (46.4%) 0.76 0.33 0.79 0.614 Above 24 (17.1%) 34 (24.3) 4.5.2 Relationship between Training of HUMCs and Performance of HCs The research hypothesis had the null stating that there is no significant relationship between training of HUMC members and performance of health centres. Parametric T-tests were performed on the coefficients derived from the regression analysis to ascertain significance of the relationship between performance of health centres and training of members of HUMCs. The decision rule for the tests was based on rejecting the null hypotheses if the absolute values of the computed t-statistics are greater than critical values of a standard student-t distribution at 95% levels of confidence and p-value less than 0.05. The findings are presented in Table 4.12. The findings indicate that the null hypothesis was rejected except in one area of the themes that is in relationship to training members of HUMCs and attending antenatal care, where there was failure to reject the Null Hypothesis. This indicates that there exists a significant relationship between training of HUMC members and performance of health centres. Hence, health centres with trained members of their management committees exhibited improved performance. Table 4.12 Relating Performance of HCs to training of HUMCs Performance Measure Regression Coefficient T-Statistic P-Value Decision Training of HUMC 2.708 2.323 0.011 Reject Ho Availability of supplies 5.083 3.173 0.006 Reject Ho Delivery at health facilities 3.117 2.114 0.005 Reject Ho Immunisation Coverage 2.895 2.491 0.027 Reject Ho OPD Utilization 3.348 2.888 0.012 Reject Ho ANC attendance 0.849 1.798 0.08 Fail to Reject Ho Management Committee meetings -2.321 1.369 0.001 Reject Ho Absenteeism of HCWs 5.243 2.137 0.005 Reject Ho 4.5.3 Performance Improvement as viewed by HUMC after Training The following description and analysis illustrates the impressions that emerged regarding performance improvement of HCs as expressed by members of HUMCs. The opinions of the HUMCs were elicited by asking two related questions; 1. Did HUMCs members have any idea or opinion about the performance of the HC. 2. What would the members of HUMC have desired to see and consider it as good performance? The objective was to assess whether the training had an effect on perception of performance of HCs. Also to find out whether the HUMC members had concern about performance of the HCs after they had been trained. Whether the variable considered in performance of the Hcs and the objectives of HUMCs towards improving performance were matching with those from the MOH performance indicators after their training. Respondents were probed for examples to clarify their views. Table 4.13 provides a few selected themes and the interview-extracts that best captured the attributed meanings. The results show that after the intervention, HUMCs had positive attitudes towards HC activity and were willing to involve in activities that would ensure better ranking in performance of their HC. Table 4.13 Changes in Perceptions of HUMCs after training Interview extract Pre-intervention Interpretation Interview extract Post-intervention Interpretation Theme  ―Our main concern is whether those people have got our allowances‖  ―It is not our concern on number of people attending the services‖  ―We do not know about referrals and reason for referral and we are not the responsible people  HUMC members were only available and concerned with getting some allowance but were not interested in the performance improvement of their HCs  ―We help management to trace the PHC funds and allocate funds according to priorities‖  ―We get to trace patients attending and those referred and the reasons. We find out if the referrals have necessary logistics and whether HC can assist‖  HUMC members assertive and know their responsibility of linking community to services in HC and know which services are available for consumption Knowledge about roles and services availability to explain to the community  ― The buildings are old and the HC may collapse on our people‖ Management of plants and development is  ―We are looking for resources to improve our HC. Have approached HUMC now responsible for improvement Expansion and improvement of working  Government had better wake up…. Where are our taxes going?‖ none of HUMC concern our member of parliament to loby and have given him our requirements‖  ―We need to do renovations and buy tools‖ of HC infrastructure and machinery HUMC now responsible for resource mobilisation condition to motivate staff performance  ―Staffs here are rude and we would rather die than coming here. Our people are safer off this HC‖ HUMC have poor attitude to services and staff and drive patients away  We explain to patients and ask them to report to us their complaints on staff behaviour then reassure them and ensure proper handling of public‖  ―We are concerned about the handling of patients and staff behaviour and these inform our agenda during meetings HUMC ensure public is counseled and reassured and staff are reminded of their ethical code of conduct HUMC improving user satisfaction good handling of staff and improving quality of care. Improved quality of care as a component of performance improvement. Management Competency 4.5.4 The Changes in HC Performance as Potrayed by Health Workers after Training of HUMC Members Health care workers showed satisfaction with the operations of members of HUMC after the training. The results of this training were an increase in level of trust between HUMCs and health workers thereby leading to a highly motivated workforce. correlation values despite the myriad challenges facing their facilities such as drug stock One senior facility nurse explained thus: “Compared to elsewhere where I worked, here we do not have much committee interference, we enjoy good relations with the committee. A week won‟t pass without the Chairman passing by to ask how we are doing. We feel the committee trusts us with the management of the facility and is responsive when we need help. As you can see the work is demanding, just look at the queue… but at least we know we can now count on our committee of recent and the community is also very supportive”.(FGD- HCW) 4.5.5 The Relevance of Themes of HUMC Members Training and Performance of HCs From the table 4.14, there is a significant relationship between performance of the HCs and all the themes that were selected for training. Training in monitoring and supervision with Chi Square 55.68 and P value 0.002 implies that it is important to train members of HUMC in monitoring and supervision to improve performance of HCs. Training the HUMC on their roles with Chi Square 9.11 and p value 0.012 shows significance of training HUMC to improve performance. Training HUMC in managing resources with supplies management (Chi Square 5.25 and p-value 0.019), finance management (Chi Square 40.28 and p-value 0.006), and human resource management (Chi Square 6.19 and p-value 0.014) show the relevance and significance of training of HUMC in improving performance of HCs. Table 4.14 Relevance of training themes to improving performance of HCs Themes Outputs Intervention Control X2 P - value Pre Post Pre Post Monitoring and supervision Proportion of HUMC members trained Good performance 16 140 11 11 55.68 0.002 Bad performance 124 140 18 18 Have a schedule for monitoring and supervision Good 15 140 13 13 Bad 125 140 127 127 Roles of HUMC Do you know roles of HUMC member? Good 20 140 18 18 9.11 0.012 Bad 120 140 122 122 List at least three roles of HUMC Good 23 140 24 116 Bad 117 140 21 119 Supplies management Witness delivery of supplies, get reports. Good 16 140 18 18 5.25 0.019 Bad 124 140 122 122 Financial management Know the workplan and budget for this health centre, accounting Good 22 140 20 20 40.28 0.006 Bad Performance 118 140 120 120 HRM Know whether the health centre achieved staffing level, staff attend duty, and manage time Good 17 140 17 17 6.19 0.014 Bad 123 140 123 123 Table 4.15 shows changes in means for the extracted factor data between the baseline in 2018 and post intervention in 2019. Perceptions on governance improved significantly for health centres in the intervention arm but declined significantly among health centres in the control arm (t =2.83 (0.10) and p Value =0.012). Perception for availability of medical supplies showed numbers increasing after training in the intervention arm although the relationship between supplies, training of members of the HUMC and improving performance of health centres was not significant ( t=0.65 (0.68) p. value 0.068). However the findings provide reduced numbers in perceptions/performance in the health centres in the control arm with still non significant relationship (t-test -1.42 (-0.15 ) p. value 0.154). The change in the level of satisfaction/performance in the health centres in the control arm was negative implying that whereas there was improved performance in health centres in the intervention arm where members of HUMCs were trained, there was decline in performance in the control arm HCs whose members of HUMC had not been trained. The number of deliveries at baseline for intervention arm was 1347 and this improved to 4249 post intervention (t=0.07 (0.10), P value=0.103) where as this showed a small improvement from 1488 at baseline to 1556 at exit (t=-0.18 (0.05) and P value =0.858) among the control HCs. The improved out-puts for immunization coverage in the survey round done in 2019 for the intervention health centres had a statistically significant relationship between training members of HUMCs and improvement in performance of HCs. Statistics for immunization gave (t=4.60 (0.13) and P value 0.0000) for health centres in the intervention arm as compared to (t=1.51 (1.55) and P value=0.131) in the control arm. The mean percentage change after training HUMCs for immunization coverage in HCs in the intervention arm was 0.19 as compared to -0.14 for the HCs in the control arm. The OPD utilization improved from 71960 at baseline in intervention arm to 158340 post training of members of the HUMCs (mean change 0.22, t = 3.22 (0.05) and P value 0.001). In the control arm OPD utilization dropped from 62720 at baseline in 2018 to 56191 in 2019 (t=-0.15 (0.10) and P value=0.885). The ANC attendance improved from 1001 at baseline in 2018 to 3707 post intervention in 2019 in the intervention arm (t=1.98 (0.08) and P value = 0.048) where as it declined from 1851 in 2018 at baseline in control arm to 1829 in 2019 (t=-0.51 (0.05) and P value=0.608). Compared to the baseline, staff absenteeism reduced in the intervention arm from 98 in 2018 to 53 in 2019 post intervention (t= 0.09 (-3.25), and P value=0.001) where as in the control arm, it increased from 78 at baseline to 109 in 2019. The number of management committee meetings increased from 1 at baseline in the intervention health centres to 2 post intervention (mean change 0.53, t = 2.33 and P value=0.021) whereas the meetings reduced from 1 at baseline in the control health centres to 0 in 2019 (mean change -0.18, t = -0.60 and p value = 0.552). Table 4.15 Mean Variable Changes-Baseline (2018) to Post Intervention (2019) t-test for equality of means Arm Variable Survey Round N Mean Change SD Mean Diff SE t P Value Intervention Arm Good Governance (Yes) 2019. 253 0.27 0.94 0.25 0.10 2.83 0.012 2018 (BL) 143 Availability of Supplies (Yes) 2019. 232 0.32 1.07 0.68 0.09 0.65 0.068 2018 (BL) 122 Deliveries in HCs 2019. 4249 0.31 0.87 0.52 0.10 0.07 0.103 2018 (BL) 1347 Immunization Coverage 2019. 2837 0.19 1.04 0.45 0.13 4.60 0.000 2018 (BL) 1680 OPD Utilization 2019. 158340 0.22 1.02 0.33 0.05 3.22 0.001 2018 (BL) 71960 ANC Attendances 2019. 3707 0.15 1.13 0.20 0.08 1.98 0.048 2018 (BL) 1001 Absenteeism of Staff 2019. 53 -0.45 0.79 0.40 -3.25 0.09 0.001 2018 (BL) 98 HUMC Meetings 2019. 2 0.53 0.93 0.32 0.05 2.33 0.021 2018 (BL) 1 Control HCs Good Governance 2019. 108 -0.02 1.04 0.00 0.10 -0.05 0.958 2018 (BL) 142 Availability of Supplies 2019. 149 -0.11 1.08 -0.15 0.10 -1.42 0.154 2018 (BL) 214 Deliveries in HCs 2019. 1556 0.12 0.92 0.01 0.05 0.18 0.858 2018 (BL) 1488 Immunization Coverage 2019. 1264 -0.14 1.11 -0.13 1.55 1.51 0.031 2018 (BL) 1419 OPD Utilization 2019. 56191. -0.02 1.07 -0.02 0.10 -0.15 0.085 2018 (BL) 62720 ANC Attendances 2019. 1829 -0.11 1.01 -0.05 0.05 -0.51 0.608 2018 (BL) 1851 Absenteeism of Staff 2019. 109 0.01 1.03 0.10 0.10 -0.59 0.557 2018 (BL) 78 HUMC Meetings 2019. 0 -0.18 1.06 0.09 0.14 -0.60 0.052 2018 (BL) 1 4.5.6 Effectiveness of Training of HUMCs on Improving Performance of Health Centres Regression analysis was used to find out to what extent the training of members of HUMCs in the intervention arm accounted for improvement in performance of these health centres. The results provide the magnitude of influence the independent variables and intervention variables had on the performance of health centres. Linear regression technique was employed with all variables entered together as a block. Backward stepwise log likelihood ratio was used to control for confounding. All the motivating factors for performance identified during bivariate analysis, all plausible factors and potential confounders for performance enhancement were entered into the model. Logit P(Y) = α + β1 (Performance of Health Centres) + β2 (Sex of respondent) + β3 (Age of respondent) + β4 (Education level of respondent) + β5 (Marital status) + β6 (Economic status) + β7 (Availability of supplies) + β8 (Availability of policies in place) + β9 (Support supervision done) + β10 (HUMC meetings held) + β11 (Knowledge of performance targets) + β12 (Satisfied with remuneration) + β13 (adequacy in staffing levels) + β14 (HUMC trained) + β15 (Staffs keep time) Where: Logit P(Y) is the probability of improving performance of the health centre that is explained by the variables in the model α is the Y intercept β is the coefficient estimate of the exposure or potential confounder variables in the model. Table 4.16 displays results of the best fitting model. After a log likelihood ratio test, all the variables extracted for the 12 health centres in the intervention arm and 12 health centres in the control arm were included in the analysis. Overall, 88.8% of the dependent variable was correctly predicted by the variables in the model with a specificity of 94.6% and sensitivity of 78.3%. The -2log-likelihood was 340.642, and the Negelkerke R square was 74.5%. The Hosmer and Lemeshow test revealed a significant chi-square (chi-square χ²= 212.45; df =8; p-value = 0.004). After adjusting for confounding and testing for effect modification, the variables that remained significantly associated with improving the performance of health centres included: Age of respondent, (OR=38.56, 95% CI: 3.19- 55.52). Economic status of respondent (OR= 1.41, 95%CI: 1.47 – 13.24). Education level of respondent (OR=59.43, 95%CI: 2.49 -65.33). Improving on support supervision (OR= 12.12, 95% CI: 7.01 – 35.44). Training of HUMCs (OR=164.22, 95%CI: 42.60 -988.45). and Availability of supplies (OR=1.19, 95%CI 1.89 – 22.10). The findings show that training of members of HUMCs had the strongest effect on improving performance of health centres. Sex of respondent (OR=0.126 95% CI 0.0001 -0.049) and marital staus (OR=0.298 95% CI 0.009 -0.167) were not statistically significant. Table 4.16 Results of best fitting model for improving performance of HCs Variable coefficient Adjusted OR 95% CI p- value Age of respondent Less than 35yrs More than 35yyrs 3.112 38.56 3.19- 55.52 0.001٭ Economic status of respondent High low 2.239 1.41 0.47 – 13.24 0.05٭ Education Level High Low 2.878 59.43 2.49 -65.33 0.003٭ Number of HUMC meetngs Yes No 3.113 12.12 7.01 – 35.44 0.008٭ HUMC trained Trained Not trained 8.175 164.22 42.60 -988.45 0.000٭ Availability of supplies Available Not Available 2.110 1.19 0.01 – 22.10 0.031٭ Remuneration Satisfied Not Satisfied 1.996 26.16 2.69- 51.44 0.042٭ Management of time Assured Not Assured 1.889 5.05 1.61 - 10.22 0.011٭ Sex Female Male -2.015 0.03 0.0001 -0.049 0.126 Marital Status Married Not Married -3.532 0.125 0.009 -0.167 0.098 Occupation Doctor Allied 2.723 22.19 4.15- 48.42 0.002٭ Nurse Religious Leader Politician Others * Statistically significant CHAPTER FIVE: DISCUSSION, SUMMARY, CONCLUSION AND RECOMMENDATIONS 5.1 Discussion The discussion was related to research questions and objectives. These entailed determining the effect of socio-demographic characteristics on performance of HCs, ascertaining the current performance of health centres and testing the effect of training of the HUMCs on performance of the HCs in East-Central Uganda. The theoretical discussion sought to highlight implications for designing and adopting training programmes for HUMCs as a means to improve the performance of health centres. They enabled comparison of the generated responses as predicted by expectancy theory (psychological contract) and process theories (Maslow‘s heirachy theory of needs and Herzberg‘s motivation hygiene theory and provided guidance to the study. 5.1.1 Socio-demographic Characteristics of the Respondents The study findings revealed that majority of the respondents were in age bracket of 35-60 years while those aged above 60 years were least. In regard to performance of health centres results indicated that there was a non-significant relationship between age of members of HUMCs and the performance of the health centres prior to training. This finding is in agreement with the observation recorded by Kavanaugh et al. (2006) while investigating demographic variables for health care professionals in USA where there was no significant relationship between demographic factors and job satisfaction among health care workers in the USA. However after training the HUMC members, age became significantly associated with performance. The finding in this study is explained on the fact that ability to perform is dependent on the age holding skills and knowledge in positive context. The younger ones are more active and ready to learn while the aged are slowed down by many factors and have a lot of encumbrances that deter performance despite the varied experiences gained. The Uganda Public service ministry is cognizant of this fact of life and encourages employing mainly the youth with cut off age for public employment set at 60 years. Incidentally some HUMC members were aged above 60 years While Kavanaugh et al. (2006) recorded a non significant relationship between education of health care workers and job satisfaction; this study established a significant relationship between performance of HCs and the education level of its HUMC members. Findings of the study showed that most of the respondents had a diploma with almost similar proportion attaining a Bachelors degree while those who had a high school certificate were least. This may be due to the fact that community tends to select educated people to do community work as they are regarded as more knowledgeable. The higher the qualifications the more knowledge possessed by the holder and presumably the better the performance. For education to be relevant and significant as regards performance of HCs before and after training of HUMCs reflects the power of reasoning and decision making when the holder is well educated and to what level of education. This was well demonstrated in this study and this finding is corroborated by findings from Muathe and others (2013) in their study in Kenya where they found education to be key to adoption and utilization of information technology. The findings show that most of the members of HUMC were males compared to females and this is explained by the impacts of Confucianism that reigns big in Uganda and reflects a highly patriarchal system in the study area. This pattern of gender for the members of HUMCs is in contrast to the general trend in healthcare settings where most of the professional workers are female. The findings about the sex of respondents also differ from those of (Muathe, 2013) while studying factors influencing ICT adoption among workers in SMEs in Nairobi, Kenya where he observed that most of the workers were females compared to males. It is well explained by the phenomenon of patriarchal bearings in the country. The findings in this study showed a non significant relationship between gender and performance of HCs for members of HUMCs. This finding is in agreement with those observed by Kordic (2013) while studying influence of social economic and demographic environment of health care providers in Croatia where it was found that there was no significant relationship between gender of the health workers and type of communication channels for youth. The lack of significant relationship between gender for HUMC member and performance of health centres may also be explained by the government policy on employment that requires employers not to discriminate against either gender. The results of this study indicated that most of the members of HUMCs were married. This could be attributed to the fact that most people in Uganda marry between the age of 20-40 years when they finish school and get employed. It could also be due to the fact that HUMC members are individuals of high level of responsibility therefore have to be married people. There was however a non significant relationship between marital status and performance of health centres agreeing with Kavanaugh et al. (2006) findings. This could be due to the fact that employers in Uganda are not bound by any laws to consider health workers‘ marital status when recruiting or assigning work. It can also be viewed in the context that matters in relation to performance of health centres have not much connection between being married or not. The results indicated that most respondents were in the economic bracket of above poverty line (either well off or neutral but not poor). This was explained by the observation that many of the HUMC members were doing some other employments and therefore were salaried and may be engaged in other income generating economic activities. The result shows that to be selected as a HUMC member one has to be a respected person trusted by the community and having some income. Findings reported in this study agree well with those recorded earlier by Balbao- Osorio et al. (2013) while investigating ICT for jobs and growth in a hyper connected world. They found that majority (70%) were economically strong. However like Balbao et al (2013) there was no significant relationship between economic status of stakeholders (HUMC/Health Care Workers) and performance of health centres prior to the study. This finding should not be found as surprise since all members of HUMCs in both the control arm and intervention arm had marched economic levels driven by the same economic policies and economic abilities. Economic status of members of HUMCs however became weakly significantly associated with good performance of HCs when HUMC members had been trained. This shift from the conclusions by Balbao in this study is explained by the belief that empowered HUMCs could then exploit their economic abilities to improve performance of the HCs. This was however a demonstration to prove that training of HUMCs is effective in improving performance of HCs and a basis for rejecting the null hypothesis. 5.1.2 Ascertaining Performance of Health Centres An assessment was made on the prevailing performance of the health centres. To measure performance was an indirect assessment of quality of care that was reflecting appreciation from the community by increasing utilization of the services and an increment in numbers attending the health centres. Although this could be confounded by the feeling that preventive services were deteriorating leading to increase in cases to health centres and therefore a sign of poor performing health system. This study confirmed that the performance of health centres in East-Central Uganda was poor and below the Uganda National desired average performance. The average performance for the monitored indacator was at 65 percent for all the 24 health centres as was reported by MOH (2018) in the annual performance report. Some explanation forr this finding was embedded in inadequate supplies, poor attitude of the health care workers but also on the fact that there was minimal participation of community. And this is further explained on the finding that the community was not owning services because the HUMC lacked skills to comprehend their roles and therefore were unable to mobilise their commrades for services. This study identified that following guidelines in place was important for improving performance of HCs. Just as Johns, (2010) did conclude that improvement in health status and the development of robust national health delivery systems did accrue to some level from the available guidelines and funding provided to the neediest. In this study, only out-put indicators were used to assess the effects of variables on performance. Although better measurements would be on impact indicators. The period available for this study was however inadequate to evaluate the impact of indicators traced by World Health Organisation which include literacy levels, Maternal Mortality ratios, Infant Mortality rates in the study area. At national level the indicators for the health sector performance and ranking were process indicators and these were well outlined in the National Health Sector Performance League Table as reflected in MOH report of 2018. These were directly harnessed by the study and related to other health centre performance and the service objectives which were not the subjects of this performance assessment. The performance factors in reports from MOH included services like in-patient care, surgeries, diagnostic services, and measures of efficiency such as bed occupancy rates. But like Sengooba (2010) did, this study did no assessment along these indicators and therefore no assessment was made for these harnessed factors in gauging for quality of care. Assessing for these in this study would call into play the SUO that is used to rate performance of the hospitals being done annually by MOH. But SUO was not among variables extracted in this study. Therefore like MOH league table performance indicators (MOH, 2018), the post implementation of training HUMC performance measurements and targets included OPD attendance, immunization coverage, delivery in health facilities, ANC attendance selected to represent the whole spectrum of performance measurements for the HCs. These were well complimented by staff perceptions factors like perception on leadership and governance, availability of supplies and job satisfaction in effect to achieve alignment and synergy. The study established that there had been efforts to improve performance of HCs as explained also in earlier studies by Ngulube (2004), Asiimwe (2008) and Mugisha (2004). The efforts to enhance health centre performance were many and varied in their capacity to address more critical constraints to performance. In the previous studies success and failure of performance was attributed to a number of contextual variables, such as increased costs of providing services, staff exodus and the flow and size of the government grants. Other contextual interventions like funding received from donors to run programmmes also provided concurrent synergies and alternative drivers for addressing performance improvements among health centres. In this study success was attributed to the intervention of training members of HUMCs. Among the critical constraints was the high dependence on uncertain financial flows (grants) from the government by the health centres. The low staff salaries was also a thorn in motivating staff to up their performances. Nevetheless since these were almost constant for both control and intervention health centres, then improved performance in the intervention health centres can be confidently attributed to training given to members of HUMC In this study, satisfaction with leadership and governance issues, results reflect that staffing levels, staff attending to duty, HUMCs monitoring, HUMCs holding meetings, availability of drugs and satisfaction of clients and better coverage were important performance indicators as also is followed by the ministry of health MOH (2018). In general these indirectly relate to quality of care provided. This study was able to consider the health service level utilisation (OPD, Deliveries, Immunisation, ANC) of health centres (a perennial concern of decision-makers), but not the quality of care provided, and even the degree to which different social groups in the population were being equally treated for similar conditions. HUMCs were observed to be ubiquitous health centre management mechanism at the peripheral in East Central Uganda. The same scenario was alluded to in earlier study of exploring effect of user fees on equity and quality of care in health facilities in Uganda (Mugisha, 2004). According to Mugisha, the main purpose of HUMCs was ensuring accountability. However in this study they are introduced in the mix for performance of health centres and discover that they are vital in all aspects of managing health care services if only they were trained. In this study, trained HUMC members in the intervention arm account for the improvement in performance of HCs when other factors were held constant like in HCs in the control arm. This finding was similar to that discovered by Sebastian, A. (2010) in a study on effective management of faith based organisations in Ghana and also by Abor, P. (2015). In this study, overseeing operations and management of the health facility can be seen to be about performance improvement and accountability aimed at improving service delivery which HUMC members accepted to have mastered in at the exit interviews. The driving forces behind the intervention points to the objective – that HUMCs should mobilise the community, raise and control revenue, oversee the management of staff, facilitate outreach and health promotion activities, and help to manage supply essential drugs. These roles are easy to implement if only the committees are trained and empowered as evidenced in results of performance comparing the control arm HCs and the intervention arm HCs in this study. It has been demonstrated by results of this sudy that performance of health centres in the intervention arm improved as compared to those in the control arm. The improvement is attributable to training of the members of HUMCs. 5.1.3 Effects of Training HUMCs on Performance of HCs The finding that performance improved in intervention health centres and did not improve in control health centres provides proof that training of members of HUMC leads to improvement of performance of HCs. And this agrees with findings by Abor (2015) who for his case in the study of effect of health care governance and ownership structure on the performance of hospitals in Ghana discovered that training of the professional workforce improves performance of the hospitals. In this study it is added emphatically that training HUMC members causes performance of HCs to improve. Training of HUMC members and its effectiveness to improve performance of HCs was being introduced into the health system that had several performance targets and objectives and performance gaps in this intervention study. To comprehend and assess the bigger picture in the health sector performance with a close eye on the study area was a crucial step in assessing the fit and synergy of the intervention of training HUMC members. The assessment answers the question of how the HCs could respond to training of their HUMCs. The main mechanisms for stimulating performance improvement in the intervention arm health centres were the training given to HUMC members. Although there were suggestion boxes and patient rights charters, these had been available in these health centres, were still available and used in HCs in the control arm and therefore could not explain improvement in performance observed in the intervention arm HCs. Training empowered HUMC members to have significant powers over the management of the health centres. As demonstrated in the results, many factors were at play to account for the performance of these HCs. Never the less, training of HUMcs was a huge stimulus for improving performance of health centres. This finding is in conformity with Machingula et al (2013) in the study in East and Southern Africa; they observed that: ―Extra resources, support supervision, training in skills, redevelopment of care processes, temporary support or consultants, information materials for patients‖ are a package approach‖ to organisational development and performance improvements‖. In a resource constrained country like Uganda, knowledge to be able to perform tasks correctly breeds effctiveness and efficiency. Training of stakeholders was key to creating the knowledge in health centres in the intervention arm. In this respect, the training of HUMCs or empowering them with knowledge on how to manage and contribute to the running of health centres wielded strong influence and provided high powered incentives for the HCs to respond to performance expectations. All the respondents in the intervention arm reported that their HUMC members had recently been trained in health facility goals and management and were reminded on the objectives of the health facilities and performance targets. However, many of them also felt that they were greatly lacking skills, especially in the area of community engagement and performance targets prior to the training. Respondents in the intervention arm attributed improvement in attitudes and performance of their health centres to the training of their HUMCs. The mean changes in the parmeters after training of HUMCs pointed to improvement in quality of care. Some of the mean changes that point to improved quality of care are: Perception in good governance (mean change 0.27, p value 0.012), availability of supplies ( mean change 0.32, p-value 0.008), and absenteeism of health workers (mean change -0.45, p-value 0.001) in the intervention arm. These findings are in contrast and the opposite of those seen in the control arm at the end of intervention and somehow imply or reflect on the effectiveness of training on improving quality of care. Adi (2012) in the study of driving performance and retention to employee engagement noted similar findings that training did significantly improve the performance out puts of the workforce. This was explained on the knowledge and skills gained by the work force that they were applying to solve bottle necks in performance. During and after the training of the HUMCs, ethical standards were delved on in detail in the intervention arm HCs. The trainers and trained HUMC members called for equity while delivering health services to patients. This operationalisation of equity – in effect, equality of treatment – is close to that advocated and recommended by Meessen, B., J.-P. I. Kashala, et al. (2007) in their study in Rwanda in their report on racial and ethnic disparities in health care. However, while results in this study are plausible at the indicator level, the correlation of indicators within dimensions for quality of care and equity is weak, and there is limited congruence in the ranking of health centres across such dimensions as some of these indicators were not captured in this study as is also seen in the Annual Uganda National Health Sector Performance Reports of the Uganda Ministry of Health. Information on HUMC committtee contribution for continuous linkage to HC performance and the qualitative data is not being routinely collected. The data to derive assessment for equity, quality of care is not up to detail in the routine management information being collected. Recommendations to adress such gaps to the ministry of health could be a basis for further studies. The relationship between rewards/sanctions and performance is a cardinal concern for the expectancy theory. Poor relationships imply low ability of workers to put in a performance therefore leads to decline in out-putsas observed by (Paina 2011; Gauld 2011; Smith 2012; Sengooba 2010; Kacmar 2016). As regards the context of training of HUMCs to stimulate productivity, the individualised incentives accorded among both the control and intervention arms was salary. Salaries thus remained a constant. However, high powered incentives as predicted from expectancy theory would have been also necessary to be provided to staff and HUMCs to be able to stimulate improvement in performance. In this study such high powered incentives and performance enhancement bonuses were not catered for. Yet performance tremendously improved in the intervention health centres. In this training of HUMCs instead, group incentives were provided to a section of stakeholders (HUMCs) and group incentives sometimes undermine performance. In this case contray to the expectancy theory predictions for group incentives provided, this led to improved performance for health centres in the intervention arm. The training of HUMCs ensured that practices in communicating the link between performance expectations of health centres and all stake holdres and the incentive of training as well as the link between the impetus for trained HUMCs to monitor and ensure improved performance were galvenized. These synergised each other to augment the prediction that expectancy theory effects should predict improved performance even if there was not individualised rewards given out. A similar scenario was observes by Kacmar (2016). The performance accountability to district leaders was enhanced and provided visibility of improvements being attained. This also was a marker for local sustainability of achievements made in case there was no body pushing for results as the case was with the demands from this study. Sustained support supervision was therefore as expected ensured that it will continue to be done. Just in case new HUMC members came on board, the method of mentorships and follow ups was viewed as more sustainable, was easy and cheap to do in this resource constrained setting to ensure continuity of achievements since physical lecture room contact was only for two weeks yet mentorships and follow reigned for all the period of the intervention. Therefore financial insufficiency as different from price drivers and plenty of cash in perfect market theory was a major factor for going with motivating improved performance through non-monetary interventions. Increased salary to health care workers and a pay to members of HUMCs to stimuate performance was then considered unneccessary in these HCs that did not have big financial reserves. The findings do not fit the perfect market theory that would prescribe leaving alone all HCs to do their thing and letting those with money out compete those without money in gagging performance. Indeed in his work on impact of leadership on performance Zia-ud-Din, M., & Shabbir, M. (2017).recommended that cheap feasible and sustainable innovations were essential and were to be reviewed since feasibility conditions keep changing over time. From this persipective, the design and innovations like training of HUMC should build methods to assess bottle necks in performance improvement and factors that may contrain customers from acting in a manner to optimise the effctiveness of the innovations. Findings from this study differed from those of (Ssengooba 2010) where he was advocating for monetay incentives to improve performance. In this study it revealed that cheap non monetary incentives can improve attitude and perforamnce. Such cheap options let go of many complications that would arise if one was to give monetary incentives in resource constrained HCs. Criteria for nominating individuals to reward was found still wanting. Equally source of the funding to enable the rewarding was also not definite. Selection of departments to give more tools than others was not easy yet whole bus purchase of equipments was found not to be feasible. Source of funds for retooling was also a subject of contention. Improvements in the working condition would fit practices predicted by HERZberg‘s theory but for this study the Herzberg theory was not tenable. All hope and realisation of improving performance was therefore vested in training HUMCs as this had resulted in improved performance in the HCs in the intervention arm. The findings such as ―everyone needs to be recognized‖ or ―together we achieve more‖ or ―let those that will be rewarded be left to work alone‖ as reported by Bonner et al (2002) showed that the justification for not using material incentives to stimulate production in the intervention arm HCs was to emphasize equity and team spirit among HUMC members and staff as being more powerfull to improve performance in this study than what was predicted by HerzBerg‘s theory. Since HUMCs themselves were not being paid, and besides HUMCs lack of funds to provide monetary incentives to staff therefore justified other non-monetary means cultivated during the trainings and intervention to improve the performance of HCs as also cited by Adi (2012). HUMC training experiences are fairly similar whether committees were set up as an intervention as in the case of this study where they received substantial support from the study, or form part of the regular health system structures. These findings echo experiences elsewhere in Africa. Machingura F and Loewenson R (2013) findings from their study strongly suggested a link not only between trusted and skilled HUMCs and health workers improved performance, but also with the broader accountability structures supporting primary care delivery, in resource limited settings. The trust was more for HUMC members in the intervention arm HCs due to the training they had received. This is because, where facility managers/supervisors (in this case the HUMC) are trained and know how to cultivate a certain level of trust in the health workers, they also create for them a ‗decision space‘ on how, for instance, to use to maximum efficiency the limited facility resources. The training obtained therefore explains why the HCs in the intervention arm enjoyed good working relations as compared to those in the control arm HCs results which are similar to findings in another study in the coast of Kenya where cordial relations between HUMCs members and HWs were associated with trust and increased accountability-Molyneux S, Atela M, Angwenyi V, Goodman C. (2012). 5.2 Conclusions The conclusions are derived from the study findings. The drawn conclusions are anchored in the specific objectives of this study and are also enriched by reflecting on the theoretical predictions that underpinned the study. The conclusions avail blended alternative theoretical propositions that have been employed to generate and sieve evidence to inform direction of new policy. 5.2.1 Socio Demographics The findings linked performance of health centres to age, education level, profession of member of HUMC and economic muscle of the respondents as important socio- demographic variables crucial to consider for performance of health centres to improve. Particulary for the economic prowess, this conclusion is strengthened by principles underlying Herzberg‘s hygiene motivation theory and the Agency Theory provided that money or individual material gains/incentives would drive the major players to cause improved performance of health centres. The more materials individually gained, the better the performance improvement in the health centres. It was therefore concluded that socio-demographic factors like the ages of the HUMC members, their education levels and the economic status of the individuals were important characterics influencing performance of health centres bearing in view the ability and skills to manage the tasks. 5.2.2 Performance of Health Centres The study confirmed that the performance of health centres in East Centre Uganda was below average of the country performance. Many factors were responsible for the poor performance. These included the demands being exerted by different level players like Ministry of Health and District authorities, availability/non availability of supplies and tools, good/bad governance, the intrinsic motivation to work and the incentives or emoluments being given to the workers to stimulate performance. It was contended that the performance of health centres was the aggregate performance of each individual player/worker put together, it was poor in East central Uganda and improved upon training of members of HUMC. 5.2.3 The Effect of Training of Members of HUMCs Contrary to the market Theory, this study demonstrated that non-financial incentives like training of members of HUMCs have a role to play in enhancing productivity. From the study finding, the null hypothesis was rejected. Health Centres in the interventional arm where members of HUMCs were trained generated better performance out puts than those in the contral arm where HUMC members were not trained. From these HCs, it was possible to conclude that factors constraining performance of HCs were hidden in lack of training of HUMCs. Therefore it has been concluded that training of members of HUMCs has a positive effect in improving performance of health centres. 5.3 Recommendations 5.3.1 Socio Demographics It is hereby recommended that all members of HUMC should be adults of average 35 years, still energetic individuals and should be trainable individuals. They should be of education level of at least diploma preferably in medical related field. This would enable them to be able to read and comprehend guidelines and policy and make them offer meaningful guidance to performance of HCs. 5.3.2 Performance of Health Centres The Ministry of Health should provide management support to implement the policy for involving HUMCs to improve the management/ performance of HCs and reduce Staffing gaps in EC Uganda, provide HCs with ample supplies to enable improve the performance of the health sector in East Central Uganda. By so doing, Ministry of Healthy improves the working environment of health care workers including members of the management committes to be able to improve the performance of health centres. 5.3.3 Effect of Training of Members of HUMC on Performance The Ministry of Health should provide a policy to ensure that all the members of HUMCs be trained to enable them to adequately perform their roles. This will enable them to appreciate the role, tasks and challenges and participate in improving services. Ministry of Health should provide all resources that are required by HCs to invest in training of HUMCs to be able to keep at pace with increasing work demands and ensure improved performance of health centres. 5.3.4 Further Research This study applied data from hospital and sub-hospitals but did not capture data from lower level HCs and from bigger regional referral hospitals and national referrals. 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Muwanguzi David (+256 702 436 474) a student of Kenyatta University is pursuing postgraduate studies in Health Management and Informatics. The area of focus is on the contribution that can be made by Health Unit Management Committees to performance of health centres. Purpose We are requesting you to take part in this research because we would like to learn more about the impact of training of HUMCs on performance of health centres and evaluate the outcomes of such training in selected health centres/districts of East Central Uganda. This will guide government and community on how to better engage HUMCs and ensure quality of care. and how the contribution can be improved through training. Effectiveness of the training to improve performance will be assessed at the end of the research. Why we want to talk to you in particular and what does it involve? You have been identified as a key stakeholder directly or indirectly involved in the performance of health centres and decisions affecting performance of HCs. If you agree to participate we would like to interview you today. We will ask you questions about your knowledge, experience and opinions about HUMC practice and performance of health centres. Our interview will last a maximum of one hour. We are here to learn from you and seek your opinions. Therefore it is important that you feel free to answer in any way you feel most appropriate and that you understand that all of your opinions and ideas are valuable. Potential risks There is no major risk that you will be exposed to. This is a minimal risk study which does not involve any invasive procedure. However, you may experience embarrassment during the discussion. I will guide the discussion to minimize any potential embarrassment. The interview will be conducted at a time and place most convenient for you to minimise any potential costs or disturbance. Benefits There are no material benefits you are getting as a result of your participation in the study, but we hope that the issues you raise and the recommendations you give will be taken up by different actors to ensure that we have health centre performance improved and the recommendations are adequately used by the different stakeholders both government at local government and central government and the none government level. Voluntary participation It is important to note that taking part in this study is up to you and no one will be upset if you don‘t want to participate. Even if you agree to participate, but half way through the discussion you change your mind, nobody will be upset. You can ask me to stop the discussion at any time. It is also okay if you do not want to answer any particular question you find uncomfortable. But, even though you will have initially agreed, you can still decide not to take part or discontinue at any time. Confidentiality and privacy If you accept, this discussion will be digitally recorded to save on your time and enable us to capture everything we discuss. The files will then be transcribed and, following verification, the electronic copy destroyed. Nobody will know what you told us. The information we get from you will not be accessed by anyone outside the research. All of our documents and recordings will be stored securely in locked cabinets or on password protected computers. Although your views may be used in the report, your personal details will not be included. Questions You can ask any questions that you have about the study before we start. If you have a question later that you didn‘t think of now, you can call me on 0702436474 and I will explain more about this study to you. Contacts of Supervisors for Any Other Issues: In case of any queries concerning this study you are free to contact the listed people below who are my supervisors. Dr. Otieno George Ochieng Telephone No +254 719 506 770 Dr. Rucha Kenneth Kibaara Telephone No +254 723 227 480 Prof. John Francis Mugisha Telephone No +256 772 648 223 / +256 702 088 494 I have read or received explanation on the content of this Consent Form and I have been encouraged to ask questions. I have received answers to all the questions. I agree to participate in this discussion. YES -------- (Elicit signature) NO------- (Thank and terminate the discussion) 1. ________________________________________ Signature/Thumbprint of Consenting Subject Printed Name of the Consenting Subject ________________________________________ Date I agree to have this discussion recorded? YES -------- (Elicit signature) NO------- (Thank the participants and continue the discussion without the recorder. Write notes)) ________________________________________ Signature/Thumbprint of the Consenting Subject ________________________________________ Printed Name of the Consenting Subject Date Appendix II: Questionnaires Questionnaire A Assessment tool for HUMC No. Questions and Filters Coding Categories Skip Section 1 Demographics 1 What is the name of this health centre? 2 What is your age? [ ] Years [ ] don‘t know ………….……………00 3 What is your sex? Female...……….………………….……..1 Male..………….……………….………..2 4 What is your religion? Christian Orthodox ………………….......1 Other Christian…………………………..2 Muslim …………..………….……3 Roman Catholic..…………………...........4 Adventist …………………………...5 Traditional religion………………………6 Other …………………………..7 None …………………………..8 5 What is your current marital status? Single/ never married…….……………...1 Married.. ………………………...2 Divorced/ separated …….…..…………...3 Widowed…………….…………………..4 6 Have you ever attended school? Yes ……………………………….……...1 No………..…………………….……...…2  8 7 What is the highest level of education completed by you? Pre- School………….……………….………..0 Primary…………………………………..1 Secondary…………..……………………2 University…………………..………........3 Postgraduate………………..……..……..4 Other……….…………………….………5 8 For how many years have you been serving on the HUMC? Less than a year……………….…………1 1-5 years ……………………………..2 5-10 years ………………….……………3 10 years and above ……………..........4 No. Questions and Filters Coding Categories Skip 9 What post do you hold on the committee? Chairperson …………….....……........1 Vice Chair ……………………....…….2 Treasurer ………………………….……3 Secretary …………………………4 Members ………………..........5 Staff Representative………….….…….............6 Other ……………….……….........7 Section 2: Current Performance of Health Centres 10 What is the composition of the committee? All post are filled ……….…….……….1 Half filled …………………………...2 Just one person ………………………..3 Lacks gender balancing ……………….4 Other ..…………………….……….......5 11 If the HUMC is not fully constituted then why? 12 What roles do HUMC play in this hospital/health centre? Allocate funds to activities ……1 Discuss budgets ..……………2 Ensure staff attend to duty……………….3 Supervise work….…….……….…...........4 Mobilise community ..…………...……...5 Ensure accountability for drugs..………..6 Make reports to relevant offices ………..7 Other……………………………………..8 13 What motivates the HUMC to work in this hospital/health centre? Salary ..………………...…........1 Satisfied with family issues . …...2 Staff are friendly……...…………………3 Availability of recreation.…….……........4 Hospital in town ……..…………...……..5 Respected by managers of hosp.………...6 Respected by Community……..………...7 Other….……………………………….....8 14 How often do members of HUMC come to the hospital/health centre? Daily……………………………...….......1 Monthly……………….……….……. ….2 Quarterly....……………………………...3 Rarely..…….…………………….............4 Never come ………..…………................5 Other……………………………………..8 No. Questions and Filters Coding Categories Skip 15 How often do HUMC members hold meetings in this health centre/hospital? Weekly…………………………...….......1 Monthly……………….……………. …..2 Quarterly....………………………….......3 Rarely……….……………………...........4 Never…..……………..………….............5 Other ………………………………......6 16 What are the channels through which HUMCs can make suggestions to improve performance? Meetings………………………...….........1 Reports ….……………... …....2 Suggestion boxes.…………………..........3 Workshops..……………………...............4 Input in Client Charter.………….............5 Other …………………………………...6 17 How does the HUMC get to know about performance of this hospital/HC? Section 3: Factors that influence performance 18 What is the staffing level of this hospital/HC? All posts are filled..…………….………..1 Half filled..…………………………..…..2 A quarter…………………………………3 Lacks critical position..…….………........4 Other ..……………..……….……….......5 No. Questions and Filters Coding Categories Skip 19 What motivates staff to perform in this hospital/HC? Salary ……………………………...…….1 Job Security …..2 Staff are friendly………………….……...3 Availability of recreation..…...……..........4 Availability of supplies and tools....……..5 Respected by managers of hosp..………..6 Respected by Community……….……....7 Opportunities for promotion.……..……..8 Opportunities for further training…..........9 Other ………………………………….10 20 How is training of staff done in this hospital/HC? 21 How is budgeting/planning done in this hospital/HC? 22 What is the situation about logistics and supplies in the hospital/HC? 23 What is the situation as regards infrastructure and building in this hospital/HC? 24 What was the OPD attendance level in this hospital/HC last six months? 25 What is the immunization coverage in the catchment area of this hospital/HC in the last six months? 26 What is the level of supervised deliveries in this hospital/HC in the last six months? No. Questions and Filters Coding Categories Skip Section 4: Training of HUMCs Roles of HUMC 27 How do new members of HUMC get introduced to their work in this hospital/HC? 28 Are members ever trained on their roles? Monitoring and supervision 29 What proportion of HUMC members here has been trained in monitoring and supervision? All of them (12)……..…………………...1 9 – 11 ……….…………………………...2 6 – 8 ………...…………………………...3 3 – 5 .………..…………………………...4 <3..………………………………………5 None …………………………………..6 DON‘T KNOW………………………..00 30 How often do members of HUMC come to the hospital/health centre? Daily……………………………...….......1 Monthly……………….……….……. ….2 Quarterly....……………………………...3 Rarely..…….…………………….............4 Never come ………..…………................5 Other……………………………………..8 31 Do you have a schedule for monitoring and supervising health centres ? Yes……..…………………………….......1 No………………………………………..2 32 If No, why? Financial management 33 Do you know the workplan and budget for this health centre ? Yes……..…………………………….......1 No………………………………………..2 34 How does this health centre account for the budgeted resources? No. Questions and Filters Coding Categories Skip Supplies management 35 Do you witness delivery of supplies in the health centre ? Yes……..…………………………….......1 No………………………………………..2 36 Do get reports on the consumption of the supplies? Yes……..…………………………….......1 No………………………………………..2 37 In your opinion, are the supplies adquate ? Yes……..…………………………….......1 No………………………………………..2 Human resource management 38 Has the health centre achieved its staffing level? Yes……..…………………………….......1 No………………………………………..2 39 Are the staff attending to duty? Yes……..…………………………….......1 No………………………………………..2 40 Are the staff arriving in time ? Yes……..…………………………….......1 No………………………………………..2 Can you rate this hospital on a list of criteria? 41 Cleanliness 1.Excellent 2.Good 3.Fair 4.Poor 42 OPD Attendance 1.Excellent 2.Good 3.Fair 4.Poor 43 Stock availability 1.Excellent 2.Good 3.Fair 4.Poor 44 Deleveries in the hospital 1.Excellent 2.Good 3.Fair 4.Poor 45 Antenatal Care 1.Excellent 2.Good 3.Fair 4.Poor 46 Rate the supervision you did in the last six months Very low..... …………….....………....1 Low.......... ……………………....….....2 Moderate..…………………………….…3 High...... ………………………….4 Very high ………………...........5 Dont Know.............……….….……........6 47 Rate apprecaition of this health centre by clients Very low..... …………….....………....1 Low.......... ……………………....….....2 Moderate..…………………………….…3 High...... ………………………….4 Very high ………………...........5 Dont Know.............……….….……........6 No. Questions and Filters Coding Categories Skip 48 Rate your satisfaction if your hospital/HC emerged the best performing facility in the country Very low..... …………….....………....1 Low.......... ……………………....….....2 Moderate..…………………………….…3 High...... ………………………….4 Very high ………………...........5 Dont Know.............……….….……........6 That is the end of the questions, thank you very much for taking part. Questionnaire B Assessment tool for performamce extracted from HMIS monthly report and DHIS2 No. Indicator(s) Target Number achieved OPD attendance 1 Total number of new clients 2 Total number of reattendance Monitoring and Support Supervision 1 Number of visits made Immunisation coverage 3 Number of children immunised for DPT3 ? 4 Number of children immunised for measles ANC attendance 5 Number of mothers who attended ANC1 6 Number of mothers who attended ANC4 Deliveries 7 Number of mothers who delivered from the health centres 8 Number live births Number of mothers who died That is the end of the questions, thank you very much for taking part. Appendix III-Interview Guides KII Interview 1 Baseline assessment for DHMT intervention and control 1. What are the benefits of having HUMCs in HCs/hospitals? 2. What is your view on the current performance levels of the HUMCs in the facility? 3. What is your assessment of the performance of HC/hospital? 4. How do you view the community‘s involvement in the management of this hospital/HC? 5. What do you think are the functions of HUMC? 6. What is the state of functionality of HUMCs? 7. Give suggestions on how to improve performance of HCs. SECTION B: HUMC supervision and monitoring performance 1. How has the HUMC been influencing the performance of this HC/hospital in the last 4-6 months? Probe aspects of performance in regard to the National performance indicators for a hospital/HC. 2. What are some of the tasks being carried out by the HUMC? 3. What are the strengths that this hospital/HC has got as regards performance? 4. What are the gaps in this hospital as regards performance? Probe for current gaps as of now the time of this interview. 5. What are the factors that make it possible for members of HUMCs to do their work? 6. What are some of the challenges in the work of HUMCs? 7. How are the HUMC using the policy guidelines that govern work of HUMC in the hospitals/HCs over the last 4-6 months? 8. What are the extra skills required of members of HUMC to have skills to do the work? HUMC characteristics 1. What are the selection criteria for members to the HUMC? 2. What changes should be adopted to make HUMC Members better performers? 3. What do you think is missing in the setup, composition of HUMCs? 4. What do you think are the strengths in the set-up, composition of HUMCs 5. What do think can improve linkage roles of HUMCs? 6. What changes can be done to make HUMC be able to do their work in order to improve performance of this HC/hospital? 7. Which individual factors do you think are significant in HUMCs enhancing performance? 8. How are HUMCs motivated to do work? Probe institutional and individual End. Thank you for your time KII Interview 2 Baseline assessment for HUMC intervention and control 1. What do you think are the main roles of hospital/HC HUMC? 2. How would you describe the interaction between the HUMC and Managers of the hospital/HC? 3. How successful is the management in running of HC/hospital? 4. How have your view changes in the last 4-6 months of the running of the hospital/HC? 5. How does the HUMC ensure that managers and staff do the right thing? 6. How effective is the HUMC in supervising the workers? 7. Give suggestions on how to improve performance of HCs. KII Interview3 Baseline assessment for Hospital/HC Management intervention and control arm 1. What are HUMCs?................................................................................... 2. What do you think are the benefits of having HUMCs in HCs? 3. What do you see as your main roles as a manager of this HC/hospital?. 4 How would you describe your relationship with the HUMC in this hospital/HC?……… 5 How does the hospital/HC management prepare for HUMC meeting? 6 What are the major/usual discussion issues during the meetings?. 7.Tell me about performance of this hospital/HC.. 8. What are the main interests of the HUMC members in this hospital/HC?… 9 What are the strengths that this hospital has as regards performance?. 10 What are the gaps in this hospital as regards performance? 11 Describe the relationship/interaction between management and staff. 12 Desribe the existance of staff meetings in this hospital/HC. 13 What is often discussed in the meetings? 14 What are the policy guidelines that govern work of HUMC? 15 How do you ensure that staff do the right things?………… HUMC characteristics 1 How are HUMCs formed?................................................ 2. What is the selection criteria for members? 3. What do you think is missing in the setup, composition of HUMCs? 4 What do you think are the strengths in the set up or composition of HUMCs 5 What do you think can improve linkage roles of HUMCs 6 Which individual factors do you think are significant in HUMCs enhancing performance? 7 How are HUMCs motivated to do work? Health care workers and systems 1. What are the trainings offered in this hospital?.................................................. 2. Who often is the beneficiary to the training?……………………….. 3. How do you perceive working in this Hospital?……………………….. 4. What individual challenges do you have? ………….. 5. What would you suggest to be in place to improve performance in this hospital? That is the end of the questions, thank you very much for taking part. KII Interview 4 End of intervention assessment for DHMT intervention and control arm KII Guide District health team 1. How have the benefits of having HUMCs in HCs changed in the last 4-6 months? 2. What is your view on the current performance levels of the HUMCs in the facility? Probe the intervention facility. 3. What is your current assessment of the performance of HCs? i.e. probe the selected facilities in the intervention. 4. How have your views changed in the last 4-6 months of the community‘s involvement in the management of these hospitals/HCs? 5. How do you think the functions of HUMC have changed in the last 4-6 months? Probe for before and after the intervention 6. What is the current state of functionality of HUMCs in the last 4-6 months? Probe for the changes from the time the HUMC‘s were trained up to now. 7. Give suggestions on how to improve performance of HCs. SECTION B: HUMC supervision and monitoring performance 1. Tell me about how the performance of this hospital has changed in the last 6-9 months? Probe for the citable changes before intervention and now 2. In the last 6 months how has the HUMC changed in the frame as regards performance? Probe aspects of change in regard to the National hospital performance indicators for a hospital/HC. 3. What are some of the tasks shifts being carried out by the HUMC? Probe the hospitals/HC in the intervention. 4. What are the strengths that this hospital/HC has acquired as regards performance? Probe from the training related to the HUMCs in these intervention facilities. 5. What are the gaps in this hospital as regards performance? Probe for current gaps as of now the time of this interview. 6. What are the factors that make it possible for members of HUMCs to do their work? Probe the different aspects in the intervention and also other factors that may not be in the intervention. 7. What are some of the challenges in the work of HUMCs? Probe for institutional and individual 8. How are the HUMC using the policy guidelines that govern work of HUMC in the hospitals over the last 4-6 months? 9. What are the extra skills required of members of HUMC to have skills to do the work? Probe aspects of leadership, governance and monitoring together with budgeting HUMC characteristics 1. Has the selection criteria for members to the HUMC changed in the last 4-6 months? Probe for any noticeable changes for intervention arm 2. What changes should be adopted to make HUMC members better performers after this intervention for facilities in the intervention arm? 3. What do you think is missing in the setup, composition of HUMCs after these 4 months? 4. What do you think are the strengths in the set-up, composition of HUMCs after these 4 months? 5. What do think can improve linkage roles of HUMCs even after the training received? 6. What do you think about the need to change to improve the way management committees enhance performance of Hospitals/HCs? Probe for aspects that need to change in order to improve performance. 7. Which individual factors do you think are significant in HUMCs enhancing performance? 8. How are HUMCs motivated to do work? Probe institutional and individual Health care workers and systems 1. What do you think has made it essential to have HUMC? 2. What is your current view on tools to use to enhance performance in this hospital/HC? 3. What are the trainings offered in this hospital? Probe in the last 4-6 months 4. Who often is the beneficiary to the training? 5. How do you now perceive working in this Hospital? 6. What keeps you happy and makes you able to work well? 7. What individual challenges do you have? Probe for individual opinions 8. What would you suggest to be in place to improve performance? Probe own perspectives End. Thank you for your time KII Interview 5 Endline assessment for HUMC intervention and control 1. What do you think are the main roles of hospital/HC HUMC? Any changes in knowledge after the intervention in the intervention arm? 2. How would you describe the current interaction between the HUMC and Managers of the hospital/HC? Probe for any changes after the training 3. What changes have occurred in the management and running of this HC/hospital in the last 4-6months? Probe intervention arm 4. How have your views changed in the last 4-6 months of the running of the hospital/HC? 5. How does the HUMC ensure that managers and staff do the right thing after the intervention? 6. How effective is the HUMC in supervising the workers and how do you compare this now and before the training? 7. Give suggestions on how to further improve performance of HCs/hospital. KII Interview 6 End of intervention assessment for Hospital management team intervention and control KII Medical Superintendent/Senior Hospital Administrator and SNO 1. Are you aware of the current training intervention for the HUMC to better their performance? a. What is different with the HUMCs members after the intervention (in the last 4-6 months 2. What are the new benefits of having HUMCs in HCs currently after the intervention (the last 6-9 months? 3. What is your current assessment of the performance of HCs after the intervention (the last 4-6 months? ....................................... 4. How do you rate the HUMCs involvement with community and the management of this hospital in the (the last 4-6 months? 5. How have the functions of HUMC changed from the time of the intervention (the last 4-6 months? 6. What is the state of functionality of HUMCs in the last 4-6 months? 7. How would you now describe your relationship with the HUMC in this hospital/HC? Probe for intervention arm health centres 8. How has the hospital/HC management prepared for HUMC meeting in the last 4-6 months? 9. What now are the major/usual discussion issues during the meetings as compared to last time before the training? 10. What are the main interests of the HUMC members in this hospital/HC now after the training received?…Please compare now and previously and in the last 4-6 months 11. What now are the strengths that this hospital has as regards performance? 12. What are the current gaps in this hospital as regards performance? Probe in the intervention arm 13. Describe the relationship/interaction between management and staff in the last 4- 6months 14. How do you ensure that staffs do the right things and what changes have you witnessed in the last 4-6months? 15. Give suggestions on how to further improve performance of HCs. SECTION B: HUMC supervision and monitoring performance 1 Tell me about performance of this hospital in the last 4-6 months? 2 How does HUMC come into frame as regards performance in the performance indicators? 3 What are some of the tasks being carried out by the HUMC now? Probe the different areas 4 What are the strengths that this hospital/HC has as regards performance? Probe in the last 4-6 months ……. 5 What are the current gaps in this hospital as regards performance? Probe the MoH performance indicators for hospitals/HCs 6 What has made it possible for members of HUMCs to do their work? 7 What are some of the challenges in the work of HUMCs in this facility or district and how have challenges been modified in the last 4-6 months as compared to the period before the intervention? 8 How are the HUMC using the policy guidelines that govern work of HUMC in the hospitals over the last 6-9 months? 9 What are the extra skills required of members of HUMC having skills to do the work? Probe aspects of leadership , governance and monitoring together with budgeting HUMC characteristics 1. Has the selection criteria for members to the HUMC changed in the last 4-6 months? 2. What changes should be adopted to make them better performers? 3. What do you think is missing in the setup, composition of HUMCs? 4. What do you think are the strengths in the set-up, composition of HUMCs 5. What do think can improve linkage roles of HUMCs? 6. What do you think about the need to change the way management committees in performance of Hospitals? Probe for aspects that need to change in order to improve performance. 7. Which individual factors do you think are significant in HUMCs enhancing performance? 8. How are HUMCs motivated to do work? Probe institutional and individual Health care workers and systems 1. What do you think has made it essential to have HUMC? 2. What is your view on tools to use to perform in this hospital? 3. What are the trainings offered in this hospital? Probe in the last 4-6 months? 4. Who often is the beneficiary to the training now after the intervention? 5. How do you perceive working in this Hospital now as compared to before? 6. What keeps you happy and makes you able to work well? 7. What individual challenges do you have? 8. What would you suggest to be in place to improve performance? End. Thank you for your time Appendix IV: Focus Group Discussion Guide Theme 1: Selection and Training of HUMCs Probe to understand how HUMC members were selected and to establish whether there was any training offered to them, the training duration and content. Establish whether the members gained adequate knowledge and skills during the training. What factors are considered when selecting you as HUMCs? Theme 2: Provision of incentives to HUMCs and HCWs Probe to understand types of incentives provided to HUMCs and HCWs, and the extent to which expectations for such incentives have been met? What are the incentives provided to HCWs? What are the incentives provided to HUMCs? Which are the preferred incentives? Theme 3: Supervision and Management of HCWs and HUMCs Probe to understand the knowledge and skills in carrying out HCWs performance planning, appraisal. What are the appraisal mechanisms in place for HCWs? What are the appraisal mechanisms in place for HUMCs? What arrangements have been put in place to make HUMCs feel part of the formal health system? Theme 4: Performance of HCs Probe to understand which working tools HUMCs and HCWs require and whether such tools are provided regularly Which reports are HUMCs expected to generate, discuss and submit and how often are such reports to be submitted? Appendix V-Training Needs Assessment Pre and post training of HUMC Questionnaire for needs for training; the impact of training; and on the effectiveness of training HUMC on performance A: Background of HUMC 1. Gender a) Female ( ) b) Male ( ) 2. Age a) 18 – 25 ( ) b) 26 – 35 ( ) c) 36 – 45 ( ) d) 46 – 55 ( ) e) 56 – 59 ( ) 3. Marital status a) Single ( ) b) Married ( ) c) Divorced ( ) d) Widowed ( ) e) Separated ( ) 4. Department: …………………………………………………. 5. Rank: …………………………….…………………………… 6. Educational background: ……………………………………… 7. How long have you worked for the Hospital as HUMC member? …… Years ´ 8. Have you had any form of training since you joined the hospital as HUMC Member? a) Yes ( ) b) No ( ) If ―yes‖ to the question above, please continue with the questions below. 9. How were you selected for training? a) On joining the HUMC b) Supervisors recommendation c) Compulsory for all employees d) Upon employee request e) Performance appraisal f) Don‘t know 10. How often do you undergo training? a) Quarterly ( ) b) Every six months ( ) c) Once a year ( ) d) Every two years ( ) e) No specific schedule ……………………………….…………………… 11. What are the methods of facilitation at the training you have attended? a) Lecture b) Demonstrations c) Discussions d) Presentation e) Seminar 12. Do the methods used during training have any impact on your skill? a) Yes ( ) b) No ( ) 13. How will you rate the quality of the training programme/s for which you have participated? a) Very poor ( ) b) Poor ( ) c) Average ( ) d) Good ( ) e) Very good ( ) f) Excellent ( ) 14. How relevant were the trainings you received to your work? a) Not relevant at all b) Not relevant c) Not sure d) Effective e) Very effective 15. In your opinion, do you think training has helped improve your job performance? a) Yes b) No 16. Would you require further training for motivation towards performance improvement to enable you contribute to increased productivity? a) yes ( ) b) No ( ) If ―yes‖ to the question above, please provide reasons as to why below. …………………………………………………………………………………… …………………………………………………………………………………… 17. What problems do you face with regard to training and development within your Health facility? …………………………………………………………………………………… …………………………………………………………………………………… 18. Please specify any ways you think training and development in your Health facility can be improved. …………………………………………………………………………………… …………………………………………………………………………………… That is the end of the questions, thank you very much for taking part. Appendix VI: Training Instrument/Manual for HUMC Members Module 1 Introduction. Performance assessment and training framework for intervention arm The participants will be assessed through formal pre- and post-training tests. Additionally, an informal continuous assessment shall be applied through questions and answers after each module and active feedback from the participants. Attendance of at least 80% of the sessions shall be mandatory for successful completion of the course. A project for practical application in the field will be developed and implemented by participants and will also form the part of the assessment. Upon successful completion of the course, participants will be ready to implement the intervention in the 2 intervention sites Content of the HUMC training course Overview and context of the HUMC health system training Objectives of this module include: defining concepts of a health system; describing the components of a health system; explaining the importance of systems thinking for health systems strengthening; discussing the characteristics of a functioning health system; and describe the challenges and emerging health systems issues for HUMCs in Uganda. Governance in health Objectives of this module include: defining the concepts of good governance in health; outlining the principles and characteristics of good governance; describing the governance structures in health and their functions at various levels; discussing various health laws and health-related regulations impacting on good governance; and discussing factors that promote or hinder good practices on accountability and transparency. These directly fit in the role and functions of the HUMCs. Leadership in health Objectives of this module include: defining the concepts and styles of leadership; describing characteristics of effective leadership; discussing the place of leadership in the health systems building blocks; and analysing approaches for effective leadership in health care. Management for health Objectives of this module include: defining the concepts and principles of management for health; describing the functions and roles of a manager in health systems strengthening; discussing strategic management approaches; and describing characteristics of effective teams. Human resources for health Objectives of this module include: defining the concepts of human resources for health in the context of health systems strengthening; discussing the relevant human resource polices and plans in human resource management; describing the process of human resource planning; discussing performance management in the context of human resources for health; and describing the various approaches that can be used in human resource development. Health management information system (HMIS) Objectives of this module include: defining the concepts of HMIS; describing the role and functions of HMIS in the context of health systems strengthening; discussing the contribution of HMIS policies and legal frameworks in systems strengthening; discussing the role of HMIS in knowledge management in the context of health systems strengthening; describing the process of evaluating and improving HMIS; and describing the role of ICT in HMIS strengthening. Health financing Objectives of this module include: describing health financing and related concepts; discussing mechanisms of financing health; describing processes of financial management; and discussing the use financial expenditure monitoring tools. Health service delivery Objectives of this module include: defining the concepts and models of service delivery; discussing the characteristics of effective service delivery; describing an effective referral system; and discussing the concepts and approaches in accreditation. Supply chain management Objectives of this module include: defining the concepts in supply chain management; discussing the contribution of existing policies, laws and regulations in strengthening supply chain management; describing procurement management practices in health; describing an effective distribution and stock control system for supply chain management; and discussing appropriate quality control measures to enhance health service delivery. Monitoring and evaluation Objectives of this module include: defining the concepts of monitoring and evaluation in the context of health systems strengthening; describing the frameworks for monitoring and evaluation systems; discussing tools and methods for monitoring and evaluation; and describing the role of evaluative research in health systems strengthening Module 2 Gender and Human Rights TABLE OF CONTENT Page Abbreviations………………………………………………………………………(i) Module Overview…………………………………………………………….............. Human Rights and Health ……………………………………………………………. Introduction to Human Rights………………………………………………………... Characteristics of Human Rights…………………………………………………….. Gender Concepts and Analysis………………………………………………………. Gender mainstreaming(Planning Process)……………………………………..….. MODULE OVERVIEW In this module participants will be introduced to human rights and gender issues. They will learn basic human rights and gender concepts, gender as a social constraint and will be able to identify human rights and gender issues in the community. Participants will learn to analyse Human Rights and gender at different levels thus: House hold, Community and health sector. Lastly, they will learn human rights and gender mainstreaming into health service delivery, emphasising active participation of both women and men in the planning process. Target:  All district health committee members or any committee at the district that handles health issues.  All sub-county Health Committee or any committee at the sub-county that handles health issues.  All health unit management committee members  All members of hospital Governing Boards LEARNING OBJECTIVES: At the end of the session participants will be able to: 1. Explain the concepts of gender and human rights 2. Identify examples of health related human rights 3. Explain how human rights are protected by law 4. Explain the elements of the right to health (3AsQ) 5. Identify linkages between health and human rights 6. Discuss gender analysis at household and community levels 7. Identify factors that influence gender relations 8. Facilitate participation of both men and women in decision making process 9. Discuss patients‘ rights and responsibilities Part I HUMAN RIGHTS AND HEALTH 1 Introduction to human rights 2 Legal framework on human rights 3 The right to health 4 Human right analysis Part II GENDER 1 Introduction to gender issues 2 Basic gender concepts 3 Gender as social constraint 4 Factors that influence gender relations 5 Gender analysis at different levels  Household  Community  Health sector 6 Improvement of gender relations 7 Gender mainstreaming focusing on health planning process Methods:  Buzzing  Brain storming  Group discussion  Demonstration and - Role plays  Return demonstration.  Questions and answers HUMAN RIGHTS AND HEALTH Human Rights Sessions 1. Introduction to Human Rights - Definition - Characteristics - Examples of Human Rights 2. Legal Framework of Human Rights - International - Regional - National - Government Obligations 3. The right to health - Meaning - Links between health and human rights 4. Human rights analysis - Principles of Human Rights Based Approach(HRBA) - Application of analysis tool Introduction to Human Rights 1. Ask participants to explain what they understand by human rights.  Let each participant write his/her answer on a card provided.  Display the answer on a flipchart and explain. Definition of human rights Possible answers Basic rights and freedoms to which all humans are entitled According to the United Nations, all human beings are born equal in dignity and rights Emphasize on the following: - Human equality: All human beings are born equal - Human dignity: Human rights are founded on the dignity of human beings - Freedom: Human beings are expected to have a sense of judgment and are expected to exercise this judgment to enjoy civic and political freedoms 2. On their respective cards let the participants list four important characteristics of human rights. The answers should be on flip chart. Characteristics of human rights Possible responses Fundamental: Important to human survival, dignity and development Universal: Apply to everyone, everywhere Inalienable: Cannot be taken away from a person Indivisible: They are interrelated (closely connected) 3. Ask the participants to give examples of health related human rights. List the examples on a flip chart Examples of health related human rights Possible answers Right to life Right to health Right to food & nutrition Right to safe water Right to education Right to clean & healthy environment Note: All rights are interrelated therefore all human rights relate to health in one way or another Session 2: Legal framework of Human Rights Explain to the participants that human rights are legally protected. - List and explain the various legal instruments that protect health related human rights underthe following subheadings: - International - Regional - National Laws that protect health related rights International 1.Covenant on Economic, Social and Cultural Rights Article 12 (1) The States Parties to the present Covenant recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health. 2. Convention on the Elimination of all forms of Racial Discrimination 3. Convention on the Elimination of all forms of Discrimination Against Women Article 12 (1) States Parties shall take all appropriate measures to eliminate discrimination against women in the field of health care in order to ensure, on a basis of equality of men and women, access to health care services, including those related to family planning. 4. Convention on the Rights of the Child 5. Convention on the Rights of Persons with Disabilities Article 25 States Parties recognize that persons with disabilities have the right to the enjoyment of the highest attainable standard of health without discrimination on the basis of disability. States Parties shall take all appropriate measures to ensure access for persons with disabilities to health services that are gender-sensitive, including health related rehabilitation. Laws that protect health related rights Regional 1. African Charter on Human and Peoples’ Rights Article 16 (1) Every individual shall have the right to enjoy the best attainable state of physical and mental health. (2) States parties to the present Charter shall take the necessary measures to protect the health of their people and to ensure that they receive medical attention when they are sick. Laws that protect health related rights National Uganda 1995 constitution Directive Principles (non-enforceable preamble) XIV. General social and economic objectives. The State shall endeavor to fulfil the fundamental rights of all Ugandans to social justice and economic development and shall, in particular, ensure that— (b) all Ugandans enjoy rights and opportunities and access to education, health services, clean and safe water, work, Decent shelter, adequate clothing, food security and pension and retirement benefits. Chapter 4 (operative) Article 39.Right to a clean and healthy environment. Every Ugandan has a right to a clean and healthy environment. Government Obligations State and explain government obligations of human rights -Respect (refrain from violating Human rights for example no one should be denied health care) Respecting human rights requires governments to refrain from interfering directly or indirectly with the enjoyment of human rights. States have the obligation to work to ensure that no government practice, policy, programme or legal measure violates human rights, ensuring provision of services to all population groups on the basis of equality and freedom from discrimination paying particular attention to vulnerable and marginalized groups. Examples  refrain from prohibiting or impeding traditional preventive care, healing practices and medicines  refrain from marketing unsafe drugs and from applying coercive medical treatments. -Protect (prevent others from violating Human rights for example private clinics, pharmacies and drug shops should be regulated to ensure quality services, drugs and supplies) Protecting human rights requires governments to take measures that prevent third parties from interfering with human rights. Examples  Pre vent other actors in the field of health, for example pharmaceuticals and health insurance providers, from infringing human rights.  Ensure that privatization of the health sector does not constitute a threat to the availability, accessibility, acceptability and quality of health facilities, goods and services.  Control the marketing of medical equipment and medicines by third parties. -Fulfill (take measures necessary for the realization of Human rights for example government should allocate adequate resources for health services) Fulfilling human rights requires States to adopt appropriate legislative, administrative, budgetary, judicial, promotional and other measures towards the full realization of human rights. States have the obligation to take all appropriate measures — including but not limited to legislative, administrative, budgetary and judicial — towards fulfillment of the right to health, including the obligation to provide some sort of redress that people know about and can access if they feel that their health-related rights have been impinged by the state or non-state actors. Examples  Ensure provision of health care, including immunization programmes against the major infectious diseases.  Ensure equal access for all to the underly ing determinants of health, such as nutritiously safe food and potable drinking water, basic sanitation and adequate housing and living conditions.  Provide public, private or mixed health insurance system affordable for all. Explain the meaning of duty bearers (government and her agents including public servants and rights holders (human beings) Duty bearers is the government and her agents (civil servants/health workers) are the duty bearers They have the obligation to respect, protect and fulfil human rights Rights holders are all human beings. They own/hold the rights. They are expected to demand for their rights To do this they have to be empowered (informed/educated about their rights) Session 3: The right to health Ask the participants to explain what they think the right to health is. List the answers onto a flip chart 1. Explain the meaning of the right to health and then arrive at the definition Meaning of Right to health Possible responses The right to health  d oes not mean that people have a right to be healthy  is short for the "right to the enjoyment of the highest attainable standard of health", found in the Constitution of the WHO, Article 12 of the International Covenant on Economic, Social, and Cultural Rights and other international and regional human rights treaties  is a claim to a set of arrangements - norms, institutions, laws, an enabling environment that can best secure the enjoyment of this right  is an entitlement not only to access health ca re but also underlying social determinants of health  has deep historical roots. 2. Explain the elements of the right to health - The 3AsQ Definition of the right to health Possible answers It is the right of everyone to the enjoyment of the highest attainable standard of physical and mental health. 2.Explain the elements of the right to health(3AsQ) as below: Availability  Trained medical personnel)  Essential medicines Accessibility  Physical (distance and user friendly structures at the health units)  Financial/affordable  Non-discrimination  Health-related information Acceptability  Culturally e.g. people from an ethnic minority may not make use of their local hospital because the toilets are in the same building as the wards and this is incompatible with their culture  Medically e.g. patients should consent to treatment Quality must be good e.g. no expired drugs, client perceptions Group work -In small groups let the participants discuss the linkages between health and human rights -After the groups present their answers, explain the link between health and human right. Linkages between human rights and health Possible Reponses 1. Human rights violations can (and often do) have serious health consequences. Torture, female genital mutilation, and lack of access to clean water are all violations of basic human rights that can result in the spread of disease, as well as damage physical and mental health. 2. Health policies and programmes have the potential to either promote or violate human rights. For example, if governments track people living with HIV/AIDS for public health purposes, they must include carefully crafted confidentiality measures. If this is not done, the right to privacy may be violated which can result in stigma and discrimination in employment, insurance, and housing, or even to violence. 3. The health of all people is improved when human rights are respected, protected and fulfilled. For example, promoting the right to education may lead to better health, given that illiteracy is a strong predictor of health status. Education about condom use, nutrition, and hygiene also have obvious health benefits. Session 4: Human Rights Analysis 1.Explain to the trainees the principles of Human Rights Based Approach (HRBA) - Participation and inclusion Participation and inclusion = beneficiaries must be involved in developing, implementing health policies and programmes. The involvement should be free and meaningful (not mere consultation). - Equality and non-discrimination Equality and non-discrimination = health programmes should be designed and implemented so as to cater for all. The programmes should address the gender, racial, social and cultural differences. - Accountability (Transparency) Accountability (key to Health Management Committees) = duty bearers should be answerable to the beneficiaries of health programmes. They have to comply with human rights norms and standards. Scenario 1 On Mr. Musoke‘s return home, his wife asked him for some money to go to the health centre for antenatal care; but due to his poverty Mr. Musoke was not able to afford the fee of 5000/= and offered to ride his wife the following day, to the health facility for the antenatal care. On reaching the facility, Mrs Musoke is told by the midwife that antenatal clinic is only on Tuesdays not Wednesday the day they have reported. Mr. Musoke demands that they (health consumers) should be informed on the days of visitation for clinics. Mr. Musoke accepts to return the wife next Tuesday, on which day they reported but there were no prescribed drugs and HUMC members complain that they do not know where drugs go. Mr. Musoke went to the private clinic to buy drugs which, on arrival home, his friend warned him that they had expired. Ask the participants to list the health related human rights issues within the scenario Possible Answers Right to:  Access - Physical – distance to the facility - Affordability – ability to be able to pay for the services/goods  Availability – one may have money for the goods and the facilities may be near but the goods/medicines may not be available  Accountability and transparency - Participation and involvement o community not consulted on visitation days o health management committee not updated on issues of the facility  Quality – drugs in the private clinic were expired Patients’ Rights and responsibilities What are Patients’ Rights? Patient health rights are human entitlements for every body as a consumer of health services. Patients are entitled to certain rights and responsibilities that need to be observed and respected at all levels. The patients’ health rights that should be respected, include: Individual patients’ respect: Patients must have their lives, bodies and personality respected in the course of their treatment (humane treatment). The rights to receive equal treatment: A patient has the right to receive equal treatment irrespective of economic or social status, age, sex or type of disease. Rights to optimum treatment All Patients have a right to the best treatment and to request for any assistance and medical support needed. Furthermore patients have a right to select their own health workers and institutions where to be treated. Self determination Patients have a right to fully participate in selection of type of treatment and other necessary medical tests and interventions with the cooperation of the medical practitioner. Rights to privacy Patients have a right to privacy. Information about them should not be disclosed to other persons other than those or their own choice. Right to know/get information about their health All patients have a right to know all about their treatment i.e. full medical examinations and diagnosis so as to understand their health conditions, and to access information concerning their previous examinations. Participation and representation Patients have a right to be present/participate or be represented in planning and management of their health affairs. Redress and grievances Patients have a right to receive redress and a right to have grievances addressed by the health institutions. The right to die in dignity All patients have a right to die in dignity. The right to spiritual/moral comfort Patients have a right to receive or decline spiritual and moral comfort including the help or religious ministers from a religion of their choice. RESPONSIBILITIES OF PATIENTS What are Patients’ Responsibilities? Patients have responsibilities that are developed to enforce mutual relationships between health care seekers and providers. This is intended to change the current approach and relationships between the health providers and patients, because both have a common objective of quality healthcare for all. To create partnership therefore, it is important to emphasize active involvement of consumers in taking responsibilities in matters concerning their health. It is important to note that service providers also need to be supported and protected, therefore patients need to take not of their responsibilities. Patients have to fulfil certain obligations; therefore patients must: Provide accurate and complete information to health care providers about their health status. Patients have to be truthful when providing information on their current health status i.e. complaints, past illness, medical treatment obtained so far, hospitalization etc) Cooperate and comply on treatment given and follow-up actions Patients have to be committed to and to comply with the medication/appointments given to them. Fulfil financial and contractual obligations Patients have a responsibility to pay their treatment bills and not to default doing so. Understand the conditions, limitations and consequences in the process of seeking and provision of health care. It is a responsibility of the patient to take care to understand the procedures, medical decisions made, possible risks and required number of follow-up visits. Respect the rights and well-being of others (including health workers and other patients). Patients should be aware of the importance of respect for others‘ rights and those of health workers. Follow rules and regulations of the health facility Patients have a responsibility to value and follow common guidelines set up in each health facility. Avoid personal injury and harmful behaviour Patients should avoid drug/substance abuse, pollution, recklessness and other ways of personal injury and other forms of ill health. Support the health care system/institution Health consumers are duty bound to improve the health conditions of their communities like Hygiene and to contribute financially in order to sustain the health activities. Accept all preventive and curative measures sanctioned by law Patients should abide by the national recommended preventive and curative measures and emergencies or epidemics. Respect for public and personal property Patients should not destroy/or tamper with personal belongings, of others, those of the health facility and the environment. PART 2 GENDER Introduction to gender Ask participants to explain what they understand by the following concepts.  Sex  Gender  Gender roles  Gender analysis  Productive and reproductive activities  Gender stereotyping  Gender disaggregated data  Issues/concerns  Empowerment  Gender balances  Gender needs practical - strategic  Gender constraints  Gender blindness  Gender quality  Gender equity Gender Concepts Possible Answers Sex: Refers to the biological difference between men & women. Gender: Refers to social difference between men and women with variations between cultures. Gender Roles: Gender roles are learned behaviours in a given society, conditioning which activities, tasks and responsibilities are considered feminine and masculine. Gender roles are affected by age, class, religion, ethnicity regional origin and history. Gender Analysis: Is the systematic effort to document and understand roles of women and men within a given context. Productive and Reproductive Activities: Refers to a distinction made between productive or economic activities and reproductive or human resources maintenance activities. Gender Blindness: Gender blindness is the inability to perceive that there are different gender roles and responsibilities. Explain to participants that Gender refers to their roles, responsibilities, rights and limitations which societies and cultures ascribe to women & men. Activity 2: In a large group discussion ask participants to explain why gender is emphasised. Put answers on a flip chart. Possible answers: - Women were not given an opportunity in decision making. - Women had limited access to resources. - Women had limited access to developmental issues. - Preference of boy-child for Education. Solutions: - Bring the women on board. - Involve them in meetings - Give them responsibilities e.g. on Committees. - Encourage them to participate. - The men should appreciate the role of women in development. - Men to support women groups. - Complementary nature of gender based roles. - Men to share domestic chores with their wives. Conclusion - The women have no base in terms of resources to make decisions. - The man's roles are occasional. - Man has less roles Solutions: - Woman is fully occupied. Women are regarded as social objects. In many cultural settings they are part of the property of husbands. - Women have been socially groomed to be submissive. - Society has distinguished what is regarded as men‘s jobs/activities at all levels. Note - For the Health Committees to effectively function, women and men selected to represent communities must both participate in the decision making process. KEY ISSUES TO PARTICIPANTS: 1. It is very important to facilitate people to understand the "Why" of emphasising participation of women and men. This will facilitate the attainment of sustainable development. 2. Societal beliefs and stereotypes prevent men or women from participating/taking decisions despite the potential that they may have. 3 Individual women and men's views and attitudes should be respected if the health needs of men and women are to be addressed. 4. It is very important for change agents to start by establishing where the people are and build on what they have & know, so as to accelerate social economic progress. 5. Gender issues/relations are socially determined by a particular Community and can therefore be modified to suit the Community's development needs. Session 3: GENDER MAINSTREAMING (PLANNING PROCESS) Introduction: Explain to participants that:  Women must be given the opportunity to fully participate in all types of projects and programs from the health sector:  Women‘s interests should not be marginalized to minor projects or project components. Gender relations should be systematically integrated into planning, implementation and evaluation of projects and other developmental activities and lessons learned from such activities utilised in integrating gender concerns in all types of developmental activities. Solicit the following answer: 1. Because experience shows that any developmental activity planning which does not take into account gender specific differences in a society is likely to fail or be less efficient than necessary, because it tends to read mainly male members of the society. (a) Who should be responsible for ensuring that Gender concepts are included in the planning process. Solicit answer: - The committee leaders - Gender issues should be reflected in the health unit plan (b) At what point in the planning process is gender analysis needed? - At any stage of the project planning cycle for which gender-relevant information is needed. - Emphasise the need for collecting gender desegregated data. - Explain the relevance of conducting a gender analysis. Module 3 Community Diagnosis TABLE OF CONTENTS MODULE OVERVIEW Community Diagnosis is a process of learning about a community‘s health problems, needs and concerns. It is a punctual process, often done at the beginning and end of community – based work. Participatory programming is a cyclical process with four main steps:  Community Diagnosis  participatory planning  implementation of activities,  monitoring and evaluation. Participatory Programming Process Community Diagnosis Monitoring Participatory And Planning Evaluation Implementation of Activities • Health staff, health committee members, and community members use priority health and health-related problems identified during community diagnosis to plan activities that will reduce or eliminate the health and health related problems. This process is called participatory planning. • The health staff, Health Unit Management Committee, Subcountry Health Committee, Hospital Board and community members implement or start the activities they plan. • During monitoring and evaluating, the community measures the progress of the planned activities to make improvements regularly. • Monitoring and evaluation is a continuous process. • Some methods used during community diagnosis can be used in monitoring and evaluation. • The community, health committee and health staff try to solve the priority problems identified during monitoring and evaluation in participatory planning. Target groups: • All health committee members • Health staff • Formal and informal leaders and community members Learning Objectives: At the end of the session participants will be able to: 1. Define Community Diagnosis 2. Explain the importance of Community Diagnosis 3. Explain the steps in Community Diagnosis. 4. Explain data collection methods used in Community Diagnosis 5. Facilitate Community Diagnosis. Methods:  Interviews and conversations  Group discussion  Demonstration  Role play  Field trips  Record review  Observations Teaching materials - Assorted mapping materials - Pencils - Notebooks - Village health register - Ruler INTRODUCTION TO COMMUNITY DIAGNOSIS Definition of community diagnosis Community Diagnosis is a process of learning about a community‘s health problems, needs and concerns. It is a punctual process, often done at the beginning and end of community – based work. Importance of community diagnosis  The purpose of conducting community diagnosis is to learn with or about the community, its health and related problems, concerns, and priority needs.  Facilitate community diagnosis at the beginning of community-based work so that the health unit can better serve the community that uses it.  If you plan health and health related activities without facilitating community diagnosis, you may not meet the needs of the community. 2.3 Steps in Community Diagnosis a. Determine what information to collect along with the sources of information. b. Select data collection methods and prepare tools. c. Prepare for data collection. d. Collect data. e. Prepare/process data f. Present the findings during participatory planning. Step 1 - Determine Types of Information to Collect along with the Sources of information. Refer to step one on the community diagnosis flipchart. • Determine what information to collect about the community to help you plan health and health-related activities. Explain what health and health-related activities are. Let participants give the information they think is relevant to their areas of concern. Identify sources of information. • The health unit is a very good source of information about the community. • Review existing data from health unit files, records, population census reports, maps, project reports, etc. • Collect information from other sources such as individual households, local authorities, and community representatives (e.g., mothers, women's groups, community leaders). • The information you collect will depend on the reason why you are doing community diagnosis. • What type of information do you need to collect about your community to plan effective health and health-related activities? From whom or where can you get this information? When participants give you examples of data to collect, identify which types of data are quantitative and which types are qualitative data considers views, opinions and perceptions. Explain that qualitative information relates to one’s opinion. Quantitative data is usually expressed with numbers, proportions and percentages. Type of Information Meeting community basic health needs - people's health problems - people's needs in relation to identified problems. - how they would like to improve the health situation. - their interests and commitment to solving identified problems. - potential community resources that could be mobilized for health. Beliefs and values - how beliefs and values influence people's health Facilities and infrastructure - Community facilities (e.g., schools, churches, markets and drug stores) - water supplies - number of households with access to clean water - number of household with latrines and other sanitary facilities e.g. hand washing facilities, bath shelters etc. - means of transportation - number of households with access to health facility. (5km) - source of information like radio, news papers, Television Health Unit - amount of revenue generated over a period - expenditures for reported period update on drug prices, consultation fees Source of Information households, community, health unit records. households, community - health unit records Hints to the facilitator  Commitment is measured in budget allocation so in the Community you can try and find out what they have done.  As participants give you answers, you can draw another table with one side qualitative and another side quantitative.  The person who collects information should be the one to interpret it. Explain that participants will learn how to collect information from health unit records in later modules. Step 2 - Select Data Collection Methods and Prepare Data Collection Tools. Show participants the community diagnosis flipchart. Explain that they have just learned how to decide the types of information to collect and the sources of information. Remind participants that if information is available in the community, they should use it. Refer to the sources of information identified in step one. (a) What methods can you use to collect information from these sources? Make sure the following methods are mentioned. They will be discussed throughout the module and let each method be fully demonstrated and discussed. -informal interviews and conversations -group discussions -village mapping -census -records -Observation  You may need to use more than one method to collect information. Choose the method that is the most convenient and most appropriate for the type of information you collect.  There is no one person in the community who knows everything about his or her community. The more people you speak to, the more you can find out.  When you plan data collection, arrange to speak to as many people as possible. Informal Interviews and Conversations  Observation  Ask certain questions or discuss issues with one or two community members at a time.  Prepare a list of questions as your data collection instrument.  Ask open-ended questions instead of closed-ended questions. Note the key things/issues to be observed (prepare a list of things to be observed). Eg: - presence of latrine - presence of a door for privacy on the facility - cleanliness of the facility - sign of use of the facility - presence of hand washing facility - sign of use of the hand washing facility  Ask certain questions or discuss issues with one or two community members at a time.  Prepare a list of questions as your data collection instrument.  Ask open-ended questions instead of closed-ended questions.  What is the difference between open-ended and closed-ended questions?  What are some examples of each? Possible answers: - open-ended questions allow the participant to provide more of an explanation. example of open-ended question: "What do you think are some of the most serious health problems in our community?" - close-ended questions limit the participant's answer to a one- word response. example of close-ended question: "Is the health unit meeting your needs?"  Prepare the list of questions so that it will be easy for you to ask the questions and record the appropriate responses.  Interview as many people as possible. Work with the participants to demonstrate informal interviews and conversations 1. Ask for three volunteers to participate in a role play on data gathering using interviews and conversations. - One volunteer to carry out data gathering. - Two volunteers to play the role of community members. 2. Ask the volunteer who will collect data to role play how to use informal interviews and conversations. 3. Show the volunteer the following list of questions that he or she can use it to collect data. Questions for informal interviews and conversations -What are some of the most serious health problems in your community? -What are the most common or widespread health and health related problems in your community? -How would you like to improve your health situation? -How would you be able to participate in improving the health status of the community? 4. Ask the volunteers to role play for approximately 5 minutes. Explain that, in reality, the interview would last approximately 15 to 20 minutes. Do not interfere with the role play unless participants are doing something very wrong. 5. After the role play, provide constructive feedback on how the participant facilitated data collection. (c)What are some advantages and disadvantages of informal interview and conversation data collection method? Solicit responses. Possible answers: Advantages: - people feel comfortable/free answering questions - this is a good method for collecting information of the health needs of individuals. Disadvantages: - since this is not a brainstorming method, people may not be prompted for new ideas. - it could take a long time because only one or two people can be addressed at a time. -Costly and time consuming Group Discussions  The place to assemble for discussion should be neutral for the members and facilitator. • Assemble a group of six to ten community members. Ask them to discuss certain issues and concerns. • Facilitate the group discussion by asking one question at a time and allowing participants to respond individually. • Ensure that each participant has an equal chance to express his or her view. • Prepare a discussion guide. • Include the types of information you may want to collect and specific questions to ask on your guide. • During the discussion, you may want to use a separate pad of paper to record the participants' responses. Or, another team member can record the responses. Work with the participants to demonstrate how to conduct group discussions. 1. Ask for six to ten volunteers to participate in a role play on data gathering using group discussion. - One or two volunteers to carry out data gathering. Five to eight volunteers to play the role of community members. 2. Ask the volunteer(s) who will carry out data gathering to role play How to use group discussions to collect data on their community's - customer care to clients - awareness and satisfaction with health services - opinions on quality of health service - views on accessibility of health services - waiting time of clients at facility 3. Show the volunteer the following list of topics that he or she can use for group discussion. Topics to discuss during group discussions -Discuss awareness of health services: - family planning - outreach for immunization -Discuss satisfaction with services at the health unit - Ask for opinions on the quality of care received at the health unit - Discuss views on accessibility of health services 4. Ask the volunteers to role play for approximately 10 minutes. Explain that, in reality each group discussion can last one to one and half hours. Do not interfere with the role play unless participants are doing something very wrong. 5. After the role play, let participants give their views. What are some advantages and disadvantages of this data collection method? Possible responses: Advantages: - you can speak to more people at the same time through brainstorming, people might get ideas they otherwise might not have had - this method is good for getting information on quality of health services Disadvantages: -people might feel uncomfortable speaking in a group -it may be time consuming to organize Village Mapping • During village mapping, community members draw a map or create a model of their village. • Maps can be drawn either on the ground or paper. • Village mapping is fun and a useful way of getting many people involved in assessing their health situation. • Accuracy should not bog down the process. • Every member should be encouraged to participate. • Those who are able can start up the drawing of the map. Start by identifying the most familiar feature in the village, e.g. a main road, a river or a hill. Other features can easily be located in relation to the prominent landmark. (e) What type of information can you obtain from village mapping? Possible responses - basic population data (e.g. number of location of households) - people' s health (e.g. households with premature deaths) • Prepare a list of information for the community to map. • Prepare materials that participants will use to draw the map such as paper, pens, chalk and powder. • If participants will draw the map on the ground, decide how they will use the materials. For example, use different chalk colours to classify adults and children. • Do not interfere when community members are mapping. • Look, listen and learn! • Facilitate. Do not dominate. • After the community maps the information, record it on a piece of paper. Record the maper‘s names to give them credit for the contribution. Work with participants to demonstrate village mapping 1. Divide the participants into groups: One group will play the role of community members. These participants should be from the same village, if possible. One group will choose one or two volunteers to facilitate the village mapping. The rest of the group will observe the data collection. 2.Ask the volunteers who will facilitate village mapping to collect basic population data and information on the facilities and infrastructure in the participants' village. 3.Show the volunteer the following list of questions that he or she can use as a data collection tool: Examples of possible information to map - location of roads, markets, schools, churches - location of homes with latrines - water sources - location of health units 4. Bring participants to a location where they will role play village mapping. 5. Give participants the materials you prepared before training. Explain how to do the mapping. The main purpose is to display accessibility to available service. 6. Ask volunteers questions to role play village mapping for approximately 20 minutes. Explain to participants that, in reality, village mapping can last several hours, depending on the information to map. Do not interfere with the role play unless participants are doing something very wrong. 7. After participants map the information, ask the volunteer(s) who facilitated village mapping to total the information shown on the map. 8.Lead a plenary discussion: Ask the participants who observed the village mapping for their impressions on the approach, for example: - Did the facilitator allow the participants to map the data or did he or she dominate or interfere? - Did it appear that the participants could map the data without much difficulty? Provide constructive feedback on how the participant facilitated data collection. (f) What are some advantages and disadvantages of this data collection method? Possible answers: Advantages: - it will help people to visualize the community's problems and achievements - this method is good for collecting basic population data - you can involve many people Disadvantages: - organizing it may be difficult - it is time consuming. Census and Records • A census is a count of the entire population. It provides a denominator (total population). • Information collected is mostly quantitative, for example: - number of adults and children in the community. - number of males and females, including an age breakdown. - number of people by marital status. - other categories, religion, language, employment, education. • Prepare a questionnaire ahead of time. Specify the information to collect. • Since the census is going to involve the entire community make sure that all community members are aware of the day you will conduct the census. (g) What are some advantages and disadvantages of this method? Possible responses: Advantages: - it gives you a baseline data to which you can compare future information. Disadvantages: - it is time consuming to prepare and conduct. - It is costly - you may not be able to count everyone if the population is nomadic or transient. Some information can be obtained by reviewing existing data from health unit sub county files, records, population census reports, maps, project report, etc. PRACTICAL EXERCISE FOR SELECTING DATA COLLECTION METHOD Facilitator Instructions Read the following instructions to participants. Write or draw any instructions on the flipchart or board, as needed.  For this Practice Exercise, your group will identify the data collection method or methods that are appropriate for collecting certain types of information.  You will work in small groups to complete the Practice Exercise.  After everyone has completed the Practice Exercise, review the answers.  Let participants go back in their previous groups formed in step 1: Plenary Discussion Let one representative from each group fill in the methods on the already prepared sheet by the facilitator. Review participants‘ answers to the Practice Exercise Facilitate Community Diagnosis Show participants step three on the community diagnosis flipchart  Before you can collect the information from the community, make appropriate preparations by answering the following questions. - Make a pre-visit to the community to agree with the community leaders on the venue, date, target and what the community leaders can help in the data collection.  Community entry process is necessary for the researchers coming from outside the community. - Refer to the sample worksheet on the following page, if needed. - Discuss how to answer each question on the worksheet as follows: WORKSHEET FOR PREPARING DATA COLLECTION 1. Who has the information you want to collect ------- Women‘s Group ------- Youth Group John Mukasa (Community Leader) Nathan Okello (religion leader) Stephen Mwanga (VHT) member 2a Who in the community can help in data collection? Jane Akot (Community Leader) John Wako (teacher) Mary Acen (teacher) 2b How can they help? They can help by inviting the target populations to data collection. Mary Acen can help record people‘s responses during group discussions. Jane Akot can suggest additional people to involve 3. Where will data collection take place? church, outside health unit and at the market, house hold. 4. When will it take place? Church - first Monday next month in the evening outside health unit - first Tuesday next month in the afternoon market - first Wednesday next month at noon. 5. How will you inform the target group(s)? Announcements at church, health workers at health unit, community leaders. 6. What is the type of resources needed? paper pen/pencil, bicycle, motor cycle, vehicle 7. What is your source of Resources? Community, sub county, Developmental partner. 1. Who in the Community can help in data collection?  Identify who can help with data collection. How can they help? Solicit responses. Possible answers: They can: - suggest when and where data collection should take place. - suggest who should be involved. - invite the target population to participate. - help to make questionnaires, discussion outlines - help conduct informal interviews, group discussion, village mapping. - record people‘s responses during group discussion 2. Where will data collection take place? Discuss with participants possible locations where data collection can be carried out using the different methods.  Select locations that are convenient for interviewees and interviewers.  Locations should be free from distractions and conducive to the data collection method selected.  Possible locations for informal interviews: - Quiet area at or near the home of the interviewee/respondent.  Possible locations to conduct village mapping: - convenient place in the village, at a health unit or a school.  If you will use the ground to map, the area should be flat, large enough, and in good condition. 3. When will it take place?  The time you schedule for data collection should be convenient, for the targeted group. 4. How will you inform the target group(s)?  Use all available means to let people know where and when data collection will take place, for example: - ask health unit staff to inform patients - Ask community leaders to inform community members 5. What material Resources are needed?  Determine what resources you will need to conduct data collection. For example, newsprint, markers, chalk board and chalk used for group discussions: What material resources would you need to facilitate village mapping? 6. What is your source of resources?  Determine where to get your resources from Step 4: Conduct Data collection  At this stage facilitator prepares to take participants for field visit to collect data in an already identified community. • During data collection you may have to probe for specific information. For example: (a) during interviews with community members you learn that many children are dying from diarrhoeal diseases. Contact the health unit to obtain specific information on the number of deaths due to diarrhoeal diseases. (b) you may learn that 50 out of 200 people in the community are not satisfied with health services. To calculate the percentage of the population not satisfied with health services: 50 X 100 = 25% 200  A problem is in the gap between what is now and what should be. Make each problem as specific as possible, using terms like who, what, and how much. For example, ―people are dying of malaria‖ is not a specific problem. This could be stated more specifically as ―25 children died of malaria in 1995 in Rubongi Village with a population of 1,000 people.‖ You may need the assistance of health unit staff and health unit records to make the problems more specific.  After data collection – share experiences from the field. TIPS FOR SUCCESSFUL DATA COLLECTION Discuss the following tips for successful data collection: - welcome target groups and thank them for accepting to participate. - introduce yourself explain the purpose of data collection and how the information collected will be used. - encourage everyone to participate - reassure target groups that there are no rights or wrong answers - Listen without interrupting - do not ask lengthy questions - speak clearly Ask participants for additional tips  When you facilitate community diagnosis, you may have to probe for specific information. Step 5 ANALYSE AND INTERPRET DATA  It is important that conclusion be made from the information collected.  To do this you need to organize data to bring out the prevailing problems, improvements or changes in the situation and their magnitude.  Gather all information collected together.  Decide on how to categorize your information so that information on similar issues are grouped together e.g. by sex, age, problem areas etc.  Group information according to categories identified.  Summarize data under each category to establish some meaning. To do this you may have to add up some data and calculate percentages.  Compare data categories for differences, similarities, improvement etc.  List problems or improvements observed from the community diagnosis. (The elements of standards at their level must come out)  Some tips on how to analyze data should be given (summarization and interpretation and analysis data.) Step 6: Prepare information for presentation. After you decide what information to share with the community, determine how to present the information to the community.  Determine the clearest way to present the important findings to the community. Avoid mis-interpretation of the results.  The way you present the findings should depend on the intended audience. (h) What are some effective ways you have presented information to the community? Ask participants for example of when they would use each method. Possible answers: Possible answers: -pictures/drawings -role plays -statements -percentages - Pictures/drawings - to illustrate information, to draw a picture of a health unit with many patients waiting outside. - Role plays - to express information, to show how long patients are waiting at the health unit. - Statements - to provide acts, such as ―Only 20 households are using mosquito nets. - Percentages - to compare data, for ―At least 85% of the homes should have latrines. Only 10% of homes have latrines.‖ Example of How to Present Quantitative Data 85% should have latrines Show participants Show participants the following example of sample information collected from a community diagnosis, supported by health unit records: - Our medicine store does not provide good conditions for storage. - Community members live far away from a source of water supply. - Only one quarter of the homes have latrines. - 25 children have died of malnutrition during the year. - Many people complained that the health unit had too many patients and not enough nurses and doctors. - Most people are satisfied with the quality of care they receive at the health unit. - The roads are poor, making it very difficult to get to the health unit. - Only 10% of expectant mothers visited the health unit last year for prenatal care. - Many mothers do not know when to get their children immunized and many children are dying from childhood diseases. Ask participants to identify the most important information that they would share with their community. Ask them how they would present each of the important problems to their community (e.g. through pictures, role plays). Review steps of facilitating Community Diagnosis Before you introduce the Performance Check, briefly summarize the steps for facilitating community diagnosis and answer any questions. PERFORMANCE CHECK Facilitator Instructions Read the following instructions to participants. Write or draw any instructions on the flipchart or boards, as needed • You will work in small groups to complete the performance check. • You will prepare to conduct community diagnosis in your own community. • You will role play facilitating community diagnosis. • After you complete the role play, you will read case scenario that includes sample data collected during community diagnosis. • You will identify the most important problems to share with your own community during participatory planning. You will describe how to present the problems to your community. • Let the facilitator know when your groups has completed the Performance Check. • When all groups are ready, we will discuss the Performance Check. Divide the participants into groups of four. Participants should be from the same health unit. Ask the participants to let a facilitator know when they have completed question 3. Explain that a facilitator will give them instructions on how to do the role play. Although instructions for the role play are detailed in the Participant Guide, participants may have difficulty understanding the assignment. When participants are ready for the role play, carefully explain the instructions. Explain that during the role play they can either provide real data from their community, or make up data. Emphasize that participants should focus on the process of facilitating community diagnosis, not on the type of information they collect during the role play. Refer participants to the Observation Checklist in their Participant Guide. Ask them to use an Observation Checklist to evaluate each colleague facilitating community diagnosis. Explain the instructions. Ask participants to share their checklist responses after each colleague completes facilitating community diagnosis. Each person should receive a completed Observation Checklist from the participants in the group. Ask participants to begin the Performance Check. PERFORMANCE CHECK Do not begin the Performance Check until the facilitator has given you the instructions! Work in your group to complete the following: 1. You are preparing to conduct community diagnosis in your own community. - List at least eight specific types of information to collect in the following table. For example, ―location of the households with access to clean water‖ is specific; ―facilities and infrastructure‖ are not specific. - List the source(s) of information for each type of information listed. Type of Information Source of Information 2a. Identify the data collection method(s) you will use to collect the information you listed in the table. 2b. For each data collection method you will use, prepare the necessary tools in the space below. For example, if you are going to conduct village mapping, identify and collect the materials you will need. 3. Organize data collection by answering the questions in the worksheet below: Data Collection Preparation Sheet 1.Who is the target group for data collection? 2a. Who in the community can help in data collection? 2b. How can they help? 3. Where will data collection take place? 4. When will it take place? 5. How will you inform the targeted group(s)? 6. What material resources targeted group(s) 7. How much money is needed? See a facilitator for instructions on how to complete the following role play. Do not begin the role play until you have seen a facilitator. 4. Role play collecting data (a) Prepare for the role play (i) Decide who in your group will facilitate data collection first. The other participants will play the role of the target groups that you identified on the organize Data Collection Worksheet. (j) Refer to the information you listed in question 1 of this Performance Check. Each of you will select at least two pieces of information to collect. No one should collect the information as his or her colleague (b) Conduct the role play: use the appropriate tool or tools your group has prepared in question 2b of this Performance Check. Collect at least two pieces of information from your group. (c) Review the role play: 1. Complete an Observation Checklist for your colleague who facilitated community diagnosis. (Three checklists follow these instructions). 2. Provide feedback to your colleague on how well he or she facilitated community diagnosis. Give the completed observation checklist to your colleague. (d) Repeat steps b and c until everyone in your group has facilitated data collection. OBSERVATION CHECKLIST FOR (Name of participant who facilitated community diagnosis) Instructions: 1. The chart below lists the guidelines your colleague who is facilitating data collection should follow. Place a check mark [<] next to each guideline if your colleague met it. If he or she did not meet particular guideline or if the guidelines do not apply to the situation, do not check the column. 2. Use the comments column to make brief, specific notes about how the person facilitated community diagnosis. Include what he or she did well and suggestions for improvements. THE FACILITATOR COMMENTS 1. Welcomed participants and thanked them for participating 2. Explained the purpose of data collection and how the information collected can be used. 3. Encouraged everyone to participate 4. Reassured participants that there are no right or wrong answers 5. Listened to participants without interrupting 6. Did not ask lengthy questions 7. Spoke clearly 5. Read the case scenario below that includes sample data collected during community diagnosis. Answer the questions that follow. Case Scenario A group of health committee members, health workers and local leaders wanted to get a photograph of their community‘s health problems and priority needs. They facilitated community diagnosis. The group then referred to health unit records to support information collected from the community. The following are some results: Basic population data: - Health unit is serving a population of 5,000 people - Only half the population lives within 5 kilometres of the health unit Major community health problems: - 50 children under five died of diarrhoeal diseases during the year. - 10% of the population was treated for malaria during the year. - Half the children under five were malnourished last year. Facilities and infrastructure: - Most of the households do not have access to clean water. - Only 10% of the homes have latrines Health Services: Approximately half the people in the community are aware of family planning services. - Most people are satisfied with the quality of health services, but many complained about having to wait for a long time to see nurse. - Most mothers do not know which vaccines their children need and when they should be immunised. - It takes many people several hours to get to the health because of poor conditions. Answer the questions on the following page. 5a. Assume the results of the community diagnosis on the previous page were from your own community. Identify the most important problems that you would present to your community during participatory planning. Write your response in the space below. 5b. For each important problem you identify, describe how you would present it to your community during participatory planning (e.g. through drawings, role plays, statements, percentages). WHAT TO DO Let a facilitator know when your group has completed the Performance Check. Module 4 Participatory Planning TABLE OF CONTENTS MODULE OVERVIEW When a community is to begin community-based work, health committees, health facility staff and local leaders must learn about the needs and problems of the population the health facility serves. This timely process is called community diagnosis. Community based work is initiated and owned by the community. Health and health-related problems identified during community diagnosis are shared with the community during a process called participatory planning. During participatory planning, the community is involved in prioritising, analysing, and trying to solve the problems. In this module, participants learn how to analyse and solve the health and health- related problems they identified during community diagnosis and at the end of the module participants will be able to facilitate participatory planning. Target group:  All district health committee members or any committee at the district that handles health issues.  All sub-county Health Committee or any committee at the sub-county that handles health issues.  All health unit management committee members  All members of hospital Governing Boards LEARNING OBJECTIVES: At the end of the session participants will be able to: 1. Explain participatory planning and its importance. 2. Explain the steps of participatory planning. 3. Facilitate participatory planning. Sessions: 1. Introduction to participatory planning 2. Steps for facilitating participatory planning Methods:  Group discussion  Role play.  Demonstration MATERIALS  Pencils - one for each participant.  Notebooks - one for each participant.  Posters  Extra copies of all blank worksheets - one or two for each participant. Estimated length of the Module: 8 hrs Session 1 Introduction to Participatory Planning Explain to participants that:  Participatory planning helps the community and health staff to identify possible solutions to priority problems identified during community diagnosis and monitoring and evaluating.  It is the second step in the Participatory Programming Process. In participatory planning priority areas that need community action are determined, clear and measurable objectives are set and a workplan based on the objectives is prepared. Review of Participatory Programming Process discussed in the community diagnosis module. Community Diagnosis Monitoring Participatory and Planning Evaluation Implementation of Activities  The community makes decisions during participatory planning  Certain members of the health committee and health staff work as a team and facilitate the planning process.  Participatory planning provides additional information, if needed.  They agree on the criteria for constituting the Planning Team. Note: Health workers are part of the Community; they can guide in technical areas and are advocates for the community on policy issues. Through their reports they can make recommendations that can necessitate policy formulation. • Select a suitable location/venue for participatory planning (for example, the health unit, community centre, sub-county headquarters, school, etc). • Invite the community members who participated in community diagnosis and other community members, for example, women's groups, youth groups, religious leaders, community leaders, users of health services to attend participatory planning. Importance of participatory Planning Facilitator‘s instruction: Ask participants to brain storm the importance of participatory planning Possible answers:  Increases or crates awareness  Promotes self realization.  Creates ownership. (Things stop being theirs and becomes ours).  Creates sense of responsibility (members become protective)  There is commitment and  Improvement in health care provision. Session 2: Steps for Facilitating Participatory Planning Briefly explain the seven – steps of participatory planning process: Steps: 1. Present problems and improvements. 2. Prioritize the problems. 3. Develop an objective for each problem identified. 4. Identify possible causes of each problem to be solved. 5. Identify possible solutions for each problem. 6. Prioritize the solutions. 7. Develop a work plan. • The first step of participatory planning is to present the most important findings from community diagnosis and/or monitoring and evaluating and other sources of information to the community. • Work with the community to prioritize the problems. • Identify an objective that describes by how much each priority problem will be reduced or eliminated and by when. • Determine the possible causes of each problem the community will solve. • Facilitate the community to prioritise the problems and solutions because the community does not have enough resources (i.e.,. people and money) to carry out all the solutions it identifies at the same time. Select the most feasible one(s) to carry out. • Assist the community in developing a workplan for each solution. This will assist the community to carry out the solutions and meet the objectives. • Each workplan should contain – emphasise these key areas: - tasks to be done - resources needed to do each task - sources of resources - estimated date for completing each task - who is responsible for ensuring that each task is done. Step 1 - Present Problems and Improvements Refer to step 1 on the participatory planning filpchart. • The purpose of planning is to decide how to address problems identified. • The outcome of step one is a list of problems that the community will try to solve. • Present the most important findings on problems and improvements identified during community diagnosis, monitoring and evaluation. • While presenting the community with significant findings of the community diagnosis, monitoring and evaluation; it is important to lay emphasis of participatory planning on addressing problems bearing in mind Gender responsiveness. • Ask the community to identify additional problems that may have been missed either by community diagnosis or by monitoring and evaluation. Show participants an example of problems and improvements that can be presented:  Community members live far away from a health facility.  Only one quarter of the homes have latrine  The number of malaria cases has decreased Step 2 - Prioritizing the Problems 1 hour Show participants step 2 on the participatory planning flipchart.  To prioritize is to put things in a specific order according to certain reasons.  Facilitate Community to reach a consensus on their priority problems considering. - How common? - How serious? - What are the causes? - How much does it cost? - How long does it take to solve a problem? - How many resource persons does the community have? • Work with the community to decide how many top priority problems the community can feasibly try to solve now. • The community's decision will depend on: - how much money the community has to invest in solutions to the problems - how much time the community wants to invest in solving the problems. - how many and what type of resource people the community has. • Some problems may cost little money to solve and may require a minimum amount of effort by the community. • If the community decides not to solve all of the problems on the priority list, remind them that if the problems still exist at the next participatory planning session, they will be addressed again. In other words, the problems will not be ignored. Step 3: Develop an Objective 2 hours Show participants step 3 on the participatory planning flipchart. • Develop an objective so that you will know by how much to reduce or eliminate a problem. • An objective tells us what will be accomplished and by when. • It is very important that the community develops a realistic and measurable objective for each problem they plan to solve. • A realistic objective is one that is reasonable or practical to achieve. • A measurable objective is one that has results which can be evaluated and does not necessarily entail numbers.  Elaborate the process with the word Specific, Measureable, Achievable, Realistic and Time bound (SMART) Use Worksheet as a summary sheet for one top priority problem. Write the problem on the blank Worksheet. Ask participants to identify a realistic and measurable objective. Explain that the objectives will be revisited after the causes and solutions have been analysed. Step 4 - Identify Possible Causes of each Problem to be Solved 1 hour • How can you identify causes of problems? Solicit responses. Ask participants who have identified causes of a problem to explain the process they used. Ask: - Whom did you meet with to identify the possible causes? - What types of questions did you ask? • Work with the community members to identify all the possible causes of the priority problem(s) you are trying to solve. • Ask the participants to identify specific causes. For example, if a community member tells you that a possible cause to a problem is "many obstacles," ask him or her to explain the types of obstacles. • If participants are having difficulties in giving you possible causes, you may want to ask them if the causes relate to: - lack of resources (e.g. inadequate supply of drugs, equipment: insufficient funds or staff) - geographical conditions (e.g., poor roads, flood conditions) - insufficient time (e.g., health workers do not have enough time to manage a stock room) - people not willing to do what they are supposed to do (e.g., health workers do not want to manage a stock room because it takes them away from their job responsibilities) - people do not know what to do or do not have the skills to do what is needed (e.g. health workers do not know how to provide good storage conditions for drugs) - use a cause – effect analysis process. •When you identify possible causes, ask for technical assistance from the health staff, district health officer, and others (e.g. the community development officer, the water and sanitation officer). Refer to the completed Worksheet A as needed. • Refer to the problem and objective the participants identified. Ask participants for possible causes of the problem. Record their answers on the worksheet. Step 5 - Identify Possible Solutions 1 ½ hours Show participants step 5 on the participatory planning flipchart. • During step 4 of participatory planning, you and the community identified possible causes of each problem to be solved. • Help the community identify solutions that will reduce or remove each cause of the problems the community wants to solve. • Make the solutions as specific as possible for example concerning what will be done and where it will be done. • Tell the community to be creative when determining possible solutions. • Since identifying possible solutions is a brainstorming session, do not eliminate any solutions that a community member offers. • During the next step of planning, you will work with the community, health staff and other technical people to ensure that solutions are prioritized. WORKSHEET : A PROBLEM, OBJECTIVE, CAUSES AND SOLUTIONS PROBLEM: Our medicine store does not provide good storage conditions OBJECTIVE: By 1st June 2010 our medicines store will provide good storage conditions for medicines POSSIBLE CAUSES POSSIBLE SOLUTIONS The medicines are not kept in a secured stock room Use the back storage room at the health unit as a stock room The roof is leaking and causes water damage to medicines. Repair the health unit's roof It is too hot in the health unit to store the medicines use the back storage room at the heath unit as a stock room. Buy a fan for the health unit to reduce temperature. Buy special insulating roof materials to reduce temperature in the room Too many people have access to the medicines; some medicines are stolen Use the back storage room at the health unit as a stock room. Limit access to the drugs to one or two people at the health unit (e.g., pharmacist, health unit head) Practice exercise for developing an objective, identifying possible causes and possible solutions Facilitator‘s Instructions: Read the following instructions to participants. Write or draw any instructions on the flipchart or board, as needed. • For this Practice Exercise, divide the participants into small groups. • Ensure that each group selects a chairperson and a secretary. • Assign each group a problem from the list. • Ask each group to (1) Develop an objective. (2) Identify possible causes (3) Identify possible solutions  Ask participants to begin the assignment. Tell them to spend approximately 20 minutes.  After each group has completed the assignment, ask each group to present their work to the other participants. Ask the group if they can add to the list of solutions. Step 6 - Prioritize the Solutions Show participants step 6 on the participatory planning flipchart. • Prioritize the list of solutions because resources may not be adequate to implement all the solutions. • When you prioritize solutions, discuss the effectiveness of each solution with appropriate technical people (e.g., health staff, district health officer, community development officer, water and sanitation officer) according to the type of solution being proposed. • Rank the effectiveness of solutions in the order of the most achievable to the least achievable. • If the technical people decide that a solution is effective, work with the community to identify how feasible each solution is to be implemented. • Write all effective solutions on Worksheet B indicated below. Facilitate prioritization of the solutions based on the responses to the following questions. 1. Do we have the skilled people to carry out the solution?  Discuss with the community the skills needed to carry out the solution.  Discuss whether there are enough people in the community who have the skills to carry out the solution.  Develop data on or a pool of resource persons. 2. Do we have enough money to implement the solution?  Determine the resources needed to carry out the solution (e.g., materials, equipment).  Ask the community to consider whether they have enough money to implement the solution.  Is the community willing to spend the required amount of money on the solution?  Estimate how much the resources will cost. 3. Is the solution culturally acceptable? • Ask the community if they think the solution meets their cultural needs and standards. Work sheet B: Solutions in Priority Order 1. Limit access to the drugs in stock room to one or two people at a time. 2. Use the back storage room at the health unit as a stock room. 3. 3. Repair the health unit's roof. 4. Buy special insulating roof materials to reduce the temperature in the room. Practice Exercise for prioritizing solutions 3 hours Facilitator Instructions: • Let participants go back to their groups with improved list of solutions. • Assign an appropriate number of problems to each group for which solutions should be prioritized. Step 7 - Develop a Work plan Show participants step 7 on the participatory planning flipchart. • After you and the community prioritizes solutions, develop a workplan for each objective the community will achieve. • Complete a work plan to identify: - What to do to carry out each activity to achieve each objective (i.e., what tasks/milestones should be completed), - The resources you need to do each task, - By which date should it be completed? • Ask the community to estimate when each task should be completed. • All tasks should be done in time to implement the solution.  Work with participant to identify the date by which each task or milestone should be completed. Record the information on the blank Worksheet on the flipchart or board.  Who should be the person responsible? - If you do not specify who is responsible for making sure each task is done, the solution may not get carried out.  Refer to each task, resource, and time estimates listed on the worksheet.  Decide who in the health unit management committee or health unit will be responsible for making sure each task is completed. - This person will not necessarily be the one who does the task.  Work with participants to identify people in their community who will be responsible for each task/milestone. Record their names on the blank Worksheet on the flipchart or board.  Use the established pool / data of resource persons.  Use the Sub-county officers responsible for the health related operations e.g. Sub – county accountant and Sub-county chief who is the accounting officer at the Sub-county. Practice exercise for developing a workplan 3 hours Facilitator Instructions Read the following instructions to participants. Write or draw any instructions on the flipchart or board, as needed. For this Practice Exercise, your group will develop a work plan for one of your top priority solutions. • You will work in the same groups as in the previous Practice Exercise. • Select a person in your group to facilitate developing a work plan.  Ask participants to get into their groups.  Have participants refer to Worksheet C. (quote the page)  Tell participants to write the solution for which they will develop a work plan in the top section of the worksheet.  Ask the groups to begin the assignment. Tell them to spend approximately 20 minutes developing a work plan.  After each group completes the assignment, ask them to present their work plan to the other participants. Ask the group how to modify the work plan, if necessary.  Discuss any difficulties participants experienced.  Refer to Worksheet on the flipchart and explain that the work plan can be written on the worksheet. Ask participants to refer to Worksheet C.  What needs to be done? - List all the tasks to be done to carry out the solution. - Rewrite the list of tasks on the worksheet in the order in which they should be completed.  Work with participants to identify tasks or milestones of the top priority solution. Refer to sample Worksheet as needed. Record the information on the blank worksheet on the flipchart or board.  With what resources? - Identify the main resources you need to meet each task or milestone. Do not be too detailed. - You may need to purchase some resources. Other resources may already be available at the health unit or in the community.  Work with participants to identify the resources needed.  Record the information on the blank Worksheet on the flipchart or board. WORKSHEET : C WORKPLAN SOLUTION: Use back storage room of the health unit for the storage of medicines (e.g. stock room) What needs to be done? By which date should it start? By which date should it be completed Who should be the person responsible? With what resources? Source of resources 1. Clean out storage room. 1 February 2020 Malcom Unanyo Cleaning supplies 2. Paint storage room. 15 March 2020 John Mashuka 2 cans of white paint. 2 brushes 3. Buy and install shelves for medicines 15 April 2020 Ekinaidhanga Farouk 2 shelving units box of 50 nails 2 hammers 4. Buy and install a lighting fixture 30 April Mutemo Charles 1 light 2020 fixture and bulbs 5. Install lock on storage room door 15 May 2020 Kadome Alex 1 lock with two sets of keys 6. Store drugs in new stock room according to expiration dates 1 June 2020 Adong Mary PERFORMANCE CHECK 1 Facilitator Instructions • You will complete the Performance Check with the group you worked with during the Facilitate Community Diagnosis module. • Your group will pair up with another group in the training to role play facilitating participatory planning. • The groups will try to solve the most important problem(s) your group identified at the end of the Facilitate Community Diagnosis module. • Each group will take turns facilitating all participatory planning steps. • Let facilitator know when each group has completed the Performance Check. • When all groups are ready, we discuss the Performance Check.  Ask the participants to get into the same groups they were in during the Facilitate Community Diagnosis module.  Make sure those participants who did not complete the Facilitate Community Diagnosis module are in a group with persons who have completed that module.  Assign two groups to work together for the Performance Check.  When all groups have completed the Performance Check, assemble participants for the plenary discussion.  Refer to the following pages which show the Performance Check exercise in the Participant Guide. PERFORMANCE CHECK 2 Do not begin the Performance Check until the facilitator has given you the instructions! Your group will work with another group in the training course who is playing the role of community members to complete the following: (a) Prepare for the role play: 1. Take out the Facilitate Community Diagnosis module. 2. Refer to the important problems you identified in question 5b of the Performance Check. 3. Describe which group will present its findings first. (b) Conduct the role play: 1. Present important findings from the Performance Check of the Community Diagnosis module to the group which is playing the role of community members. 2. Ask the group to identity at least two additional problems that are important in their community. ( c ) Work with the other group to complete the following steps: 1. Use Worksheet A to prioritize the problems identified in the steps. Identify the priority problem the group will try to solve. 2. Develop one objective for the highest priority problem. Write the problem and objective on Worksheet A.(indicate page) 3. Identify at least two possible causes of the priority problem. Write the causes on Worksheet B. (indicate page) 4. Identify at least one solution for each cause listed on Worksheet B. 5. Prioritize the solutions. Decide which high priority solution (s) to implement and approximately how much they will cost. 6. Use Worksheet C to develop a work plan for the highest priority solution. (d) Change roles and have the other group complete step b. Plenary Discussion After each group has successfully completed the Performance Check, encourage participants to ask questions or share any observations, problems, or concerns they experienced in completing the Performance Check. Discuss the difficulties that you noted participants experienced during the Performance check. Ask participants questions such as: • What was the most difficult part of the participatory planning process? • Have you had any difficulties with facilitating participatory planning in your community that this training did not address? • What obstacles may you face when you facilitate participatory planning in your own community? • During participatory planning, work with the community to plan activities to solve the major community problems identified during community diagnosis and monitoring and evaluating. • Prioritize the problems, since the health unit may not have enough money to solve all the problems the community identified. • Identify an objective that describes by how much each problem will be reduced or eliminated and by when. • Work with community to identify the possible causes of each problem to be solved. • If you and the community understand why a problem exists, you can identify solutions which will reduce or eliminate the causes. • Prioritize all possible solutions since the health unit and community may not have enough resources to carry out all the solutions. • Prioritize the solutions by answering these questions: - Do we have skilled people to carry out the solutions? - Do we have enough money to implement the solution? - Has the solution a positive impact on existing services? - Is the solution culturally acceptable? • To ensure that the community implements each solution and meets the objective, develop a work plan for each solution. • Each work plan should contain: - what to do to carry out the solution - the resources you need to do the task - the date each task should be completed - who is responsible for ensuring in that each task is completed.  Discuss with participants your expectations of how they are to perform back in their community.  Discuss how and when participants will go to the community and practice facilitating the participatory programming process.  Conclude the module with positive comments about how participants performed, expectations of how they are to perform back at the health unit, and a summary of the major points of the module: HUMC members Health Unit Procedures Screen Baseline first Interview second Interview third Interview fourth Interview fifth Interview Recruitment screening form X Consent form for study entry X performance measurements X X X X X X capacity needs assessment from selected HUMC X X X X X X Hospital performance indicator measurement X X X X X X development of baseline tools X X baseline assessment of the HUMC members and the health units X X X Intervention HUMC Members in the intervention arm/group identifying needs of HUMC members X X Support HUMC members with capacity needs X X X X X Review of performance and capacity every 3 months X X Qualitative interviews on the impact of the interventions X Appendix VII : Summary of intervention procedures Appendix VIII : Map of Uganda Showing Regions Image result for map of east central uganda 2017 Map showing districts in East and Central Uganda.jpg Appendix IX: Approval of Proposal by Kenyatta University Graduate School Appendix X: Research Authorisation Appendix XI : Kenyatta University Ethical Review Appendix XII: Nsambya Ethical Review Committee Approval Appendix XIII: Clearance by Uganda National Council for Science and Technology