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Perform2Scale: Contributing to Universal Health Coverage in Ghana, Malawi and Uganda

Perform2Scale was a five year research project designed to develop and evaluate a sustainable approach to scaling up a district-level Management Strengthening Intervention (MSI) in Malawi, Uganda, and Ghana. Through context analysis and process evaluation, KIT Royal Tropical Institute helped the scale-up of the MSI to respond to different and changing decentralised contexts across these countries.

Improving the health workforce and service delivery to achieve Universal Health Coverage

A critical challenge in global health is to achieve Universal Health Coverage (UHC) by 2030. This means that worldwide, all individuals and communities can obtain the health services they need without suffering financial hardship. An adequate workforce is essential for the achievement of UHC. The PERFORM2Scale project developed a district MSI using action research cycles that aimed to improve the health workforce and service delivery in three African countries (Ghana, Uganda and Tanzania).

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How to improve the chances of a successful scale-up?

KIT, together with the research partners, was responsible for the project’s context analysis and process evaluation. The context analysis focused on understanding the context of each country where scale-up was meant to take place, with a focus on their political economy. In particular, we aimed to generate a clear understanding of the relevant power relations, including how decisions are made, and the people and factors that influence these decision-making processes.

During the process evaluation, we assessed the factors which influenced the implementation and scale-up of the MSI. Overall, the process evaluation contributed to a better understanding of how scale-up takes place and by what and who this process is influenced. By improving the chances of a successful scale-up, we also helped to increase access to quality health care and UHC.

“The Perform2Scale approach is very important because service delivery depends on the availability of a number of key factors including human and financial resources. Empowering of the human resource can assist in service delivery, because you can have the human resource and the financial resources but if the human resource doesn’t have the capacity then the service delivery will be poor”
Member of Local government, Malawi

Responding to changing and decentralised contexts

KIT is providing concrete recommendations for the scale-up strategy in the form of several reports.

Based on the findings of the initial context analysis, recommendations were formulated to ensure that the MSI implementation and scale-up is suitable to the unique context of each country. For example, the context analysis conducted for Malawi and Uganda demonstrated the importance of involving the district council and/or district assembly in the scale-up process. This is due to their increased power in district health decision-making as a result of decentralisation.

The project met with mixed success in the three countries. In Malawi and Uganda, the scale-up strategy was adopted at the highest level. However, in Ghana, it was concluded that the absence of clear steps in implementing the strategy resulted in a less desired outcome.

Success was dependent on a few factors: shared vision, champions, taking a flexible approach, and context. These were determined because of the use of a comparative study approach to the research and validation of data from the country teams.

See also



  • Applied Research & Knowledge Management

    As a knowledge institute KIT Royal Tropical Institute compiles, analyses and develops new knowledge about health systems, sustainable economic development and gender, and supports others in using this knowledge for sustainable change.

  • Monitoring, Evaluation & Impact Assessment

    Monitoring, evaluation, and impact assessment are powerful tools to assess health, social, and economic impact. They allow us to learn what works and why. Our expertise and track record in these areas make us well-equipped to evaluate your work.