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


Perform2Scale is 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 is helping 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 PERFORM project developed a district MSI using action research cycles aiming to improve the health workforce and service delivery in three African countries (Ghana, Uganda and Tanzania).

The evaluation of the PERFORM project demonstrated that the MSI is effective in enabling district-level, health management teams to improve health district management based on local evidence, solve workforce performance problems and improve service delivery. The MSI will now be scaled-up in Malawi, Ghana and Uganda through the PERFORM2Scale programme.

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

KIT, together with the research partners, is responsible for the project’s context analysis and process evaluation. The context analysis focuses on understanding the context of each country where scale-up will take place, with a focus on their political economy. In particular, we aim 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 will assess which factors influence the implementation and scale-up of the MSI. Overall, the process evaluation will contribute to a better understanding of how scale-up takes place and by what and who this process is influenced. This knowledge is not only relevant for the scale-up of the MSI, but also for the scale-up of other, similar interventions. By improving the chances of a successful scale-up, we also help 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.

During implementation and scale-up, continuous data collection will take place as part of the process evaluation. This will enable the MSI to be responsive to the challenges and opportunities that will be faced during the scale-up phase. Concrete recommendations will be developed on stakeholder involvement, capacity strengthening or adaptations in the broader implementation and scale-up. This aims to improve the likelihood of success in the scale-up of the MSI.