Journal of
African Studies and Development

  • Abbreviation: J. Afr. Stud. Dev
  • Language: English
  • ISSN: 2141-2189
  • DOI: 10.5897/JASD
  • Start Year: 2009
  • Published Articles: 220

Full Length Research Paper

Performance management and health service delivery in the local governments of Uganda

Malowa Davis Ndanyi
  • Malowa Davis Ndanyi
  • School of Management Sciences, Uganda Management Institute, Kampala, Uganda.
  • Google Scholar


  •  Received: 06 February 2019
  •  Accepted: 05 September 2019
  •  Published: 31 October 2019

 ABSTRACT

Today, many African countries are faced with enormous challenges of health service delivery; one of the arguments advanced for the persistent health service delivery malaise is the inadequate management of the health sector human resource. It should therefore be noted that performance management in the health sector has been paid lukewarm attention by both health resource managers. Performance management has increasingly become a prominent public sector reform in most of the developing countries given the fact that the people resource is a proactive resource in most of the organizations. The paper used a case study as a methodology. The major findings were that performance management can be improved by the use of performance contracts and the revitalisation of the rewards and sanctions framework to staff in the health facilities. The paper unravels the influence of performance management to health service provision in Uganda.

 

Key words: Performance management, health service provision.


 INTRODUCTION

Health Service Provision is globally a function of the state given its contribution to human livelihood. Many countries globally have attempted to provide intervention in health service delivery through a number of reforms such as privatisation, decentralisation and performance management initiatives (Lutwama et al., 2013).
 
Performance Management is a pivotal unit of human capital management that facilitates the effective and efficient utilisation of an organisation’s valued resources. Performance Management is an on-going process that endeavours to solicit, classify and upgrade the performance of people or groups of persons through alignment and re-alignment of the work processes of employees  to  match   with   the   set    out   organization strategic goals. Performance Management has been attributed to possessing three cardinal typologies, which include strategic, administrative and enhancement. Strategy in this sense attempts to provide the nexus between the individual employee’s output and the organisation’s set strategic goals. The administrative phenomenon utilises the information asymmetry, available to make valuable decisions on the performance of individual workers such as pay decisions, leave decisions and working environment ergonomics. The enhancement typology, on the other hand invests the performance management function to study the employee to establish his/her strength and weaknesses and recommend possible   employee    development    strategies for an organization.
 
 
Tobias and Peter (2009) argues that performance management thrives on three fundamental stages, namely; performance planning, performance monitoring and performance evaluation. Performance planning is the most critical stage because if things go wrong at planning then the two stages cannot function effectively. It is expected that at the beginning of each planning period, each employee together with his/her appraiser agree on the performance plan. The second stage is performance monitoring. Under performance monitoring, the employee is expected to keep tracking the plan together with her/his supervisor weekly, monthly and quarterly on the progress of work. The last stage is performance evaluation, where both the appraiser and appraisee meet to evaluate the performance of the employee by determining the specific scores for the performance of the employee in a specific period of time (Tobias and Peter, 2009).
 
Smith (2002) argues that for performance management to be effective, six (06) important principles must be observed as follows: transparency, consistence, proactiveness, responsibility, balanced, and proportionateness. Under transparency, there is need to establish clear parameters to be used during the process of performance management, there is need to match the set out objectives and the overall goal of the organization that is consistence. Proactiveness requires organizations to track performance challenges in time and be able to mitigate the challenges as they appear. Under responsibility, it is imperative to set objectives which must be met to the expectation of the citizens who are the consumers of the health services. A good performance management system should be balanced in order to ensure aspects of quality, safety and coherency are observed.
 
Finally, there is the principle of proportionateness. This calls for consideration of local needs and requirements, performance measurement should be based on what a particular community needs and how their community needs can be addressed in terms of health care provision.
 
Performance management in the health sector
 
In an attempt to define performance management, the words will be defined separately.
 
What is performance?
 
Performance can be defined as the process of planning the value creation and taking action to control value creation, however, in terms of health care, performance should focus on health care, financial strength, health care operations and health care people development and finally health care patient satisfaction (Tobias and Peter, 2009).
 
What is management?
 
Management is the act of conducting, supervising, planning, controlling, organizing and budgeting for an organization with a view of achieving the organization’s desired goals?
 
What is performance management?
 
Performance management is a notion borrowed from the management literature that has only recently been adopted in the health service delivery field. It is a strategic and integrated approach to delivering sustained success to organizations by improving the performance of the people who work in them and by developing the capacities of individuals and their teams to ascertain their immense contribution (Armstrong and Baron, 1998).
 
Overall objective of the paper
 
The objective of the paper is to interrogate how performance management can improve health service delivery in the Ugandan District Local Governments.
 
Research questions
 
The paper is guided by the following research questions:
 
(1) Can staff performance contracting improve health service delivery in Ugandan Local Governments?
(2) Can enforcement of the rewards and sanctions framework transform health service delivery in Uganda?
(3) What are the critical challenges facing performance management in the health service delivery in Uganda?
 
Despite the fact that Uganda has adopted a number of performance management reform initiatives in the health service delivery facilities in the last decade such as result oriented management (ROM) framework, rewards and sanctions framework, digital check in and check out system, performance contracts for all heads of units/divisions, integrated personnel and payroll system (IPPS), and balanced score card framework, little or no significant output has been registered (Transformation Paper: MoPS Uganda, 2011). This paper therefore unravels the strategies that can be utilised to improve performance management in the health delivery facilities.
 
Theoretical review
 
A number of theories have been advanced to explain performance management and health service delivery.  This paper is premised on the Principal-Agency theory as reviewed in the following.
 
Principal-Agency theory
 
The Principal-Agency theory presupposes that the owners of the business are the principal. The managers, who do the day-to-day management of the business or company, are the agents. In the public service, the citizens are the principal and the government is the agent. The rationale is that the principal leaves the agent to take charge of the business (service provision) on its behalf because most times the agent has more information and skills about the management of the business (Lane, 2000).
 
There is a clear relationship between the principal and the agent. The principal serves the interests of the agent. The principal is expected to put up mechanisms to monitor, supervise and control the actions and inactions of the agent. It is argued that over time the cost of supervision and monitoring the performance of the agent can be high and difficult to achieve and hence the agent is left to work independently.
 
It should be noted that the Principal-Agency theory attempts to explain the notion of public sector reforms (PSRs) which were designed with the intention of transforming public sector management through various approaches such as performance management, decongestion, and contracting-out. In addition, the Principal-Agency theory explains the variation in the behaviour or decisions when demonstrated by group members. Specifically, it explains their differences in behaviour or decisions by noting that the two parties often have different goals and, independent of their respective goals, may have different attitudes towards risk.


 LITERATURE REVIEW

Key sub-themes under performance management and health service delivery will be discussed in following.
 
In terms of definition, performance management is both a strategic and integrated approach to delivering sustained success to organizations by improving people performance who work in them and by developing the capabilities of individual contributors and teams. Performance management is strategic in the sense that it is concerned with a business broader issues to enable it to function effectively in its environment and the general direction it intends to go to achieve long-term goals.
 
Simply put, performance management is viewed as the way work is organized to achieve the best possible outcomes. From this simple viewpoint, it is not a system or technique but the totality of everyday activities of managers. In this sense, performance management approach to creating a shared vision of the purpose and aims of the organization helping each individual employee understand and recognize their part in contributing  to   them,   and   in  so  doing,  manage  and enhance performance of both individuals and the organization.
 
To carry out performance management in the public sector, the commonest approach to use is the staff appraisal tool. However, in practice the focus has more often been geared away from performance towards behavioural issues. For many years, traditional approach to staff appraisals relied heavily on the interaction between a supervisor and the person appraised and the outcomes of appraisal interviews were considered confidential, even the appraisee did not know the outcome of the appraisal. Although personal interaction is highly desirable in any performance management system, it does not per se facilitate the necessary integration and matching between individual and service or organizational objectives. In the 1980s and 1990s, many organizations still attempted to improve performance and service quality by ensuring staff compliance to objectives set at the top that are cascaded down various organizational layers (Boland and Fowler, 2000). In the past, the rationale for appraisal was that the “manager knows best” and that quality and performance management should be left to the mangers because they were largely managerial responsibilities. Today, few performance-oriented and quality-oriented organizations operate in this manner (Ibid).
 
As a public sector reform, performance management has a bearing on the delivery of health services. It should be emphasized that performance management strategy is neither about establishing a top-down appraisal system neither is it a method of generating information for pay or management decisions. It is a strategic process because it is forward-looking and developmental. It is a framework where managers can support their members rather than dictating to them. The impact of performance management will only be much more significant if it is regarded as transformational rather than as an appraisal process.
 
Accountable public institution is one of the other key sub-themes on performance management under a decentralized health service. Norman in Olum (2004) postulates that “the rationale for measuring performance is varied and includes the principle of accountable public institutions to ensure that money has been spent as agreed and in accordance with procedures and efficient use of resources”. That, to operationalize accountability, there is a need to establish how money was spent, comparing costs to ensure efficiency, relating effectiveness to intended objectives and outputs, and provision of equitable services.
 
The other sub-theme on performance management is with regard to the measurement of people responsiveness to change. Olum (2004) asserts that power of performance management is expressed in the slogan which states that “what is measured gets done”. This slogan is significant because measuring makes employees’  responsiveness   regarding   changing   their values in their organization accountable to the public about their service expectations.
 
In fact, in performance management, measurement is an important concept simply because it is the basis upon which feedback is provided and generated. In addition, measurement identifies where things are going well to provide the foundation for building further success as well as indicating potential problem areas for corrective action to be taken. In general, measurement provides the basis for answering two fundamental questions. “Is what is being done worth doing? and has it been done well, or if not well, why?” (Ibid).
 
High employee performance is another sub-theme related to performance management. Performance is about behaviour and should be distinguished from other outcomes because they can be controlled by systemic variables outside the control of the performer. Here, the implication is that performance measurement can only focus on an individual’s or group’s eventual output, if and only if, systemic factors can be controlled. This is why the overall precise impact of high performance management on employees remains enigmatic. They argue further that the research undertaken ultimately pulls upon a diverse set of organizations in a myriad of settings within the high performance management may be more or less compatible.
 
The other sub-theme on performance management is close relationship between management and staff and the action on appraisal results by managers. In other words, performance management requires close proximity between management and staff as well as the managers’ ability to act on the appraisals’ results. Unfortunately, local decision-making powers is often absent from health system (World Health Organization, 2001). Thus, decentralized health service is an essential prerequisite for performance management as is the need to avoid unnecessary bureaucracy when dealing with the results of performance appraisal.
 
In most developing countries, performance manage-ment systems suffer from numerous limitations, namely, information flaws, poor record keeping, lack of up-dated work schedules, overly formalistic communication systems, and limited or no feedback mechanisms. On the other hand, performance management systems are likely to contribute to improved system designs that focus on identifying aspects relating to performance in order to effectively address them (Martínez, 2001). Research studies across developing countries for health delivery reveal that most health units do not offer career advancement opportunities for their staff. However, when health workers are promoted they eventually get motivated and become enthusiastic about their work performance and appraisal system. As part of the feedback on performance appraisal, most health workers in Uganda indicated that they were trained in order to enhance their work-related performance. In addition, they observed that training needs assessment (TNA) had been   conducted   through   the   performance   appraisal system and some health workers agreed that they were part of this process. Training and development opportunities are normally identified by supervisors with the help of performance appraisal feedback. At times, however, the funding of these activities is quite difficult due to the inadequate budgets most of the health units suffer from (Armstrong and Baron, 1998).
 
Performance management is a key function of a vibrant system, it should be professionally displayed with key principles guided by objectivity, professionalism, consultation, openness, and result orientation. Some studies (World Bank, 1999) have alluded to the fact that the use of performance contracts has greatly improved workers’ performance in the health sector, since most of them are expected to agree on targets and the renewal of their contracts would largely depend on the achievements of the targets set. Incidentally, the use of performance contracts has not achieved its intended objectives given the fact that there is high labour turnover among the health workers.


 METHODOLOGY

The study used a case study design because it provided greater insights and understanding of the dynamics of a specific research situation which is prompted by the researcher and his or her research problem. A case study design is advantageous because it allows the researcher to see beneath the responses of the respondent specifically the case study design provided an opportunity for intensive and extensive analysis of specific characteristics such as behaviour, opinion, beliefs and knowledge of respondents in relation to performance management and how it influences health service delivery.
 
The implication here is that when you use the case study design, the researcher is able to realise in depth personal and detailed information from the investigation. The study used a mixed methods approach which is commonly known as triangulation. This method was very appropriate to the study since it helped to utilise the most appropriate methodology at specific points in the research undertaking hence making it effective during data collection and data analysis. The study largely used the qualitative methodology, however, quantitative methodology was minimally used to compliment the qualitative approaches. The quantitative approaches were utilised especially in the analysis of performance management reforms in the health sector during the verbatim recordings of the responses.
 
The sample selection at the District Local Government was non-random using purposive sampling from the heads of units and senior staff at health centre III. The key informants were purposively selected because they are knowledgeable and experts in their fields of specialisation.
 
Five (05) officers were purposively selected from each sub county to participate in the study. Ten (10) sub-counties were used in the study. The following officers were purposively selected, Local Council three III, Chairpersons, Clinical Officer In-Charge Health Centre III, Nurse In-Charge, Sub-county Chief, and the Sub-county Heath Assistant.


 FINDINGS

The paper discusses the research questions following analysis of primary data subsequently.
 
Table 1 shows that the majority (80%) of the respondents are aware that there is a functional performance management system in the health service facilities in Uganda. It is clear that health workers at all levels are involved in the performance appraisal process. All government institutions are involved in the process of performance appraisal right from the lowest to the higher officer in the health facilities. It is also clear that no health worker can be confirmed in his or her appointment unless he or she has up-to date performance appraisal forms for at least two sets, that is, a minimum of six months with assessment of three (3) months each. One Key Informant (KI) observed that: Performance appraisal in the healthcare facilities goes on like in any other public service institution using the same calendar that follows a normal financial year for staff who are confirmed in their appointments. For those on probation, they are supposed to be appraised after three months so that by the time they have completed six months they have two sets of appraisals done on a three monthly basis. The appraisal has four important stages: (a) performance planning which is carried out in one of the last month of the preceding financial year in preparation for the following financial year; (b) secondly, there is performance monitoring. This is the continuous assessment of the employee to ascertain whether he or she is on course. (c) Then, there is the performance assessment. This is done periodically but finalized at the end of the financial year; it must be completed by the second week of July each year. (d) Lastly, there is the performance improvement plan. This comes after the appraisal process has been completed and the health workers agree on areas that need   intervention  either  through  training  or  any  other form of capacity enhancement.
 
Table 2 shows that the majority (80%) of the respondents agree that performance management is weakly linked to the rewards and sanctions framework. For performance management to have a direct linkage with the rewards and sanctions framework there is need to systematically utilize the reports of the appraisal process in a more elaborate manner by summarizing the key issues and then identifying action points. Some of the recommendations could be to intervene through short-term or long-term training, a mentoring session or an attachment. The other recommendations could be rewards for good performance in form of a certificate, a handshake, the 13th cheque, a holiday for a staff and family or sanctions could be a warning, reprimand or dismissal from the public service, demotion, and reduction in salary, or appearing before a Rewards and Sanctions Committee to explain one’s defence if any.
 
Table 3 illustrates the respondents’ opinion on whether the use of performance contracts is necessary for accounting officers in healthcare institutions. The majority (70%) of the respondents agree with the view that accounting officers in healthcare facilities should use performance contracts. Performance contracting is a management tool where performance targets are set at the beginning of the assessment year and the assessment is done at the end of the assessment period (Financial Year). The performance is monitored throughout the year specifically during quarters 1, 2, 3, and 4. At the end of the financial year, there is a detailed assessment of the officer in line with the performance targets that were set out at the beginning of the financial year.
 
 
The respondents observed that Accounting Officers/ Hospital Directors for Regional Referral Hospitals (RRHs) and Medical Superintendents for general hospitals should be put on performance contracts so that they are monitored continuously, quarter by quarter, based on the performance targets they will set in the first quarter. By implication their terms of appointment may also need to change so that they are appointed on contract terms. In the event that they do not perform to the expectation of the appointing authority then, their contracts would not be renewed. The essence here is that performance will greatly determine the renewal of appointment of the accounting officers.
 
The policy shift to performance contracting is still a big challenge not until all parties are brought on board or enough training is undertaken for all staff. Supervision by appraisers remains a critical challenge, even at the ministry level, a minister has no capacity to supervise and meaningfully appraise the permanent secretary. Even the current arrangement where the head of the public service supervises the permanent secretary, it is still complicated because these two officers are far apart from each other. Besides, the head of public service is too busy to supervise around thirty one (31) permanent secretaries. Yet there are several benefits that can accrue from the utilization of performance contracts (Table 4).
 
Table 4 shows that responses from the 50 key informants (KIs) who were interviewed on the benefits of using performance contracts for staff of the healthcare facilities. The majority (50%) of the respondents observed that performance contracts (PC) would lead to employees being put on their toes to deliver. The performance contract or performance agreement tool aims at ensuring that what is planned at target setting is actually delivered. Supervisors or appraisers ensure that smart target setting is carried out at the beginning of the planning period, and when these targets are agreed on, the appraisers continuously monitor the appraises throughout the year, that is, quarters I, II, III and IV.
 
Performance contracts put the employee on his or her toes to deliver in a timely manner. The performance contracting or agreement emphasizes output and timely results. The respondents were of the view that when the tool is administered to staff because it emphasizes results, there are a number of benefits that accrue from this, such as timely delivery of results or outputs, timely feedback, timely responses, and timely monitoring and evaluation (M&E). Improvement in staff performance (30%) is obviously one of the benefits of performance contracting when health workers agree on their targets and the assessment period, then, staff performance will obviously improve and when staff performance improves productivity will be high, and attendance to duty (that is, doctor-patient attendance) will also be high, the delivery of medicine will also heighten and the level of hygiene in the health facilities will improve. All these compounded together will lead to limited mortality rates in the healthcare facility. With improved staff performance, respondents argued that this will lead to client satisfaction (14%) and patient recovery levels as a result of hard work and commitment to patients by the health workers.
 
Much as performance management can lead to client satisfaction, its implementation faces several challenges as shown in Table 5.
 
Results from Table 5 clearly indicate that most respondents observe that the absence of performance monitoring (50%) is one of the biggest challenges facing performance management   in   the   health   sector.  The process of performance management begins with the process of planning where targets are identified and set, and it is those targets that are constructed in a performance plan clearly spelling out the key performance outputs, performance indicators and performance targets. Once this has been done then the plan is used to continuously monitor how the targets are being achieved throughout the assessment period. Unfortunately, most employers and employees do not do performance monitoring; they wait until it is time to assess performance at the end of the assessment period or financial year. This is therefore a big challenge because one cannot wait to assess an employee after one year when he or she has been performing the tasks that he or she set out to achieve at the beginning of the assessment period (July of each year).
 
There is also a need to use modern performance management initiatives to improve on performance planning (Table 6).
 
In Table 6, the interview results indicated that the introduction of performance contracts to all health workers (50%) is the most appropriate mechanism for improving performance management initiatives in the healthcare units. A performance contract is an agreement between the individual employee and the Government of Uganda promising to deliver quantifiable targets within one financial year. Performance contracting improves the culture of work within the healthcare facilities. It envisages that every health worker at any service point will sign an agreement with government clearly stating that at the end of a particular financial year, one should be able to accomplish certain targets.
 

 


 DISCUSSION

Several issues were considered pertinent to this study. Performance contracting is one of them. Performance contracting is a clear assessment tool which every employee can sign with his or her superior on behalf of government at the end of every financial year. The employee is evaluated against the targets he or she has made vis-à-vis the agreed goals by making this assessment at the end of the assessment period to see the outputs that were set at the beginning of the financial year. Overall, the assessment tool brings out high levels of accountability among the health workers. This result is supported by Perry and Toonen (1996) who state that: Performance management is expected to increase accountability because clear and explicit managerial targets, combined with managerial autonomy and incentives to perform, make it easier to establish the basis for managerial accountability and to achieve the outputs at planning.
 
The respondents observed that there is no doubt that performance contracting is an appropriate performance management tool which has to be rolled out to all officials in the public service.
 
The other mechanism of improving performance management is revitalizing the rewards and sanctions framework. This tool was introduced in the public service about four years ago. The respondents ranked it at 30%. This framework is an accountability tool which was introduced in the public service around 2012, its aim was to enforce performance in the public service which uses a variety  of methods  such  as  attendance  biometric  data capture system, use of cameras, and manual attendance registers. The framework has two distinct pillars. The first pillar emphasizes the reward side of an employee which the accounting officer at every government facility should plan for the various reward items. Characteristically, they do not need to be very expensive, an employee may be recognized before a staff meeting for excellent performance, may get an offer of a holiday abroad with a family, may receive certificates of merit, or end of year parties for staff may be organised. The second pillar deals with the sanctions side. This pillar demonstrates a clear approach on the sanctioning of staff. This should be in tandem with the existing regulations such as the Public Service Standing Orders, the Public Service Act, and the Public Service Commission Regulations. Sanctioning is obviously the negative feedback to the employee for failure to do his or her part of the bargain. However, it should be done professionally so that staff does not lose morale and self-esteem.
 
The other mechanism the respondents identified is the “utilization of performance reports” (14%). Many performance reports are never attended to, let alone being prepared. It is proper to produce reports for all performance related activities. Whenever these exercises are conducted reports should be discussed at senior management level so that officers can pick them up for immediate action. Otherwise, when reports are never presented to senior management, they are not enforceable. Furthermore, the respondents observed that a report gives either positive or negative feedback, no matter the nature of the reports, they must be given out otherwise it will not make sense to carry out performance evaluations when they are never released. It is pertinent to engage in meaningful feedback to the two parties, appraiser and appraise. It is advisable to be involved in performance measurement which encourages proactive engagement rather than combative engagement. This view is supported by Rock et al. (2014) when they note that: typical feedback is not motivating, rewarding or pleasant; employees often perceive feedback and ratings as negative. This usually degenerates into a fight or defensive response hence limiting the perspectives and possibilities for learning with intensions of improved performance.
 
Hence, it is proper to bring out reports that are objective whether or not they give negative or positive feedback. Any feedback should be able to elicit response that addresses the given problems and in time.
 
The last mechanism according to the respondents (6%) is CPD. Far from following the normal class engagement, the CPD is a continuing process which involves informal approaches of a health worker to maintain and improve standards of medical performance through skills, attitudes, and knowledge development. One key informant (KI) who spoke on CPD said: CPD is an important mechanism that we can use to improve performance management in the healthcare facility. It is an approach which is self-driven; you do not need to wait for directions but you can know through interactions, experience and sharing with colleagues.
 
The respondents further argued that CPD is a learning approach where the Ministry of Public Service releases a policy framework on how to carry on with it for individual employees, departments or institutions. The respondents stated that CPD is a framework that may require documentary processes when starting to engage with it. Also, it emphasizes self-direction, self-motivation and it is not driven by supervisors or heads of department. It also focuses on attaining skills. Finally, CPD demands that the learning process should include both formal and informal interactions. One Kl observed as follows: CPD is very relevant intervention in the performance management debate that can raise or improve the standards of employees especially health workers in the following ways: (i) promotion of individual professional development, (ii) guiding towards achieving goals, objectives and outputs, (iii) focusing on individual employees on their career planning and progression, (v) promoting demonstrated individual employee professional standards and competences.
 
Henceforth, CPD is a key pillar in performance management given the arguments raised by the respondents. These arguments resonate with views expressed by Feldacker et al. (2017) who noted that: CPD is often closely associated in the literature with appraisal and revalidation and was also linked to performance management not only was CPD described as inspirational, it was also to be considered as being owned by the individual and not run by any agency. CPD is also depicted as keeping up-to-date with knowledge, skills and attitude clinically, managerially and professionally.
 
In a nutshell, CPD is a critical element that moves performance management as a paradigm to another level in the delivery of healthcare service to the population.
 
In summary, the responses of the KIs interviews reveal that the mechanisms that should be put in place to improve the use of modern performance management initiatives are introduction of performance contracts to all staff, revitalization of the rewards and sanctions framework, utilization of performance reports, and CPD for all staff.
 
On another note, it should be realized that although PSRs have attempted to improve the delivery of health services in Uganda, a number of challenges need to be addressed. One key issue that emerges from the findings is that of health workers retention. Much as trained health workers are attracted by many health units, they work for a short time and look out for better paid opportunities. It is important that the remuneration of health workers, through the development of a Performance Based Pay Model, should be enhanced to match the conditions of living within the country. The introduction of a Performance Based Pay Model will encourage health workers to work hard and most importantly, cause them to be retained. The  strategy  aims  at  pay  for hard work, resilience, and commitment from the workers. This model can be utilized to increase productivity, staff motivation and retention, thus improving on client satisfaction in most of the units.
 
When employees know that their input will be rewarded with what is worth taking home, there is a tendency for them to put in extra effort so that their productivity increases and, hence, the organization benefits from this extra effort which justifies the need for performance based pay. Health workers’ performance can be assessed in terms of duty attendance, patient/client care, overtime incidents, patients’ follow-ups, and drug administration. Performance based pay can improve health service delivery as long as it is well-monitored and followed-up closely. The care given to a customer and the possibility of extending his or her work to accomplish the day’s work contributes to a worker’s performance. Performance can easily be appraised with a clear tool that covers a wide range of aspects such as duty attendance, time management, compliance with the organization’s rules and procedures, individual innovation, and competence of the officer or worker.


 CONCLUSION AND POLICY IMPLICATIONS

The paper concludes that modern performance management initiatives in the healthcare delivery system can be supported to perform better using the following strategies or mechanisms; introduction of performance contracts to public officers (50%), utilization of performance reports (14%), revitalization of the rewards and sanctions framework (30%), and CPD (6%).
 
Performance contracting has been introduced in some parts of Africa. Uganda is still in its initial stages of implementing this policy. Performance contracting emphasizes bench making the use of private sector approaches to improve public service delivery (Balogun, 2003). Performance contracting is supposed to engage a public officer to make a commitment at the beginning of a particular financial year and be evaluated at its end. Ideally, performance contracting should move together with performance employee contracting where there are contractual targets agreed between the government and the individual public servant. In the event that the public servant does not perform or deliver the agreed target then he or she will be automatically denied the contract during the renewal of the next contract.
 
Performance contracting in Uganda is only being applied to accounting officers, directors and heads of departments. It should be noted that the performance contracting being implemented in Uganda emphasizes performance commitment/agreement between the government and the individual employee, implying that if an employee performs well he or she is rewarded and if he or she does not perform well he or she is sanctioned.
 
The second strategy which  the  study  identified  is  the utilization of performance reports. Many activities take place and good reports are generated and yet they are never utilized. The respondents argued that if service delivery in the health sector is to improve, there is need for feedback in form of utilization of the reports that are generated from field inspection, performance appraisal, benchmarking, and M&E reports. Therefore, performance related reports are important in the day-to-day management of employee performance. It is only when there is documented evidence that one can accordingly make an informed decision on an officer’s performance. For instance, when performance reports indicate that an officer needs mentoring to perform certain tasks, then until such mentoring takes place the officer’s performance will not improve. At the same time, respondents observed that in order to increase compliance to performance reports during appraisal exercise, evaluation indicators should be allocated to every appraiser on the utilization and follow-up on performance reports.
 
The study also concludes that the revitalization of the rewards and sanctions framework is one of the strategies or mechanisms that can improve or support performance management initiatives in the healthcare facilities. The rewards and sanctions framework was introduced in the Uganda’s Public Service for the purpose of improving performance for effective and efficient public service delivery. Rewarding is meant for better performers and sanctions is meant for non-performers who need to be guided, mentored, supervised and reprimanded to ensure that they change their bad ways to improve their performance.
 
The study further observes that in the past, institutions focused on sanctioning non-performers without focusing on rewarding best performers. This did not encourage performers to work harder or keep up their standard of performance. The respondents observed that performance rewards do not need to be too costly; it is small things that count greatly such as an air ticket for a holiday, a certificate, public handshake, and official notification on the notice-boards for best workers of the year. These are strategies that do not necessarily require huge funding to implement. The respondents observed that for purpose of performance management initiatives, it would matter a lot if the rewards and sanctions framework was revitalized. To them, this would greatly improve the performance initiatives in the health sector where the numbers of patients is too high thus requiring huge human resources.
 
The study concludes that there is need to introduce CPD as a strategy to enhance performance management initiatives. CPD presupposes a systematic approach beginning from self-individual assessment. This is where an individual employee undertakes to examine his strengths, weaknesses, opportunities and threats (SWOT), analysis of himself or herself to establish the performance needs that he or she must have to deliver on   his   or    her   role.   After   establishing   his   or   her performance needs, the officer plans how to mitigate the performance needs as the second step. Then he or she decides on the approach or plan of activities which he or she may observe. CPD is not an orderly classroom learning approach; it is experiential learning, environmental acclimatization, benchmarking and copying approaches to learning. During the planning and implementation of activities, employees choose from the aforementioned range of activities to mitigate the challenges, and, finally the employee will go through an evaluation to establish whether there is any impact on his or her performance arising out of the initiatives undertaken earlier.
 
CPD was identified as one of the key strategies that can support the performance management initiatives for staff in the healthcare facilities. Health workers need on a continuous basis to develop their capacities through benchmarking, twinning, attachment, understudying and mentoring. This is one of the ways in which health workers can cope with the performance needs of their jobs in order to satisfy their clientele (that is, the patients).
 
Conclusively, the study argues that four important strategies must be adopted in order to support the utilization of modern performance management initiatives in order to improve healthcare delivery in Uganda, namely, (i) introduction of performance contracts for all health workers, (ii) utilization of periodic performance reports, (iii) revitalization of the rewards and sanctions framework, and (iv) CPD, introduction of performance related pay and devolution of monitoring and evaluation of health workers performance.


 RECOMMENDATIONS

In view of the foregoing, the paper proposes the following policy recommendations:
 
(1) Before local authorities can be given discretionary powers to budget, financial allocations from the central government should be sufficient to meet their budget proposals. Decentralized health facilities need adequate budget provisions to handle their basic constraints such as low pay, poor housing, career progression opportunities through training or capacity building;
(2) Capacity building is a clear retention strategy. However, it must systematically be undertaken through the development of training budgets, carrying out training needs analysis (TNA) for all staff, and coming up with training programs and actual training interventions;
(3) Some deliberate effort should be designed to attract and retain the available health staff by providing good accommodation, lunch, transport, school fees, and health insurance schemes. If all these are put in place, the following challenges would be addressed: labour turnover, low staff morale, refusal to go to hard-to-stay or reach areas and poor attendance to duty.
(4) The bottom-line is that as privatization is introduced in the health sector it should be moderated by government by setting standards, policies, and guidelines. If this is not done, then it leaves the ordinary Ugandans to be exploited by the private providers whose main interest is to make profits and not to provide a service to the population. Therefore, government must regulate privatization from its onset.


 CONFLICT OF INTERESTS

The author has not declared any conflict of interests.



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