Logical pathway for healthcare services improvement towards achieving Universal Health Coverage in Ghana: A participatory action research approach

Logical pathway for healthcare services improvement towards achieving Universal Health Coverage in Ghana: A participatory action research approach | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Logical pathway for healthcare services improvement towards achieving Universal Health Coverage in Ghana: A participatory action research approach Samuel Amon, Patricia Akweongo, Joanna Raven, Tim Martineau, Moses Aikins This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9059452/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background Evidence from low- and middle-income countries (LMICs) shows that a comprehensive strategy that uses a participatory approach to problem-solving improves health workforce performance and service delivery. This study assessed the logical pathway for health services improvement towards achieving universal health coverage (UHC) in Ghana using participatory action research (PAR) methodology. Methods A convergent parallel mixed-methods study design was used to assess the logical pathways of the integrated health systems strategies outcomes in three districts. The Logical Framework Approach (LFA) was adopted for the intervention pathway assessment. Using PAR approach, health system problems were identified, solution strategies designed and implemented by local health managers, community health committees and researchers. For the intervention effects on service delivery, pre- and post-intervention data for selected service delivery indicators were collected in September 2018 and September 2020 respectively, and analyzed. The data were collected using structured questionnaire and interview guide. Quantitative data was descriptively analyzed. Qualitative analysis was done using thematic approach, aided by QSR NVivo version 14. Results Our study findings indicate that using a participatory approach for health system problems identification, solution strategies selection and implementation can effectively strengthen district health managers’ performance and consequently improve health service delivery indicators at primary healthcare (PHC) level. Service delivery indicators in the three study districts were observed to have improved, with increases in OPD per capita by 4.1%; ANC coverage by 7.5%; and yaws case detection by 15 times, addressing equity in UHC. Conclusion The logical pathway to the impacts reported by this study demonstrates that through PAR, the selected HR/HS strategies can be effective for strengthening workforce performance in the lower tiers of decentralized health systems, thereby leading to improved healthcare access, coverage and quality towards the achievement of UHC. participatory action research health workforce performance strengthening universal health coverage healthcare services improvement district Ghana Figures Figure 1 Figure 2 BACKGROUND The World Health Organization acknowledged the multiplicity of interactions and interrelationships among the health system building blocks to strengthen the health system ( 1 ). Hence, health system strengthening requires a comprehensive improvement of performance drivers rather than focusing on individual aspects of the health system building blocks ( 2 ). The health workforce is at the core of the health system ( 3 ). Several health workforce related challenges leading to poor performance have been documented in various studies ( 4 – 6 ). A WHO report in 2016 advocated for health workforce capacity development and motivation to overcome service delivery bottlenecks and achieve national and global health goals such as universal health coverage. The report further stressed that the quality of health services, their efficacy, efficiency, accessibility and viability depend primarily on the performance of those who deliver them ( 5 ). Thus, the availability of qualified and motivated human resources for health (HRH) is essential for adequate health service provision. Improving health service delivery requires innovative interventions that strengthen health workforce performance at all levels of health governance ( 7 , 8 ). Also, the relevance of well performing health workforce for the achievement of universal health coverage (UHC) is well documented ( 7 , 9 , 10 ). In Ghana, health services and functions were decentralized from 1996 under the Ghana Health Service and Teaching Hospitals Act 525, with the aim of transferring key functions, responsibilities, power and resources from the central government to the local authorities, as well as strengthening the capacity of local authorities( 11 , 12 ). There are three management levels in Ghana’s health system: the district, regional and national or central levels. The district is managed by a small team made up of senior staff and supervisors referred to as the District Health Management Team (DHMT) ( 13 ). Every district in Ghana has a DHMT. The core DHMT members include the district director of health services, the district public health nurse, the district disease control officer, the district health information officer, and the district nutrition officer. The team is responsible for the supervision of all health services as well as the implementation of plans and policies at the subdistrict level. The decentralized structures offer DHMTs some degree of authority and decision space in human resource management and service delivery. Allowing greater decision space at the local level for planning, budgeting, and financing has been reported to result in better performance ( 14 ). This notwithstanding, frontline managers like DHMTs rarely receive management training and/or are promoted from non-management staff positions (such as clinical positions), and therefore often lack the necessary awareness and understanding to effectively coordinate service delivery ( 15 ). Kuvaas, Dysvik ( 16 ) reported that frontline managers’ motivation and competencies could be enhanced through innovative support and training. Meanwhile, health workforce management strengthening interventions to improve health workforce performance and service delivery in Low- and Middle-Income Countries (LMICs) have mainly focused on capacity building, incentives, supervision, and quality improvement ( 17 ). The management strengthening intervention (MSI) The MSI sought to strengthen DHMTs management capacity to improve health workforce performance and service delivery ( 8 ). The intervention used a PAR approach as the vehicle for management strengthening and workforce performance improvement. The PAR cycle is comprised of (a) planning, (b) acting, (c) observing, and (d) reflecting. Firstly, the ‘planning’ stage of the PAR cycle included initial situation analysis, problem analysis and solution strategies selection by DHMTs in each of the three study districts, based on the Logical Framework Approach (LFA) ( 22 , 23 ). Secondly, the selected human resource (HR) and other health systems (HS) strategies were implemented within existing DHMTs resource envelopes at the PAR ‘acting’ stage. Thirdly, the continuous monitoring of the HR/HS strategies constituted the ‘ observing ’ stage, whereas progress evaluation constituted the ‘reflecting’ stage. Reflection on the strategies was mainly done during review meetings between the research team and core DHMT members. The DHMTs led the implementation of the HR/HS strategies, facilitated and supported by the researchers. The observation of and reflection on the strategies also made use of short workshops and inter-district meetings and spanned from September 2018 to August 2020. More information on the MSI intervention and its implementation processes can be found elsewhere ( 8 ). METHODS Study design The LFA was adopted for the assessment of the integrated HR/HS strategies logical pathway to the observed effects. A convergent parallel mixed-methods study design approach was used. By this, quantitative and qualitative data were concurrently collected and analysed to assess the logical pathway to the HR/HS strategies implementation and its effects. A qualitative study design was used to evaluate the logical pathways of the HR/HS strategies implementation, whereas a non-experimental design was employed for assessing the HR/HS effects. Non–experimental design was used because of the complexities associated with the MSI. Craig et al. ( 24 ) describe interventions like the MSI as a natural experiment, whereby the circumstances surrounding the implementation of such interventions are not under the control of researchers. In such circumstances, non-experimental design is appropriate. Relative to this design, a pre- and post-Intervention data were gathered on service delivery indicators. The Logical Framework Approach (LFA) The LFA is a highly effective strategic planning and project management methodology that also guides logical and systematic analysis of the key interconnected elements that underpin a project intervention ( 22 ). It is valuable for monitoring progress and modifying activities and outputs during project implementation ( 25 ). Based on the LFA concept, we emphasize that an understanding of the causal assumptions behind an intervention, and an evaluation of how the intervention works in practice are essential to developing evidence to inform policy and practice ( 26 ). Accordingly, this study assessed how the HR/HS strategies produced change/effects. Thus, to know how the effects of a specific strategy occurred and for replicability of the effects by similar future interventions, we assessed the mechanisms or logical pathway that produced change ( 27 ). The LFA established the complex logical pathways through which the HR/HS strategies brought about change using the LFA. These are: inputs (i.e., selection and implementation of solution strategies), outputs (i.e., HR and HS improvement mechanisms), and outcomes (i.e., reported effects on service delivery indicators) ( 28 ). The intervention hypothesized an enhancement in management competencies (i.e., problem-solving) and workforce performance resulting from the planning and implementation of integrated HR/HS strategies, and consequently improvement in UHC and service delivery indicators. The hypothesis emanates from the notion that context-specific strategies designed to tackle real problems at the district level should lead to improved performance of the health system. Figure 1 illustrates the generic pathway used in the study. The design and implementation of the integrated HR/HS bundles of strategies leads to improved health workforce performance and stakeholder participation towards the drive to achieve UHC spheres of healthcare access, coverage and quality. The path to achieving UHC towards addressing health service problems is influenced by several contextual factors. Details of the elements of the various components of the framework regarding the inputs, outputs, outcomes and contextual influence are elucidated in the results sections. Study population and settings The study population was DHMT members of the three selected study districts, namely Fanteakwa North, Suhum and Yilo Krobo Districts. The districts were selected based on the following pre-designed inclusion criteria: 1) willingness of DHMT to participate in the intervention; 2) districts being clustered close to each other; 3) No special human resource activities, projects, and programmes ongoing in the district; 4) districts representing different degrees of performance rankings (good, moderate and poor); and 5) district’s geography (urban and rural). The key characteristics of the districts are shown in Table 1 . Table 1 Study setting characteristics Item Districts Yilo Krobo Fanteakwa North Suhum Population (2010 estimates) 122,705 56,987 126,403 Sub-districts 6 7 9 Geographical setting Urban Rural Semi-urban Health Facilities: 62 40 32 Hospitals : 0 1 1 Polyclinics/clinic : 1 0 0 Health centers : 12 2 5 Maternity homes : 3 2 0 Community-based Health Planning and Services (CHPS) : 46 35 26 Sampling procedure Qualitative study : DHMT members in each of the three intervention districts were purposively recruited. A total sample size of 10 was estimated to be sufficient for saturation ( 29 ). The study participants were recruited based on the following criteria: ( 1 ) being a core member of the three selected study DHMTs at the time of the study; ( 2 ) sufficient participation in the HR/HS strategies implementation (i.e. not less than half the HR/HS strategies implementation period) including attendance of intervention workshops; ( 3 ) having supervisory, administrative and/or management responsibilities within the study district. Also, key documents/reports were purposively sampled for review. Data sources included DHMT annual reports, DHMT half-year reports, regular meeting minutes, and intervention review meeting reports. Data Collection Qualitative interviews : In-depth interviews (IDIs) were conducted among core DHMT members (n = 10) using an interview guide developed by the researchers based on literature review, the PAR implementation protocols and researchers’ knowledge of local context. The interviews covered the inputs and outputs used in the MSI which included: problem identification; selection of strategies to address identified problems; development of a work plan; implementation of the action plan; observation and reflection on the process; general perception on the PAR approach; and contextual factors affecting HR/HS strategies implementation. The face-to-face interviews were conducted in the offices of the respondents, in English language and lasted on average for 45 minutes. Experienced and trained research assistants conducted the interviews. The interviews were recorded and detailed notes of the interactions with interviewees including observations were taken. The data were collected in September 2020, post-intervention strategies implementation. A summary of the data collection approach is shown in Table 2 . Document review : A document review template was developed for data extraction by the researchers. It consisted of two sections. The first section focused on the key components of the HR/HS strategies implementation and the inputs and outputs, as well as contextual factors affecting HR/HS strategies implementation. The following documents were reviewed: HR/HS strategies workplans, DHMTs’ strategies review reports, monitoring visit reports, and inter-district meeting reports. Data were collected in September 2020. The second section focused on the outcomes, whereby data was collected on quantitative indicators for the specific selected district problems for the MSI (i.e., antenatal care (ANC); outpatient attendance (OPD); and Yaws case detection). Data were collected pre- and post-Intervention strategies implementation in September 2018 and September 2020 respectively. Table 2 summary of data collection approach Focus Data collection tool Data collection Period LFA: HR/HS strategies implementation process, mechanism of change and context Interview guide (strategies inputs and outputs, and context) Face-to-face in-depth interview Post-Intervention Document review template (strategies inputs, outputs, outcomes and context) Structured template Pre- and post-Intervention Data Processing and Analysis Qualitative analysis: In-depth Interviews (IDI) were transcribed verbatim in English and anonymised in accordance with standard procedures. To ensure the quality of transcripts, we listened to five randomly selected interview recordings and compared them with corresponding transcripts. Analysis was done using a thematic approach with the aid of NVivo version 14. By this, we developed a coding framework for data coding using both inductive and deductive approaches. The key themes of the topic guides developed for the IDIs formed the first draft of the coding frame (deductive technique), with emergent themes added iteratively through analysis of the data (inductive technique). We used the coding framework to categorize the data to identify themes that correspond with the topic. Queries were run to summarise themes under appropriate sub-headings, which included inputs and outputs dimensions. A codebook was developed for the themes and augmented with field notes from the interviews. Appropriate quotations were selected to support the themes. Concerning the document review, the thematic framework synthesis approach by Mukumbang, Orth ( 30 ) was followed. By this, we coded relevant documents included in the review independently according to the inputs, outputs and outcomes variables. We reflected on the appropriateness of the codes and categorized identified themes within the observed variables. The process was iteratively done by scrutinizing codes, identifying themes and aligning them with the evaluation variables. Aided by the coding framework, analyses of the IDIs and documents were brought together, and key patterns within and across cases and themes were described and interpreted. Furthermore, based on an objective review of the HR/HS strategies implementation reports, the HR/HS strategies were rated as planned and fully implemented ( 1 ), planned and partially implemented (0.5), and planned but not implemented (0). Quantitative analysis: For the effects of the strategies on service delivery, pre- and post-Intervention data for selected district service delivery problems were analyzed using Microsoft Excel Version 13. Pre- and post-Intervention indicators for the selected problems were descriptively analysed and compared, to determine the change in service delivery performance. The findings from the qualitative and document review, and quantitative analysis were synthesized by categorizing the findings to identify complementary themes that correspond with the inputs, outputs and outcomes dimensions. The results are presented in summarized themes and figures (30), encapsulating the logical pathway of the processes and effects of the HR/HS strategies implementation (i.e., mechanism of change relative to f inputs, outputs and outcomes) in each of the three districts. RESULTS The core DHMT members interviewed included District Directors of Health Services (n = 2), Disease Control Officers (n = 3). Nurse Managers (n = 2) and Health Information Officers (n = 3). The average age of respondents was 10 years, and 7 of the respondents were males. Inputs - Technical support and integrated HR/HS strategies implementation Table 3 shows the health service delivery problems selected by the study districts, and bundles of integrated HR/HS strategies implemented to facilitate the achievement of UHC (i.e. coverages, access and quality) and consequently address the problems prioritized using PAR. We found that the study districts aimed to increase OPD attendance (Fanteakwa), antenatal coverage (Suhum) and yaws case detection (Yilo Krobo) by improving the key UHC indices relative to coverages, access and quality. The overall PAR strategies design and implementation, as well as technical support and guidelines offered to the district health managers to develop appropriate integrated HR/HS workplans to improve the observed UHC issues and selected problems is reported elsewhere ( 8 , 31 , 32 ). Table 3 displays how the districts had performed on the implementation of the integrated HR/HS strategies toward achieving UHC at the time of data collection. Of the 14 planned strategies by the Fanteakwa North DHMT, 5/14 (36%) were fully implemented compared to 2/5 (40%) by Yilo Krobo and 1/6 (17%) by Suhum after 24 months. A third (2/6) of the planned Suhum strategies were not implemented due to resource constraints. Districts with strong donor and stakeholder support significantly improved their UHC dimensions and consequently the selected health service delivery indicators compared to those with weaker support, for instance Suhum. “Japanese Organization for International Cooperation in Family Planning (JOICFP) is our partner, they are into supporting us in the area of maternal and child health. Without them, our HR/HS strategies implementation which addresses maternal-related issues would have seriously been challenging.” (Suhum DHMT member) Table 3 Integrated HR/HS strategies and level of implementation District Overall aim Strategy/Activity Level of Implementation Fanteakwa North Improve OPD attendance Additional recruitment of clinical staff 0 Retention incentives 0.5 Use temporary staffing measures 0.5 Orient staff on Job content and make copies available to all 1 Strengthen monitoring and supervision of staff 1 Strengthen regular open appraisal 1 Strengthen team meetings 1 Facility level training 0 Implement multi-task plan 0.5 Award best-performing staff/team at the end of the year 0.5 Adhere to disciplinary guidelines 0.5 Train staff on customer care 0.5 Use of health volunteers and non-formal health workers 0.5 Community engagement and participation 1 Suhum Improve ANC coverage and skilled delivery Training and development in ANC services 0.5 Supportive supervision 1 Code of Conduct orientation 0.5 Application of rewards system 0 Stakeholder/Community Engagement 0.5 Engage private laboratory providers 0 Yilo Krobo Increase Yaws case detection Use volunteers for case search 0.5 Educate through community durbars and information centers 0.5 Active and passive case search 1 In-service training on NCD case detection 1 Monitoring and Supportive supervision 1 Planned and fully implemented = 1; Planned and partially implemented = 0.5; Planned but not implemented = 0 Outputs and Outcomes of the HR/HS strategies towards UHC Overall, our findings as shown in Figs. 2 demonstrate that the HR/HS strategies implementation (inputs) in the three study districts contributed to improved health workforce performance (outputs) and consequently UHC dimensions of access, coverage and quality and healthcare service delivery (outcomes). The following results demonstrate the path to achieving the outputs and outcomes of the HR/HS strategies, and contextual influences in each district. Fanteakwa North: increased OPD per capita and service quality Of the twelve strategies selected to address the district’s prioritized OPD attendance problem (referred to as inputs), eleven directly tackled health workforce performance issues whereas one addressed other health systems performance issues. Among others, these contributed to improved volunteer participation, staff knowledge of job content, staff attitude towards clients, and staff performance in OPD services (referred to as outputs ). “…I will say that the [HR/HS] strategies have helped the district a lot, because now we are able to collaborate with community members and volunteers better in OPD services.” (Fanteakwa DHMT member) The effects of the strategies (outputs) contributed to improving service delivery access, coverage and quality, thereby increasing OPD attendance by 4.1% (2018–2019) and OPD per capita by 0.1% (2018–2019). However, there was a decline of 19.5% (2019–2020) in OPD attendance and 0.1% (2019–2020) in OPD per capita (referred to as outcomes ). Whereas some strategies could not be implemented, the effects/change of some strategies were not anticipated; and the outcomes were impacted by contextual factors like high staff turnover, resource constraints, and more critically COVID-19. The decline in OPD attendance in the second year of the HR/HS strategies implementation was attributed to COVID-19. “Unfortunately, we recorded cases of COVID-19 among health staff in this district which triggered stigmatization among staff and from clients. This affected client-staff and staff-community relationship, and consequently OPD attendance in all health care facilities.” (Fanteakwa DHMT member) Suhum: increased ANC coverage and quality Of the four strategies selected to address the district’s prioritized ANC problem (inputs), three directly tackled health workforce performance issues whereas one addressed other health systems performance issues. This contributed to improved staff knowledge of community beliefs and skills in ANC services, as well as staff attitude towards clients (outputs). This led to increased trust in ANC services and improved quality of care (outputs). “…so the project has actually affected most of our indicators positively. You know, as part of our strategy, we said we are going to conduct customer care training. Because what was making ANC coverage go down was because the way clients are treated when they come to the health facilities was not the best. After training staff, we don't receive such complaints from clients again. And that has had effect on ANC attendance.” (Suhum DHMT member) However, the implementation of the strategies and their consequential effects were influenced by contextual factors such as socio-cultural beliefs, high staff turnover, resource constraints, and a shift in the focus of media-based education on ANC due to COVID-19. “We have Traditional Birth Attendants (TBAs) in the communities who are offering health care to pregnant women and also conducting deliveries. So, per the cultural belief system in the communities, most people prefer TBAs services to the hospital ANC services. This affects ANC coverage and birth outcomes. As part of our HR/HS strategies, we are collaborating with the TBA and sensitizing the communities” (Suhum DHMT member) Notwithstanding, the effects of the strategies (outputs) contributed to a significant improvement in ANC access, coverage and quality, thereby increasing ANC registrants by 15%, ANC coverage by 7.5% and skilled delivery by 9.9% (outcomes) between 2018 and 2020. “…I think, let me first speak on the service indicators, service indicators, I think has gone up, it has improved. When you look at our ANC coverage which was our principal problem selected, at the time we started the intervention, we were at 73.6%, then the following year, it went up after the implementation of the HR/HS strategies to 76.1%. But apart from that some other indicators have also been affected positively. For instance, postnatal care has also gone up, skilled delivery as we speak now has also improved. All these can largely be attributed to improved staff skills and quality of ANC services due to the strategies.” (Suhum DHMT member) Yilo Krobo: Increased Yaws case detection and service coverage Of the five strategies selected to address the district’s prioritized yaws case detection (inputs) in Yilo Krobo district, two directly tackled health workforce performance issues while three addressed other health systems performance issues. These contributed to improved staff competencies in NTDs (neglected tropical diseases) case detection, improved DHMT support for yaws case detection, as well as improved community knowledge on yaws and increased yaws cases search (outputs). “…. yes, I think the [HR/HS] strategies are fit for purpose, it worked because, through those strategies, we’ve been able to sensitize our health workers and communities on Yaws…We were detecting very few cases of Yaws even though we suspect more cases exist. We took it upon ourselves to strengthen our skills at both DHMT and facility levels through training on Yaws case detection, and increased support to health centers and CHPS for active case search. Now we are detecting more cases.” (Yilo Krobo DHMT member) “…we’ve been able to improve staff knowledge on Yaws case search and now detecting cases. So, for me the strategies worked. From 3 cases to 86 within eight months.” (Yilo Krobo DHMT member) However, the implementation of the strategies and their effects were influenced by contextual factors such as high staff turnover, resource constraints, and COVID-19. Notwithstanding, the effects of the strategies (outputs) contributed to improving the quality of yaws services, thereby significantly increasing yaws case detection from 3 (2017) to 33 (2018), 88 (2019), and 50 (2020) (outcomes). The decline in case detection between 2019 and 2020 was attributed to COVID-19. “You know, COVID really affected our progress in Yaws case search, During COVID, community surveillance of NTDs [Neglected Tropical Diseases], particularly active case search through durbars, outreaches, school visits, and home visits were suspended based on a directive from GHS. Some routine DHMT activities were also suspended which generally affected the HR/HS strategies implementation. Now we have drastically retrogressed on our success.” (Yilo Krobo DHMT member) “Generally, during the COVID outbreak we shifted more focus to COVID-19 activities at the expense of routine health programs within the district, which affected our active Yaw case detection. The strategies were very helpful, so we’ll surely re-strategize and continue its implementation to sustain our progress.” (Yilo Krobo DHMT member) Having presented the logical pathway to the outcome of the HR/HS strategies implementation in the three intervention districts, the next section discusses the intricacies of the HR/HS strategies implementation processes and effects. DISCUSSION The study assessed the logical pathway to desired UHC and service delivery outcomes using participatory action research (PAR) - based on an adapted Logical Framework Approach (LFA) ( 22 , 23 ). DHMTs developed quite sophisticated work plans, based on detailed problem analyses, which included coherent and integrated sets of HR strategies supported by HS strategies ( 8 , 32 ). In all study districts, the MSI inputs (HR/HS strategies implementation) addressed workforce performance and health system issues thereby improving health service performance ( outputs ), and consequently service delivery access, coverage and quality ( outcomes ). However, the degree of HR/HS strategies implementation varied across the study districts, and no DHMT fully implemented selected strategies due to contextual challenges. The implemented strategies were effective at contributing to the outputs of improved skills of health workers, community participation, supervision and patient-centered care. These outputs resulted in improved outcomes, for example increased OPD access and coverage, quality yaws case detection and services, increased ANC coverage and skilled delivery. However, the initial impact of some plans was seriously affected by contextual challenges - in particular COVID-19 which led, for example, to clinic closures and reductions of staff availability. Like many other intervention implementations ( 33 , 34 ), the DHMT members who participated in the intervention were trained on the key components of the MSI approach (i.e., PAR - comprising problem prioritization and analysis, HR/HS strategies planning and implementation, monitoring and evaluation of strategies) ( 8 , 32 ). The success observed in this study relative to the extent of HR/HS strategies execution is mainly borne out of the DHMTs capacity building on the intervention approach at the outset and the cordial relationship that existed between DHMTs and researchers throughout the HR/HS strategies implementation ( 35 ). We found that DHMTs implemented the HR/HS strategies within funding envelopes available to the DHMTs ( 8 , 32 ). Although this is appropriate for sustainability, the findings of this study corroborate the report by Ridde ( 36 ), that limited financial resources is an existential challenge for the degree of health intervention implementation and, success towards achieving UHC and improving health services in Africa. There is therefore the need for innovative thinking to overcome funding constraints. In this study, DHMTs piggybacked on projects and programmes with funding. More importantly, for integrated HR/HS strategies implementation to achieve desired goals, it requires good team teamwork, inclusive decision making, and task sharing among participants to enable flexibility to overcome challenges, without compromising process and content quality. Furthermore, the results of this study seem to indicate that regular meetings, monitoring, and supportive supervision in HR/HS strategies implementation are significant moderating factors that facilitate the extent of successful implementation and its impact on UHC and health service delivery improvement. The attendance of meetings and workshops by workforce may have been facilitated by the provision of allowances in line with normal practice. This strengthened the DHMT’s commitment to implement the HR/HS strategies, thereby accelerating the extent of execution of the workplans. Meanwhile, the DHMTs’ involvement in the intervention did not undermine health service delivery through possible diversions from competing priorities. Unfortunately, the outbreak of COVID-19 resulted in a shift in focus and interest of influential national stakeholders and DHMTs from the HR/HS strategies implementation to the pandemic. In this study, DHMTs’ trust in the strategies increased over time and consequently confidence in their value. Thus, to improve sub-national level access, coverage and quality of healthcare services in decentralized health systems like Ghana using PAR, there is a need to ensure consistent advocacy and engagement with relevant stakeholders (particularly decision makers and influential health actors) on the value and benefits of the intervention strategies, and provide regular mentoring and supportive supervision to lower decision-making levels ( 37 ). Available evidence shows that strict adherence to the integrated HR/HS strategies implementation and improvement of UHC indicators is unlikely to occur in environments where the intervention participants have diverse contextual influences ( 38 , 39 ). Likewise, this study observed varied degrees of contextual issues affecting strict adherence to the strategies’ implementation across the different study districts. For instance, whereas some districts were successful in lobbying for and leveraging available resources to implement the strategies, others faced dire resource constraints. Also, the strategies implementation was affected by high staff turnover in the health sector. Challenges regarding human resources in complex interventions are well documented ( 35 ). These challenges could militate against effective strategies implementation and thus achievement of UHC and effective service delivery. Furthermore, the decentralized health structure contributed immensely to the UHC and service delivery outcomes realized by the study DHMTs. Thus, the DHMTs’ authority allowed them to select and prioritize specific district problems and indicators, as well as incorporate their HR/HS strategies into their annual action plans for smooth implementation. Regular modifications to the modalities of HR/HS strategies implementation at the district level could only have been possible within the specific authority of the DHMTs. Also, for the strategies to significantly contribute to improving UHC and service delivery indicators, there is the need for continuous monitoring and review of the intervention processes, as well as constant review of solutions to address contextual challenges. Implication for policy and practice Firstly, future adoption of the PAR approach for health systems strengthening and UHC drive should consider using a holistic systems approach. Thus, the health systems thinking approach would facilitate the smooth embedment of the strategies into the routine operations of the health managers for better UHC outcomes. Secondly, for integrated HR/HS strategies to reach their full potential of strengthening subnational level health workforce performance through PAR in order to stimulate the achievement of UHC and improve health service delivery indicators, health managers should maintain flexibility in the design and implementation of the strategies. Finally, contextual challenges should be managed by leveraging working partnerships with key local and national stakeholders in the sector. Study strengths and limitations The major strength of this study is the triangulation of quantitative and qualitative data sources and analyses that promoted a richer understanding of the study findings through the generation of logical pathways for the design, implementation and outcome of the HR/HS strategies. This knowledge will allow for replication and/or scale-up. Also, we triangulate quantitative and qualitative results, allowing for a holistic presentation of the logical pathway of the MSI strategies to the observed outcomes. The limitation of this study is in the approach used in designing, implementing and assessing the HR/HS strategies that may have been influenced by the researchers’ subjective feelings. CONCLUSION A well-performing health workforce is needed for stronger health systems to accelerate the pace of achieving UHC in Ghana. The logical pathway to the effects and outcomes reported by this study demonstrates that the implemented HR/HS strategies can be effective for strengthening health workforce performance in the lower tiers of the decentralized health system (district) of Ghana, to facilitate efforts towards achieving UHC and improve service delivery. The versatility and flexibility of PAR render it fit-for-purpose in tackling the dual problems relating to human resource for health and health services through participatory implementation of HR/HS strategies, for better health outcomes in Ghana and similar contexts. Declarations Ethics approval and consent to participate Ethical clearance was obtained from the Ghana Health Service Ethics Review Committee, an agency under the Ghana Ministry of Health (MOH) with national oversight for all health research involving human participants in Ghana (Reference #: GHS-ERC: 004/01/20). Also, permission was sought from the Eastern Regional Health Directorate and District Directorate of Health Services for the selected study districts. All study participants were provided with written informed consent forms, which they signed to indicate willingness to participate in the study, and the data collected was anonymous. The study conformed to all the dictates of the Helsinki Declaration (40). Clinical trial number : Not applicable Data availability statement The data that support the findings of this study are available from the corresponding author upon reasonable request. Competing interests The authors hereby declare no conflict of interest in this study. Funding This work was supported by the European Union Horizon 2020 research and innovation programme: [Grant Number 733360]. Authors' contributions Samuel Amon: Conceptualization, Methodology, Data collection, and analysis, Writing - Original draft preparation. Patricia Akweongo: Conceptualization, Methodology. Joanna Raven: Conceptualization, Methodology. Tim Martineau: Conceptualization, Methodology. Moses Aikins: Conceptualization, Methodology. All: Writing - Reviewing and editing. Acknowledgements This manuscript is an output from a PhD programme sponsored by the PERFORM2Scale project (reference number: 733360): Strengthening management at district level to support the achievement of Universal Health Coverage, funded by the European Commission. The project (2017 to 2022) sought to scale up the effective Management Strengthening Intervention to have a wider impact on additional districts across Ghana, Malawi, and Uganda and to institutionalize the approach. We express our profound gratitude to the sponsor and all participants of the study from the regional and district levels of the Eastern Regional Health Administration of Ghana. References World Health Organization. Monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies. World Health Organization; 2010. Chee G, Pielemeier N, Lion A, Connor C. Why differentiating between health system support and health system strengthening is needed. 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BMJ global health. 2018;3(2):e000619. United Nations (UN). Report of the UN High-Level Commission on health employment and economic growth. Geneva: World Health Organization; 2016. Campbell J, Buchan J, Cometto G, David B, Dussault G, Fogstad H, et al. Human resources for health and universal health coverage: fostering equity and effective coverage. Bull World Health Organ. 2013;91:853–63. Africa Health Workforce Observatory. Human Resources for Health country profile: Ghana. 2010. Sumah AM, Baatiema L. Decentralisation and management of human resource for health in the health system of Ghana: a decision space analysis. Int J health policy Manage. 2019;8(1):28. Cassels A, Janovsky K, Organization WH. Reform of the health sector in Ghana and Zambia: commonalities and contrasts. 1996. Kigume R, Maluka S, Kamuzora P. Decentralisation and health services delivery in Tanzania: analysis of decision space in planning, allocation, and use of financial resources. Int J Health Plann Manag. 2018;33(2):e621–35. Liu Y. Review of Human Resource Management Function of Front Line Manager. 2017. Kuvaas B, Dysvik A, Buch R. Antecedents and employee outcomes of line managers' perceptions of enabling HR practices. J Manage Stud. 2014;51(6):845–68. Zeng W, Li G, Ahn H, Nguyen HTH, Shepard DS, Nair D. Cost-effectiveness of health systems strengthening interventions in improving maternal and child health in low-and middle-income countries: a systematic review. Health Policy Plann. 2018;33(2):283–97. El Arifeen S, Blum LS, Hoque DE, Chowdhury EK, Khan R, Black RE, et al. Integrated Management of Childhood Illness (IMCI) in Bangladesh: early findings from a cluster-randomised study. Lancet. 2004;364(9445):1595–602. Naimoli JF, Rowe AK, Lyaghfouri A, Larbi R, Lamrani LA. Effect of the Integrated Management of Childhood Illness strategy on health care quality in Morocco. Int J Qual Health Care. 2006;18(2):134–44. Thiam S, LeFevre AM, Hane F, Ndiaye A, Ba F, Fielding KL, et al. Effectiveness of a strategy to improve adherence to tuberculosis treatment in a resource-poor setting: a cluster randomized controlled trial. JAMA. 2007;297(4):380–6. Chalker J, Ratanawijitrasin S, Chuc N, Petzold M, Tomson G. Effectiveness of a multi-component intervention on dispensing practices at private pharmacies in Vietnam and Thailand—a randomized controlled trial. Soc Sci Med. 2005;60(1):131–41. The World Bank. The logframe handbook: A logical framework approach to project cycle management. The World Bank; 2005. Moore, Audrey S, Barker M, Bond L, Bonell C, Hardeman W et al. Process evaluation of complex interventions: Medical Research Council guidance. BMJ. 2015;350. Craig P, Cooper C, Gunnell D, Haw S, Lawson K, Macintyre S, et al. Using natural experiments to evaluate population health interventions: New medical research council guidance. J Epidemiol Commun Health. 2012;66:1182–6. Philip R, Anton B, Cox D, Smits S, Sullivan C, Chonguiça E, Hirt AND, Carter et al. (Pty) Ltd, Durban, South Africa. 2008. Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M. Developing and evaluating complex interventions: the new Medical Research Council guidance. Int J Nurs Stud. 2013;50(5):587–92. Grant A, Treweek S, Dreischulte T, Foy R, Guthrie B. Process evaluations for cluster-randomised trials of complex interventions: a proposed framework for design and reporting. Trials. 2013;14(1):1–10. Kok M, Bulthuis S, Dieleman M, Onvlee O, Murphy R, Akweongo P, et al. Using a theory of change in monitoring, evaluating and steering scale-up of a district-level health management strengthening intervention in Ghana, Malawi, and Uganda–lessons from the PERFORM2Scale consortium. BMC Health Serv Res. 2022;22(1):1001. Saunders M, editor. Choosing research participants. London: Sage; 2012. Mukumbang FC, Orth Z, van Wyk B. What do the implementation outcome variables tell us about the scaling-up of the antiretroviral treatment adherence clubs in South Africa? A document review. Health Res policy Syst. 2019;17(1):1–12. Bulthuis S, Kok M, Onvlee O, O’Byrne T, Amon S, Namakula J, et al. How to scale-up: a comparative case study of scaling up a district health management strengthening intervention in Ghana, Malawi and Uganda. BMC Health Serv Res. 2023;23(1):35. Martineau T, Mansour W, Dieleman M, Akweongo P, Amon S, Chikaphupha K, et al. Using the integration of human resource management strategies at district level to improve workforce performance: analysis of workplan designs in three African countries. Hum Resour Health. 2023;21(1):57. Coorey G, Peiris D, Scaria A, Mulley J, Neubeck L, Hafiz N, et al. An Internet-Based Intervention for Cardiovascular Disease Management Integrated With Primary Care Electronic Health Records: Mixed Methods Evaluation of Implementation Fidelity and User Engagement. J Med Internet Res. 2021;23(4):e25333. Cyriac S, Webb Girard A, Ramakrishnan U, Mannar MGV, Khurana K, Rawat R, et al. Making programmes worth their salt: Assessing the context, fidelity and outcomes of implementation of the double fortified salt programme in Uttar Pradesh, India. Matern Child Nutr. 2022;18(1):e13243. Low LL, Rahim AB, Hamzah FI, Ismail NAR. Process evaluation of enhancing primary health care for non-communicable disease management in Malaysia: Uncovering the fidelity & feasibility elements. PLoS ONE. 2021;16(1):e0245125. Ridde V. Per diems undermine health interventions, systems and research in Africa: burying our heads in the sand. Citeseer; 2010. pp. E1–4. Eboreime EA, Abimbola S, Obi FA, Ebirim O, Olubajo O, Eyles J, et al. Evaluating the sub-national fidelity of national Initiatives in decentralized health systems: Integrated Primary Health Care Governance in Nigeria. BMC Health Serv Res. 2017;17:1–13. Chiodo D, Exner-Cortens D, Crooks C, Hughes R. Scaling up the Fourth R program: Facilitators, barriers, and problems of practice, Report prepared for the Public Health Agency of Canada. London, ON, Canada: The University of Western Ontario; 2015. McCuaig L, Hay PJ. Towards an understanding of fidelity within the context of school-based health education. Crit Public Health. 2014;24(2):143–58. Association WM. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human participants. JAMA. 2025;333(1):71–4. Additional Declarations No competing interests reported. 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Amon","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA60lEQVRIiWNgGAWjYDACHjBpw8AGFznAwMBMhJY00rUcRhIhpEW+5/DTDR93nM/nk25/wMzzi0GO70YC8+sCPFoMzraZ3Zx55rZlm8wZA2bePgZjyRsJbNYz8GnhZzC7zdt224BNIof9N28PQ+IGoBZjHnwO62f/BtRyDqgl/QEzUEs9QS0MZ3tAthwAakkwYOb5wZBgAPTLY3xaDM6cKbs5sy3ZgA3oF8a5DRKGM888bGPG67Ce9G03PrbZGcjPbn/A8OaPjTzf8eTDn/E6DA4kgJixDUESqYXhD5jJ/IE4LaNgFIyCUTBCAAAGmkryKCmDPgAAAABJRU5ErkJggg==","orcid":"","institution":"University of Ghana","correspondingAuthor":true,"prefix":"","firstName":"Samuel","middleName":"","lastName":"Amon","suffix":""},{"id":620799980,"identity":"17dffb7f-ba73-4f29-b156-83133b8292f2","order_by":1,"name":"Patricia Akweongo","email":"","orcid":"","institution":"University of Ghana","correspondingAuthor":false,"prefix":"","firstName":"Patricia","middleName":"","lastName":"Akweongo","suffix":""},{"id":620799981,"identity":"f7852419-d4b7-4505-bd2b-6afc31009bb6","order_by":2,"name":"Joanna Raven","email":"","orcid":"","institution":"Liverpool School of Tropical Medicine","correspondingAuthor":false,"prefix":"","firstName":"Joanna","middleName":"","lastName":"Raven","suffix":""},{"id":620799984,"identity":"531478c1-fc92-4c65-8551-5525cd311133","order_by":3,"name":"Tim Martineau","email":"","orcid":"","institution":"Liverpool School of Tropical Medicine","correspondingAuthor":false,"prefix":"","firstName":"Tim","middleName":"","lastName":"Martineau","suffix":""},{"id":620799988,"identity":"3aa5530c-5ee6-4311-91cf-7cb6a4c286f3","order_by":4,"name":"Moses Aikins","email":"","orcid":"","institution":"University of Ghana","correspondingAuthor":false,"prefix":"","firstName":"Moses","middleName":"","lastName":"Aikins","suffix":""}],"badges":[],"createdAt":"2026-03-07 15:23:35","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9059452/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9059452/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107482515,"identity":"f3a1edda-10dc-4b01-b6a0-15e4edd1b40c","added_by":"auto","created_at":"2026-04-22 02:23:50","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":56853,"visible":true,"origin":"","legend":"\u003cp\u003eGeneric logical pathway to achieving UHC using participatory action research (PAR)\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9059452/v1/663fe0df3380c9331d1413dc.png"},{"id":107243085,"identity":"bff98282-0b4e-42f7-8653-5f8ed8cff6fc","added_by":"auto","created_at":"2026-04-19 07:49:23","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":70135,"visible":true,"origin":"","legend":"\u003cp\u003eLogical pathway for UHC and healthcare services improvement towards using PAR\u003c/p\u003e","description":"","filename":"groupimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-9059452/v1/e0449d13da7564dae0a41807.jpeg"},{"id":107705397,"identity":"0e6b3e84-9045-4c3d-86ce-df24727fcf0a","added_by":"auto","created_at":"2026-04-24 09:12:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":440288,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9059452/v1/008944de-c925-4da9-acd1-57a2025f3f1d.pdf"},{"id":107243084,"identity":"52925a63-133a-4114-b2ad-a5ce0b611772","added_by":"auto","created_at":"2026-04-19 07:49:23","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":39382,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryInterviewguideAmonetal..docx","url":"https://assets-eu.researchsquare.com/files/rs-9059452/v1/441a96fd87509611c32b42cf.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Logical pathway for healthcare services improvement towards achieving Universal Health Coverage in Ghana: A participatory action research approach","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eThe World Health Organization acknowledged the multiplicity of interactions and interrelationships among the health system building blocks to strengthen the health system (\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e). Hence, health system strengthening requires a comprehensive improvement of performance drivers rather than focusing on individual aspects of the health system building blocks (\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e). The health workforce is at the core of the health system (\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e). Several health workforce related challenges leading to poor performance have been documented in various studies (\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e–\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e). A WHO report in 2016 advocated for health workforce capacity development and motivation to overcome service delivery bottlenecks and achieve national and global health goals such as universal health coverage. The report further stressed that the quality of health services, their efficacy, efficiency, accessibility and viability depend primarily on the performance of those who deliver them (\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e). Thus, the availability of qualified and motivated human resources for health (HRH) is essential for adequate health service provision. Improving health service delivery requires innovative interventions that strengthen health workforce performance at all levels of health governance (\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e). Also, the relevance of well performing health workforce for the achievement of universal health coverage (UHC) is well documented (\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn Ghana, health services and functions were decentralized from 1996 under the Ghana Health Service and Teaching Hospitals Act 525, with the aim of transferring key functions, responsibilities, power and resources from the central government to the local authorities, as well as strengthening the capacity of local authorities(\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e). There are three management levels in Ghana’s health system: the district, regional and national or central levels. The district is managed by a small team made up of senior staff and supervisors referred to as the District Health Management Team (DHMT) (\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e). Every district in Ghana has a DHMT. The core DHMT members include the district director of health services, the district public health nurse, the district disease control officer, the district health information officer, and the district nutrition officer. The team is responsible for the supervision of all health services as well as the implementation of plans and policies at the subdistrict level.\u003c/p\u003e \u003cp\u003eThe decentralized structures offer DHMTs some degree of authority and decision space in human resource management and service delivery. Allowing greater decision space at the local level for planning, budgeting, and financing has been reported to result in better performance (\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e). This notwithstanding, frontline managers like DHMTs rarely receive management training and/or are promoted from non-management staff positions (such as clinical positions), and therefore often lack the necessary awareness and understanding to effectively coordinate service delivery (\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e). Kuvaas, Dysvik (\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e) reported that frontline managers’ motivation and competencies could be enhanced through innovative support and training. Meanwhile, health workforce management strengthening interventions to improve health workforce performance and service delivery in Low- and Middle-Income Countries (LMICs) have mainly focused on capacity building, incentives, supervision, and quality improvement (\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eThe management strengthening intervention (MSI)\u003c/h3\u003e\n\u003cp\u003eThe MSI sought to strengthen DHMTs management capacity to improve health workforce performance and service delivery (\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e). The intervention used a PAR approach as the vehicle for management strengthening and workforce performance improvement. The PAR cycle is comprised of (a) planning, (b) acting, (c) observing, and (d) reflecting. Firstly, the \u003cem\u003e‘planning’\u003c/em\u003e stage of the PAR cycle included initial situation analysis, problem analysis and solution strategies selection by DHMTs in each of the three study districts, based on the Logical Framework Approach (LFA) (\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e). Secondly, the selected human resource (HR) and other health systems (HS) strategies were implemented within existing DHMTs resource envelopes at the PAR \u003cem\u003e‘acting’\u003c/em\u003e stage. Thirdly, the continuous monitoring of the HR/HS strategies constituted the ‘\u003cem\u003eobserving\u003c/em\u003e’ stage, whereas progress evaluation constituted the \u003cem\u003e‘reflecting’\u003c/em\u003e stage. Reflection on the strategies was mainly done during review meetings between the research team and core DHMT members. The DHMTs led the implementation of the HR/HS strategies, facilitated and supported by the researchers. The observation of and reflection on the strategies also made use of short workshops and inter-district meetings and spanned from September 2018 to August 2020. More information on the MSI intervention and its implementation processes can be found elsewhere (\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e"},{"header":"METHODS","content":"\u003ch2\u003eStudy design\u003c/h2\u003e\u003cp\u003eThe LFA was adopted for the assessment of the integrated HR/HS strategies logical pathway to the observed effects. A convergent parallel mixed-methods study design approach was used. By this, quantitative and qualitative data were concurrently collected and analysed to assess the logical pathway to the HR/HS strategies implementation and its effects. A qualitative study design was used to evaluate the logical pathways of the HR/HS strategies implementation, whereas a non-experimental design was employed for assessing the HR/HS effects. Non–experimental design was used because of the complexities associated with the MSI. Craig et al. (\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e) describe interventions like the MSI as a natural experiment, whereby the circumstances surrounding the implementation of such interventions are not under the control of researchers. In such circumstances, non-experimental design is appropriate. Relative to this design, a pre- and post-Intervention data were gathered on service delivery indicators.\u003c/p\u003e\u003ch3\u003eThe Logical Framework Approach (LFA)\u003c/h3\u003e\u003cp\u003eThe LFA is a highly effective strategic planning and project management methodology that also guides logical and systematic analysis of the key interconnected elements that underpin a project intervention (\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e). It is valuable for monitoring progress and modifying activities and outputs during project implementation (\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e). Based on the LFA concept, we emphasize that an understanding of the causal assumptions behind an intervention, and an evaluation of how the intervention works in practice are essential to developing evidence to inform policy and practice (\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e). Accordingly, this study assessed how the HR/HS strategies produced change/effects. Thus, to know how the effects of a specific strategy occurred and for replicability of the effects by similar future interventions, we assessed the mechanisms or logical pathway that produced change (\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe LFA established the complex logical pathways through which the HR/HS strategies brought about change using the LFA. These are: inputs (i.e., selection and implementation of solution strategies), outputs (i.e., HR and HS improvement mechanisms), and outcomes (i.e., reported effects on service delivery indicators) (\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e). The intervention hypothesized an enhancement in management competencies (i.e., problem-solving) and workforce performance resulting from the planning and implementation of integrated HR/HS strategies, and consequently improvement in UHC and service delivery indicators. The hypothesis emanates from the notion that context-specific strategies designed to tackle real problems at the district level should lead to improved performance of the health system.\u003c/p\u003e\u003cp\u003eFigure \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e illustrates the generic pathway used in the study. The design and implementation of the integrated HR/HS bundles of strategies leads to improved health workforce performance and stakeholder participation towards the drive to achieve UHC spheres of healthcare access, coverage and quality. The path to achieving UHC towards addressing health service problems is influenced by several contextual factors. Details of the elements of the various components of the framework regarding the inputs, outputs, outcomes and contextual influence are elucidated in the results sections.\u003c/p\u003e\u003cp\u003e \u003cb\u003eStudy population and settings\u003c/b\u003e \u003c/p\u003e\u003cp\u003eThe study population was DHMT members of the three selected study districts, namely Fanteakwa North, Suhum and Yilo Krobo Districts. The districts were selected based on the following pre-designed inclusion criteria: 1) willingness of DHMT to participate in the intervention; 2) districts being clustered close to each other; 3) No special human resource activities, projects, and programmes ongoing in the district; 4) districts representing different degrees of performance rankings (good, moderate and poor); and 5) district’s geography (urban and rural). The key characteristics of the districts are shown in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003ctable id=\"Tab1\" border=\"1\"\u003e \u003ccaption\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eStudy setting characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003c/colgroup\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" rowspan=\"2\"\u003e \u003cp\u003eItem\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\"\u003e \u003cp\u003eDistricts\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\"\u003e \u003cp\u003eYilo Krobo\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eFanteakwa North\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eSuhum\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003ePopulation (2010 estimates)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e122,705\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e56,987\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e126,403\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eSub-districts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eGeographical setting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eSemi-urban\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eHealth Facilities:\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e\u003cem\u003eHospitals\u003c/em\u003e:\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e\u003cem\u003ePolyclinics/clinic\u003c/em\u003e:\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e\u003cem\u003eHealth centers\u003c/em\u003e:\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e\u003cem\u003eMaternity homes\u003c/em\u003e:\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e\u003cem\u003eCommunity-based Health Planning and Services (CHPS)\u003c/em\u003e:\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/table\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e\u003ch3\u003eSampling procedure\u003c/h3\u003e\u003cp\u003e\u003cem\u003eQualitative study\u003c/em\u003e: DHMT members in each of the three intervention districts were purposively recruited. A total sample size of 10 was estimated to be sufficient for saturation (\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e). The study participants were recruited based on the following criteria: (\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e) being a core member of the three selected study DHMTs at the time of the study; (\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e) sufficient participation in the HR/HS strategies implementation (i.e. not less than half the HR/HS strategies implementation period) including attendance of intervention workshops; (\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e) having supervisory, administrative and/or management responsibilities within the study district. Also, key documents/reports were purposively sampled for review. Data sources included DHMT annual reports, DHMT half-year reports, regular meeting minutes, and intervention review meeting reports.\u003c/p\u003e\u003ch3\u003eData Collection\u003c/h3\u003e\u003cp\u003e\u003cem\u003eQualitative interviews\u003c/em\u003e: In-depth interviews (IDIs) were conducted among core DHMT members (n = 10) using an interview guide developed by the researchers based on literature review, the PAR implementation protocols and researchers’ knowledge of local context. The interviews covered the inputs and outputs used in the MSI which included: problem identification; selection of strategies to address identified problems; development of a work plan; implementation of the action plan; observation and reflection on the process; general perception on the PAR approach; and contextual factors affecting HR/HS strategies implementation. The face-to-face interviews were conducted in the offices of the respondents, in English language and lasted on average for 45 minutes. Experienced and trained research assistants conducted the interviews. The interviews were recorded and detailed notes of the interactions with interviewees including observations were taken. The data were collected in September 2020, post-intervention strategies implementation. A summary of the data collection approach is shown in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e \u003cem\u003eDocument review\u003c/em\u003e: A document review template was developed for data extraction by the researchers. It consisted of two sections. The first section focused on the key components of the HR/HS strategies implementation and the inputs and outputs, as well as contextual factors affecting HR/HS strategies implementation. The following documents were reviewed: HR/HS strategies workplans, DHMTs’ strategies review reports, monitoring visit reports, and inter-district meeting reports. Data were collected in September 2020.\u003c/p\u003e\u003cp\u003eThe second section focused on the outcomes, whereby data was collected on quantitative indicators for the specific selected district problems for the MSI (i.e., antenatal care (ANC); outpatient attendance (OPD); and Yaws case detection). Data were collected pre- and post-Intervention strategies implementation in September 2018 and September 2020 respectively.\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003ctable id=\"Tab2\" border=\"1\"\u003e \u003ccaption\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003esummary of data collection approach\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003c/colgroup\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\"\u003e \u003cp\u003eFocus\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eData collection tool\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eData collection\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003ePeriod\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" rowspan=\"2\"\u003e \u003cp\u003eLFA: HR/HS strategies implementation process, mechanism of change and context\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eInterview guide\u003c/p\u003e \u003cp\u003e(strategies inputs and outputs, and context)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eFace-to-face\u003c/p\u003e \u003cp\u003ein-depth interview\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003ePost-Intervention\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eDocument review template\u003c/p\u003e \u003cp\u003e(strategies inputs, outputs, outcomes and context)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eStructured template\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003ePre- and post-Intervention\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/table\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e\u003ch2\u003eData Processing and Analysis\u003c/h2\u003e\u003ch2\u003eQualitative analysis:\u003c/h2\u003e\u003cp\u003eIn-depth Interviews (IDI) were transcribed verbatim in English and anonymised in accordance with standard procedures. To ensure the quality of transcripts, we listened to five randomly selected interview recordings and compared them with corresponding transcripts. Analysis was done using a thematic approach with the aid of NVivo version 14. By this, we developed a coding framework for data coding using both inductive and deductive approaches. The key themes of the topic guides developed for the IDIs formed the first draft of the coding frame (deductive technique), with emergent themes added iteratively through analysis of the data (inductive technique). We used the coding framework to categorize the data to identify themes that correspond with the topic. Queries were run to summarise themes under appropriate sub-headings, which included inputs and outputs dimensions. A codebook was developed for the themes and augmented with field notes from the interviews. Appropriate quotations were selected to support the themes.\u003c/p\u003e\u003cp\u003eConcerning the document review, the thematic framework synthesis approach by Mukumbang, Orth (\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e) was followed. By this, we coded relevant documents included in the review independently according to the inputs, outputs and outcomes variables. We reflected on the appropriateness of the codes and categorized identified themes within the observed variables. The process was iteratively done by scrutinizing codes, identifying themes and aligning them with the evaluation variables.\u003c/p\u003e\u003cp\u003eAided by the coding framework, analyses of the IDIs and documents were brought together, and key patterns within and across cases and themes were described and interpreted. Furthermore, based on an objective review of the HR/HS strategies implementation reports, the HR/HS strategies were rated as planned and fully implemented (\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e), planned and partially implemented (0.5), and planned but not implemented (0).\u003c/p\u003e\u003ch3\u003eQuantitative analysis:\u003c/h3\u003e\u003cp\u003eFor the effects of the strategies on service delivery, pre- and post-Intervention data for selected district service delivery problems were analyzed using Microsoft Excel Version 13. Pre- and post-Intervention indicators for the selected problems were descriptively analysed and compared, to determine the change in service delivery performance.\u003c/p\u003e\u003cp\u003eThe findings from the qualitative and document review, and quantitative analysis were synthesized by categorizing the findings to identify complementary themes that correspond with the inputs, outputs and outcomes dimensions. The results are presented in summarized themes and figures (30), encapsulating the logical pathway of the processes and effects of the HR/HS strategies implementation (i.e., mechanism of change relative to f inputs, outputs and outcomes) in each of the three districts.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThe core DHMT members interviewed included District Directors of Health Services (n\u0026thinsp;=\u0026thinsp;2), Disease Control Officers (n\u0026thinsp;=\u0026thinsp;3). Nurse Managers (n\u0026thinsp;=\u0026thinsp;2) and Health Information Officers (n\u0026thinsp;=\u0026thinsp;3). The average age of respondents was 10 years, and 7 of the respondents were males.\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eInputs - Technical support and integrated HR/HS strategies implementation\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows the health service delivery problems selected by the study districts, and bundles of integrated HR/HS strategies implemented to facilitate the achievement of UHC (i.e. coverages, access and quality) and consequently address the problems prioritized using PAR. We found that the study districts aimed to increase OPD attendance (Fanteakwa), antenatal coverage (Suhum) and yaws case detection (Yilo Krobo) by improving the key UHC indices relative to coverages, access and quality. The overall PAR strategies design and implementation, as well as technical support and guidelines offered to the district health managers to develop appropriate integrated HR/HS workplans to improve the observed UHC issues and selected problems is reported elsewhere (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e displays how the districts had performed on the implementation of the integrated HR/HS strategies toward achieving UHC at the time of data collection. Of the 14 planned strategies by the Fanteakwa North DHMT, 5/14 (36%) were fully implemented compared to 2/5 (40%) by Yilo Krobo and 1/6 (17%) by Suhum after 24 months. A third (2/6) of the planned Suhum strategies were not implemented due to resource constraints. Districts with strong donor and stakeholder support significantly improved their UHC dimensions and consequently the selected health service delivery indicators compared to those with weaker support, for instance Suhum.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Japanese Organization for International Cooperation in Family Planning (JOICFP) is our partner, they are into supporting us in the area of maternal and child health. Without them, our HR/HS strategies implementation which addresses maternal-related issues would have seriously been challenging.\u0026rdquo; (Suhum DHMT member)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIntegrated HR/HS strategies and level of implementation\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDistrict\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOverall aim\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStrategy/Activity\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLevel of Implementation\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"13\" rowspan=\"14\"\u003e \u003cp\u003eFanteakwa North\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"13\" rowspan=\"14\"\u003e \u003cp\u003eImprove OPD attendance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAdditional recruitment of clinical staff\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRetention incentives\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUse temporary staffing measures\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOrient staff on Job content and make copies available to all\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStrengthen monitoring and supervision of staff\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStrengthen regular open appraisal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStrengthen team meetings\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFacility level training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eImplement multi-task plan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAward best-performing staff/team at the end of the year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAdhere to disciplinary guidelines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTrain staff on customer care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUse of health volunteers and non-formal health workers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCommunity engagement and participation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003eSuhum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003eImprove ANC coverage and skilled delivery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTraining and development in ANC services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSupportive supervision\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCode of Conduct orientation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eApplication of rewards system\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStakeholder/Community Engagement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEngage private laboratory providers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eYilo Krobo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eIncrease Yaws case detection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUse volunteers for case search\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEducate through community durbars and information centers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eActive and passive case search\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIn-service training on NCD case detection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMonitoring and Supportive supervision\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003ePlanned and fully implemented\u0026thinsp;=\u0026thinsp;1; Planned and partially implemented\u0026thinsp;=\u0026thinsp;0.5; Planned but not implemented\u0026thinsp;=\u0026thinsp;0\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eOutputs and Outcomes of the HR/HS strategies towards UHC\u003c/b\u003e \u003c/p\u003e \u003cp\u003eOverall, our findings as shown in Figs.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e demonstrate that the HR/HS strategies implementation (inputs) in the three study districts contributed to improved health workforce performance (outputs) and consequently UHC dimensions of access, coverage and quality and healthcare service delivery (outcomes).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe following results demonstrate the path to achieving the outputs and outcomes of the HR/HS strategies, and contextual influences in each district.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eFanteakwa North: increased OPD per capita and service quality\u003c/h2\u003e \u003cp\u003eOf the twelve strategies selected to address the district\u0026rsquo;s prioritized OPD attendance problem (referred to as inputs), eleven directly tackled health workforce performance issues whereas one addressed other health systems performance issues. Among others, these contributed to improved volunteer participation, staff knowledge of job content, staff attitude towards clients, and staff performance in OPD services (referred to as \u003cem\u003eoutputs\u003c/em\u003e).\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;I will say that the [HR/HS] strategies have helped the district a lot, because now we are able to collaborate with community members and volunteers better in OPD services.\u0026rdquo; (Fanteakwa DHMT member)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe effects of the strategies (outputs) contributed to improving service delivery access, coverage and quality, thereby increasing OPD attendance by 4.1% (2018\u0026ndash;2019) and OPD per capita by 0.1% (2018\u0026ndash;2019). However, there was a decline of 19.5% (2019\u0026ndash;2020) in OPD attendance and 0.1% (2019\u0026ndash;2020) in OPD per capita (referred to as \u003cem\u003eoutcomes\u003c/em\u003e). Whereas some strategies could not be implemented, the effects/change of some strategies were not anticipated; and the outcomes were impacted by contextual factors like high staff turnover, resource constraints, and more critically COVID-19. The decline in OPD attendance in the second year of the HR/HS strategies implementation was attributed to COVID-19.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Unfortunately, we recorded cases of COVID-19 among health staff in this district which triggered stigmatization among staff and from clients. This affected client-staff and staff-community relationship, and consequently OPD attendance in all health care facilities.\u0026rdquo; (Fanteakwa DHMT member)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eSuhum: increased ANC coverage and quality\u003c/h2\u003e \u003cp\u003eOf the four strategies selected to address the district\u0026rsquo;s prioritized ANC problem (inputs), three directly tackled health workforce performance issues whereas one addressed other health systems performance issues. This contributed to improved staff knowledge of community beliefs and skills in ANC services, as well as staff attitude towards clients (outputs). This led to increased trust in ANC services and improved quality of care (outputs).\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;so the project has actually affected most of our indicators positively. You know, as part of our strategy, we said we are going to conduct customer care training. Because what was making ANC coverage go down was because the way clients are treated when they come to the health facilities was not the best. After training staff, we don't receive such complaints from clients again. And that has had effect on ANC attendance.\u0026rdquo;\u003c/em\u003e (Suhum DHMT member)\u003c/p\u003e \u003cp\u003eHowever, the implementation of the strategies and their consequential effects were influenced by contextual factors such as socio-cultural beliefs, high staff turnover, resource constraints, and a shift in the focus of media-based education on ANC due to COVID-19.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;We have Traditional Birth Attendants (TBAs) in the communities who are offering health care to pregnant women and also conducting deliveries. So, per the cultural belief system in the communities, most people prefer TBAs services to the hospital ANC services. This affects ANC coverage and birth outcomes. As part of our HR/HS strategies, we are collaborating with the TBA and sensitizing the communities\u0026rdquo;\u003c/em\u003e (Suhum DHMT member)\u003c/p\u003e \u003cp\u003eNotwithstanding, the effects of the strategies (outputs) contributed to a significant improvement in ANC access, coverage and quality, thereby increasing ANC registrants by 15%, ANC coverage by 7.5% and skilled delivery by 9.9% (outcomes) between 2018 and 2020.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;I think, let me first speak on the service indicators, service indicators, I think has gone up, it has improved. When you look at our ANC coverage which was our principal problem selected, at the time we started the intervention, we were at 73.6%, then the following year, it went up after the implementation of the HR/HS strategies to 76.1%. But apart from that some other indicators have also been affected positively. For instance, postnatal care has also gone up, skilled delivery as we speak now has also improved. All these can largely be attributed to improved staff skills and quality of ANC services due to the strategies.\u0026rdquo;\u003c/em\u003e (Suhum DHMT member)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eYilo Krobo: Increased Yaws case detection and service coverage\u003c/h2\u003e \u003cp\u003eOf the five strategies selected to address the district\u0026rsquo;s prioritized yaws case detection (inputs) in Yilo Krobo district, two directly tackled health workforce performance issues while three addressed other health systems performance issues. These contributed to improved staff competencies in NTDs (neglected tropical diseases) case detection, improved DHMT support for yaws case detection, as well as improved community knowledge on yaws and increased yaws cases search (outputs).\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;. yes, I think the [HR/HS] strategies are fit for purpose, it worked because, through those strategies, we\u0026rsquo;ve been able to sensitize our health workers and communities on Yaws\u0026hellip;We were detecting very few cases of Yaws even though we suspect more cases exist. We took it upon ourselves to strengthen our skills at both DHMT and facility levels through training on Yaws case detection, and increased support to health centers and CHPS for active case search. Now we are detecting more cases.\u0026rdquo;\u003c/em\u003e (Yilo Krobo DHMT member)\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;we\u0026rsquo;ve been able to improve staff knowledge on Yaws case search and now detecting cases. So, for me the strategies worked. From 3 cases to 86 within eight months.\u0026rdquo;\u003c/em\u003e (Yilo Krobo DHMT member)\u003c/p\u003e \u003cp\u003eHowever, the implementation of the strategies and their effects were influenced by contextual factors such as high staff turnover, resource constraints, and COVID-19. Notwithstanding, the effects of the strategies (outputs) contributed to improving the quality of yaws services, thereby significantly increasing yaws case detection from 3 (2017) to 33 (2018), 88 (2019), and 50 (2020) (outcomes). The decline in case detection between 2019 and 2020 was attributed to COVID-19.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;You know, COVID really affected our progress in Yaws case search, During COVID, community surveillance of NTDs [Neglected Tropical Diseases], particularly active case search through durbars, outreaches, school visits, and home visits were suspended based on a directive from GHS. Some routine DHMT activities were also suspended which generally affected the HR/HS strategies implementation. Now we have drastically retrogressed on our success.\u0026rdquo;\u003c/em\u003e (Yilo Krobo DHMT member)\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Generally, during the COVID outbreak we shifted more focus to COVID-19 activities at the expense of routine health programs within the district, which affected our active Yaw case detection. The strategies were very helpful, so we\u0026rsquo;ll surely re-strategize and continue its implementation to sustain our progress.\u0026rdquo;\u003c/em\u003e (Yilo Krobo DHMT member)\u003c/p\u003e \u003cp\u003eHaving presented the logical pathway to the outcome of the HR/HS strategies implementation in the three intervention districts, the next section discusses the intricacies of the HR/HS strategies implementation processes and effects.\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe study assessed the logical pathway to desired UHC and service delivery outcomes using participatory action research (PAR) - based on an adapted Logical Framework Approach (LFA) (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). DHMTs developed quite sophisticated work plans, based on detailed problem analyses, which included coherent and integrated sets of HR strategies supported by HS strategies (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). In all study districts, the MSI inputs (HR/HS strategies implementation) addressed workforce performance and health system issues thereby improving health service performance (\u003cem\u003eoutputs\u003c/em\u003e), and consequently service delivery access, coverage and quality (\u003cem\u003eoutcomes\u003c/em\u003e). However, the degree of HR/HS strategies implementation varied across the study districts, and no DHMT fully implemented selected strategies due to contextual challenges. The implemented strategies were effective at contributing to the outputs of improved skills of health workers, community participation, supervision and patient-centered care. These outputs resulted in improved outcomes, for example increased OPD access and coverage, quality yaws case detection and services, increased ANC coverage and skilled delivery. However, the initial impact of some plans was seriously affected by contextual challenges - in particular COVID-19 which led, for example, to clinic closures and reductions of staff availability.\u003c/p\u003e \u003cp\u003eLike many other intervention implementations (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e), the DHMT members who participated in the intervention were trained on the key components of the MSI approach (i.e., PAR - comprising problem prioritization and analysis, HR/HS strategies planning and implementation, monitoring and evaluation of strategies) (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). The success observed in this study relative to the extent of HR/HS strategies execution is mainly borne out of the DHMTs capacity building on the intervention approach at the outset and the cordial relationship that existed between DHMTs and researchers throughout the HR/HS strategies implementation (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWe found that DHMTs implemented the HR/HS strategies within funding envelopes available to the DHMTs (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Although this is appropriate for sustainability, the findings of this study corroborate the report by Ridde (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e), that limited financial resources is an existential challenge for the degree of health intervention implementation and, success towards achieving UHC and improving health services in Africa. There is therefore the need for innovative thinking to overcome funding constraints. In this study, DHMTs piggybacked on projects and programmes with funding. More importantly, for integrated HR/HS strategies implementation to achieve desired goals, it requires good team teamwork, inclusive decision making, and task sharing among participants to enable flexibility to overcome challenges, without compromising process and content quality.\u003c/p\u003e \u003cp\u003eFurthermore, the results of this study seem to indicate that regular meetings, monitoring, and supportive supervision in HR/HS strategies implementation are significant moderating factors that facilitate the extent of successful implementation and its impact on UHC and health service delivery improvement. The attendance of meetings and workshops by workforce may have been facilitated by the provision of allowances in line with normal practice. This strengthened the DHMT\u0026rsquo;s commitment to implement the HR/HS strategies, thereby accelerating the extent of execution of the workplans. Meanwhile, the DHMTs\u0026rsquo; involvement in the intervention did not undermine health service delivery through possible diversions from competing priorities. Unfortunately, the outbreak of COVID-19 resulted in a shift in focus and interest of influential national stakeholders and DHMTs from the HR/HS strategies implementation to the pandemic.\u003c/p\u003e \u003cp\u003eIn this study, DHMTs\u0026rsquo; trust in the strategies increased over time and consequently confidence in their value. Thus, to improve sub-national level access, coverage and quality of healthcare services in decentralized health systems like Ghana using PAR, there is a need to ensure consistent advocacy and engagement with relevant stakeholders (particularly decision makers and influential health actors) on the value and benefits of the intervention strategies, and provide regular mentoring and supportive supervision to lower decision-making levels (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAvailable evidence shows that strict adherence to the integrated HR/HS strategies implementation and improvement of UHC indicators is unlikely to occur in environments where the intervention participants have diverse contextual influences (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). Likewise, this study observed varied degrees of contextual issues affecting strict adherence to the strategies\u0026rsquo; implementation across the different study districts. For instance, whereas some districts were successful in lobbying for and leveraging available resources to implement the strategies, others faced dire resource constraints. Also, the strategies implementation was affected by high staff turnover in the health sector. Challenges regarding human resources in complex interventions are well documented (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). These challenges could militate against effective strategies implementation and thus achievement of UHC and effective service delivery.\u003c/p\u003e \u003cp\u003eFurthermore, the decentralized health structure contributed immensely to the UHC and service delivery outcomes realized by the study DHMTs. Thus, the DHMTs\u0026rsquo; authority allowed them to select and prioritize specific district problems and indicators, as well as incorporate their HR/HS strategies into their annual action plans for smooth implementation. Regular modifications to the modalities of HR/HS strategies implementation at the district level could only have been possible within the specific authority of the DHMTs. Also, for the strategies to significantly contribute to improving UHC and service delivery indicators, there is the need for continuous monitoring and review of the intervention processes, as well as constant review of solutions to address contextual challenges.\u003c/p\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eImplication for policy and practice\u003c/h2\u003e \u003cp\u003eFirstly, future adoption of the PAR approach for health systems strengthening and UHC drive should consider using a holistic systems approach. Thus, the health systems thinking approach would facilitate the smooth embedment of the strategies into the routine operations of the health managers for better UHC outcomes. Secondly, for integrated HR/HS strategies to reach their full potential of strengthening subnational level health workforce performance through PAR in order to stimulate the achievement of UHC and improve health service delivery indicators, health managers should maintain flexibility in the design and implementation of the strategies. Finally, contextual challenges should be managed by leveraging working partnerships with key local and national stakeholders in the sector.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eStudy strengths and limitations\u003c/h2\u003e \u003cp\u003eThe major strength of this study is the triangulation of quantitative and qualitative data sources and analyses that promoted a richer understanding of the study findings through the generation of logical pathways for the design, implementation and outcome of the HR/HS strategies. This knowledge will allow for replication and/or scale-up. Also, we triangulate quantitative and qualitative results, allowing for a holistic presentation of the logical pathway of the MSI strategies to the observed outcomes. The limitation of this study is in the approach used in designing, implementing and assessing the HR/HS strategies that may have been influenced by the researchers\u0026rsquo; subjective feelings.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eA well-performing health workforce is needed for stronger health systems to accelerate the pace of achieving UHC in Ghana. The logical pathway to the effects and outcomes reported by this study demonstrates that the implemented HR/HS strategies can be effective for strengthening health workforce performance in the lower tiers of the decentralized health system (district) of Ghana, to facilitate efforts towards achieving UHC and improve service delivery. The versatility and flexibility of PAR render it fit-for-purpose in tackling the dual problems relating to human resource for health and health services through participatory implementation of HR/HS strategies, for better health outcomes in Ghana and similar contexts.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical clearance was obtained from the Ghana Health Service Ethics Review Committee,\u0026nbsp;an agency under the Ghana Ministry of Health (MOH) with national oversight for all health research involving human participants in Ghana\u0026nbsp;(Reference #: GHS-ERC: 004/01/20). Also, permission was sought from the Eastern Regional Health Directorate and District Directorate of Health Services for the selected study districts. All study participants were provided with written informed consent forms, which they signed to indicate willingness to participate in the study, and the data collected was anonymous.\u0026nbsp;The study conformed to all the dictates of the Helsinki Declaration\u0026nbsp;(40).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e: Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors hereby declare no conflict of interest in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the European Union Horizon 2020 research and innovation programme: [Grant Number 733360].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSamuel Amon:\u003c/strong\u003e Conceptualization, Methodology, Data collection, and analysis, Writing - Original draft preparation.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ePatricia Akweongo:\u003c/strong\u003e Conceptualization, Methodology. \u003cstrong\u003eJoanna Raven:\u0026nbsp;\u003c/strong\u003eConceptualization, Methodology. \u003cstrong\u003eTim Martineau:\u0026nbsp;\u003c/strong\u003eConceptualization, Methodology.\u003cstrong\u003e\u0026nbsp;Moses Aikins:\u003c/strong\u003e Conceptualization, Methodology. \u003cstrong\u003eAll:\u003c/strong\u003e Writing - Reviewing and editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis manuscript is an output from a PhD programme sponsored by the PERFORM2Scale project (reference number: 733360): Strengthening management at district level to support the achievement of Universal Health Coverage, funded by the European Commission. The project (2017 to 2022) sought to scale up the effective Management Strengthening Intervention to have a wider impact on additional districts across Ghana, Malawi, and Uganda and to institutionalize the approach. We express our profound gratitude to the sponsor and all participants of the study from the regional and district levels of the Eastern Regional Health Administration of Ghana.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. Monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies. World Health Organization; 2010.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChee G, Pielemeier N, Lion A, Connor C. Why differentiating between health system support and health system strengthening is needed. 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(Pty) Ltd, Durban, South Africa. 2008.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCraig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M. Developing and evaluating complex interventions: the new Medical Research Council guidance. Int J Nurs Stud. 2013;50(5):587\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrant A, Treweek S, Dreischulte T, Foy R, Guthrie B. Process evaluations for cluster-randomised trials of complex interventions: a proposed framework for design and reporting. Trials. 2013;14(1):1\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKok M, Bulthuis S, Dieleman M, Onvlee O, Murphy R, Akweongo P, et al. Using a theory of change in monitoring, evaluating and steering scale-up of a district-level health management strengthening intervention in Ghana, Malawi, and Uganda\u0026ndash;lessons from the PERFORM2Scale consortium. 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JAMA. 2025;333(1):71\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"participatory action research, health workforce performance strengthening, universal health coverage, healthcare services improvement, district, Ghana","lastPublishedDoi":"10.21203/rs.3.rs-9059452/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9059452/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eEvidence from low- and middle-income countries (LMICs) shows that a comprehensive strategy that uses a participatory approach to problem-solving improves health workforce performance and service delivery. This study assessed the logical pathway for health services improvement towards achieving universal health coverage (UHC) in Ghana using participatory action research (PAR) methodology.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA convergent parallel mixed-methods study design was used to assess the logical pathways of the integrated health systems strategies outcomes in three districts. The Logical Framework Approach (LFA) was adopted for the intervention pathway assessment. Using PAR approach, health system problems were identified, solution strategies designed and implemented by local health managers, community health committees and researchers. For the intervention effects on service delivery, pre- and post-intervention data for selected service delivery indicators were collected in September 2018 and September 2020 respectively, and analyzed. The data were collected using structured questionnaire and interview guide. Quantitative data was descriptively analyzed. Qualitative analysis was done using thematic approach, aided by QSR NVivo version 14.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOur study findings indicate that using a participatory approach for health system problems identification, solution strategies selection and implementation can effectively strengthen district health managers\u0026rsquo; performance and consequently improve health service delivery indicators at primary healthcare (PHC) level. Service delivery indicators in the three study districts were observed to have improved, with increases in OPD per capita by 4.1%; ANC coverage by 7.5%; and yaws case detection by 15 times, addressing equity in UHC.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe logical pathway to the impacts reported by this study demonstrates that through PAR, the selected HR/HS strategies can be effective for strengthening workforce performance in the lower tiers of decentralized health systems, thereby leading to improved healthcare access, coverage and quality towards the achievement of UHC.\u003c/p\u003e","manuscriptTitle":"Logical pathway for healthcare services improvement towards achieving Universal Health Coverage in Ghana: A participatory action research approach","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-19 07:49:19","doi":"10.21203/rs.3.rs-9059452/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"180323963651113719182129950594448230268","date":"2026-04-15T20:07:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"62786059683164993659949774947823898941","date":"2026-04-10T07:40:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"31992086078036545334468026028142948430","date":"2026-04-08T18:35:09+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-08T07:08:43+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-06T08:53:15+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-17T07:39:45+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-15T13:23:44+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2026-03-15T13:20:27+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5958aa31-0886-4a54-a131-824f91f289f0","owner":[],"postedDate":"April 19th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-19T07:49:19+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-19 07:49:19","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9059452","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9059452","identity":"rs-9059452","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}