Evidence from rural healthcare centres in Nigeria suggests that managerial supervision improves health outcomes, but that it must be ongoing
Access to a clinic when you’re sick doesn’t equal healthcare. The quality of care in many countries is low despite increased access to facilities in recent years. A recent survey across seven African countries found health providers missing-in-action between 14 and 45% of the time, with an average of 29% across countries. Even when present, health providers adhered to clinical guidelines less than half the time in all seven countries (Wane and Martin 2016). What leads to good healthcare? In rich countries, there is wide variation in health outcomes even across facilities with similar resources (Skinner 2011).
Management may be the missing link. Good managers organise the staff, equipment, and facilities in efficient ways to deliver the best health outcomes. Healthcare facilities with better management have better health outcomes (Bloom et al. 2014). In countries with limited resources, good management may help healthcare facilities to get the most out of the resources they have.
How do you improve management?
Recently, the Nigerian government contracted a firm to improve the management of their rural healthcare centres in six states. In the full management intervention, staff received a brief, general training on providing quality of care, a baseline quality assessment, assistance in developing a plan to improve the quality of care, and nine months of regular visits in which staff learned to set goals and evaluate progress. In other words, staff learned – or were supposed to learn – key aspects of good management.
At the same time, the firm delivered a light intervention to another set of centres in those same states. In the light intervention facilities, staff just received the initial, general training and the baseline quality assessment. Rather than sustained training in management, they essentially just received information on the quality of their current performance. This was obviously a less intensive intervention, but if health staff already had management skills – merely lacking information about what practices they should adopt – it may have been enough to improve the quality of care.
We worked with the government of Nigeria to randomly allocate facilities either to the full management intervention, the light intervention, or a control group that continued with business as usual (Dunsch et al. 2017). As a result of the randomisation, the facilities receiving the two interventions and the business-as-usual group were all similar before the intervention, so any difference we observe after the interventions are plausibly due to the interventions.
Which was more effective – management training or information?
Over the nine months of the intervention, the full management intervention facilities demonstrated clear gains across a number of organisational practices. Some of these practices required only an easy, one-time effort, like displaying posters reminding staff and patients to wash hands or clearly marking waste bins (in order to improve the disposal of medical waste). But others required sustained effort, like labelling and organising drugs in the pharmacy or making handwashing supplies consistently available in the consulting room. The facilities were also cleaner, both in the waiting rooms and the bathrooms. The facilities that received the light intervention – alternatively – showed no clear improvements. Better information alone was not enough, but coaching mattered for achieving better management.
With an intervention like this, we test for a lot of different potential improvements, so a potential concern is that the positive impacts on management training are spurious results, or artefacts of testing lots of things and having a few show up positive by chance (an issue known as ‘multiple hypothesis testing’). We used various statistical techniques to adjust for this, and they all support the pattern of results we discuss about above.
What happens after the coaching visits stop?
Facilities receiving the full management intervention are better managed. But is that because staff have internalised new management techniques – having a plan, setting goals, and evaluating progress – or because the regular visits of coaches remind staff to stay focused on quality? To test this, we visited the facilities one year after coaching visits had stopped. If the training and coaching increase skills, we’d expect the improvements to be sustained. But if the training and coaching just reminded staff to stay focused, then they might not.
At the end of the year, virtually all impacts had disappeared. And this wasn’t because all the trained staff had transferred away – in fact, more than two-thirds remained in their posts. Ongoing supervision – focused on setting and achieving goals to improve healthcare quality – was crucial to maintaining gains. Of course, even consistent supervision didn’t solve many fundamental challenges in the quality of care, like consistent access to water, power, and a full set of lifesaving drugs. Management matters, but one way to help even rural healthcare facilities achieve better management involves consistently helping them to remain focused on it. And it may help to make sure they have essential supplies as well.
Photo credit: DFID.
Bloom, N, R Sadun, and J Van Reenen (2014), “Does management matter in healthcare?” Stanford University.
Dunsch, F, D K Evans, E Eze-Ajoku and M Macis (2017), “Management, supervision, and healthcare: A field experiment”, IZA Institute of Labor Economics, Discussion Paper 10967.
Skinner, J (2012), “Causes and consequences of regional variations in healthcare,” Handbook of Health Economics, Volume 2.
Wane, W, and G Martin (2016), “Service Delivery Indicators: Health Service Delivery in Uganda,” World Bank, African Economic Research Consortium, African Development Bank, and African Development Fund.