UNDERSTANDING HEALTH CENTER MANAGEMENT AND PERFORMANCE UNDER PERFORMANCE BASED FINANCING IN NIGERIA
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This exploratory sequential mixed method research aimed to understand the key determinants of performance for primary health care centers (PHCCs) under the performance based financing (PBF) scheme in Nigeria, and examine the relationship between health center management practices and performance. Specifically, the research carried out a qualitative case study of eight best and poorly performing PHCCs to identify key differentiating factors for performance (Chapter 1), explored management practices of health centers as a major potential driver of performance through developing a management practice scorecard (Chapter 2), and examined using the scorecard the association between the level of various management practices and performance at the PHCCs under the PBF scheme (Chapter 3). The case study in Chapter 1 found critical differences between high and low-performing PHCCs in the areas of community engagement and support, and performance and staff management. Chapter 1 also found that (i) contextual and health system factors particularly staffing, access, and competition with other providers; (ii) health center management including community engagement, performance management, and staff management; and (iii) community leader support are influencing each other to drive performance improvement of the PHCCs. Among them, the study highlighted that the good health center management can overcome some of the contextual barriers and enhance community leader support. Through Chapter 2, we developed a novel scorecard that measures management practices in the PHCCs in developing countries. The developed scorecard includes 32 measurement practices in 6 broad areas: (i) community/client engagement; (ii) stakeholder engagement; (iii) staff management; (iv) planning and target setting; (v) performance management; and (vi) use of funds and financial management. The tool was validated through the review by experts and local practitioners, high inter-rater reliability, and exploratory factor analysis (EFA) with the data from 110 PHCCs that refined the scorecard into reduced 17 items with a different grouping. Through Chapter 3, we found a strong correlation between higher total scores for the selected eight management practices and faster improvement in outcomes. The review of each of the eight management practices found positive correlations with outcomes for patient recruitment and retention activities; staff attention to targets; listening and responding to client feedback; team work building; and addressing low performing staff. This research found that improving a set of key management practices can accelerate the improvement of PHCC performance. In particular, it provided qualitative and quantitative evidence about the importance of strategic community engagement activities, health worker accountability and motivation for improvement, and team building in improving health center performance. The developed management scorecard provides a solid foundation for further development of a reliable and validated tool for government and development partners to use to measure management capacity of PHCCs.