Evidence gap map of performance measurement and management in primary healthcare systems in low-income and middle-income countries

Abstract

IntroductionWe mapped available evidence on performance measurement and management (PMM) strategies in primary healthcare (PHC) systems of low-income and middle-income countries (LMICs). Widely used, their effectiveness remains inconclusive. This evidence gap map characterises existing research and evidence gaps.MethodsSystematic mapping of performance measurement and management research in LMICs from 2000 to mid-2018; literature searches of seven academic databases and institutional repositories of impact evaluations and systematic reviews. Using a combination of manual screening and machine learning, four reviewers appraised 38 088 titles and abstracts, and extracted metadata from 137 impact evaluations and 18 systematic reviews that met the inclusion criteria. The resulting visual representation of the evidence base was uploaded to a web-based platform.ResultsSince 2000, the number of studies has increased; the first systematic reviews were completed in 2010. Two-thirds of the studies were conducted in sub-Saharan Africa and South Asia. Randomised controlled trials were the most frequently used study design. The evidence is concentrated in two types of PMM strategies: implementation strategies (in-service training, continuing education, supervision) and performance-based financing. Major gaps exist in accountability arrangements particularly the use of audit and feedback. The least studied types of outcomes were unintended effects, harm and social equity.ConclusionsThe evidence is clustered around interventions that are unlikely to achieve transformational change in health outcomes. The gaps identified suggest that routinely used PMM strategies are implemented without sufficient knowledge of their effects. Future efforts at redesigning PHC systems need to be informed by evidence on the most effective approaches for using PMM strategies.

Performance management in complex adaptive systems: a conceptual framework for health systems

“…A recent evidence gap map on performance management in primary healthcare in low-income and middle-income countries (LMICs) suggests the existing approaches—and interventions to support them—are often unsuccessful at driving organisational and population-level outcomes. 3 This mirrors findings in the broader public sector management and human resource management (HRM) literature, which also report unintended and sometimes negative effects from performance management systems. 4–6 …”

“…2 A recent evidence gap map on performance management in primary healthcare in low-income and middle-income countries (LMICs) suggests the existing approachesand interventions to support them-are often unsuccessful at driving organisational and population-level outcomes. 3 This mirrors findings in the broader public sector management and human resource management (HRM) literature, which also report unintended and sometimes negative effects from performance management systems. [4][5][6] Frameworks for considering the performance of health systems conceptualise performance management as a 'continuous process of establishing targets, monitoring performance against those targets, and implementing and adapting improvement efforts', 7 undertaken within facilities (or equivalent, such as primary care teams)-the meso-level, organisational-level of the health system.…”

“…Evidence is largely limited to studies on the effects of a narrow subset of implementation support strategies (such as in-service training) and financial incentive systems (such as pay-for-performance) on immediate individual outcomes (such as provider knowledge). 3 There are far fewer studies on other strategies (eg, audit and feedback) or distal outcomes (such as effective coverage and gains in health and/or equity).…”

“…30 31 The intention was to combine perspectives on how complexity has been considered in the design, implementation and evaluation of performance management systems from across disciplines (health systems, public management and HRM), rather than systematically covering all articles ever published on the topic. Literature was sourced from existing systematic reviews of the evidence, 3 a Google Scholar search for ‘complex performance management’ and similar combinations, and a snowball approach from references cited in reviewed papers. Data on how complexity had been conceptualised was abstracted, along with findings from empirical studies.…”

Measuring management practices in primary health care facilities – development and validation of management practices scorecard in Nigeria

“…However, there has been no instrument to help assess management practices and provide critical feedback to improve health facility management to-date. Recent systematic reviews of researches on primary health care systems in LMICs suggest that major research gaps exist in how to improve facility management [ 31 ], and that routinely used performance measurement and management strategies are implemented without sufficient knowledge of their effects [ 32 ]. This scorecard can help address these critical gaps thus strengthening primary care services.…”