Pathways to high and low performance: factors differentiating primary care facilities under performance-based financing in Nigeria

Abstract

The determinants of primary health facility performance in developing countries have not been well studied. One of the most under-researched areas is health facility management. This study investigated health facilities under the pilot performance-based financing (PBF) scheme in Nigeria, and aimed to understand which factors differentiated primary health care centres (PHCCs) which had performed well, vs those which had not, with a focus on health facility management practices. We used a multiple case study where we compared two high-performing PHCCs and two low-performing PHCCs for each of the two PBF target states. Two teams of two trained local researchers spent 1 week at each PHCC and collected semi-structured interview, observation and documentary data. Data from interviews were transcribed, translated and coded using a framework approach. The data for each PHCC were synthesized to understand dynamic interactions of different elements in each case. We then compared the characteristics of high and low performers. The areas in which critical differences between high and low-performers emerged were: community engagement and support; and performance and staff management. We also found that (i) contextual and health system factors particularly staffing, access and competition with other providers; (ii) health centre management including community engagement, performance management and staff management; and (iii) community leader support interacted and drove performance improvement among the PHCCs. Among them, we found that good health centre management can overcome some contextual and health system barriers and enhance community leader support. This study findings suggest a strong need to select capable and motivated health centre managers, provide long-term coaching in managerial skills, and motivate them to improve their practices. The study also highlights the need to position engagement with community leaders as a key management practice and a central element of interventions to improve PHCC performance.

Performance-based financing in low-income and middle-income countries: isn’t it time for a rethink?

“…By presenting itself as a comprehensive approach that makes it possible to address all aspects of the health system in any context, PBF monopolises attention and focuses policy dialogue on the short-term results of PBF programmes while diverting attention and resources from broader processes of change and necessary reforms. 53 We argue that the latter include a wide range of improvements to: working conditions; human resources management (disparities in health staff distribution; quality of initial and vocational training; low salaries and poor accountability; plethora of untrained health staff, as in the case of DRC) 64 ; transparency in use of financial resources; quality of care; integration of programmes and their monitoring and evaluation 65 ; accountability; performance of public financial management; engagement of communities (eg, as village health committees, traditional leaders and other community members) in governing the demand and supply of health services 66 ; and so on. Paradoxically, all of these are structural determinants of PBF’s own performance.…”

"It Depends on What They Experience in Each Health Facility. Some Are Satisfied, Others Are Not." A MixedMethods Exploration of Health Workers’ Attitudes Towards Performance-Based Financing in Burkina Faso

“…This resonates findings from another process evaluation of the PBF intervention in Burkina Faso 40 and previous findings for instance in Malawi 8 or Nigeria. 42 Clearly, in a setting with severe human resources shortages like Burkina Faso, appointing only managers with sufficient managerial skill is not a viable option for sheer lack of qualified candidates to choose from. However, future training measures both within the context of PBF and beyond might want to focus more on training managers not only in technical but also in interpersonal aspects of organizational change processes.…”

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

“…Among many factors that potentially determine the performance of primary health facilities, one of the most under-researched areas is health facility management. Several studies [1][2][3][4][5] have identified specific health facility management practices that are associated with the improvement of health facility performance including: (i) engaging and problem-solving with local stakeholders [3], particularly with community leaders [5]; (ii) building a system of accountability [4], through performance management activities [5]; (iii) motivating health workers for change [2,3,5];…”

“…(iv) building work around teams and creating a sense of belonging, trust and respect [1,3,5]; (v) providing management support [1,3,5]; and (vi) improving health facility managers leadership competency to build a supportive environment for staff [2,4,5].…”

“…Much of the research on primary health care (PHC) management practices in low and middleincome countries (LMICs) is qualitative in nature, employing case studies and realist evaluations to understand which types of management practices work in which settings [1][2][3][4][5]. Quantitative empirical studies aimed at measuring these critical health facility management practices and exploring the relationship between such practices and health facility performance are limited primarily to inpatient settings in developed countries [6][7][8][9][10][11][12][13][14][15][16][17].…”