SUPPORT Summaries
Evidence of the effects of health system interventions
for low- and middle-income countries
Evidence of the effects of health system interventions
for low- and middle-income countries
February, 2017 - SUPPORT Summary of a systematic review | print this article | download PDF
District managers are playing an increasingly important role in determining the performance of health systems in low-income countries as a result of decentralization. Different approaches are used to improve the quality of district managers, including ways in which managers are hired, retained, and trained.
People making decisions concerning policies about hiring, retaining and training district health system managers
Rockers PC, Bärnighausen T. Interventions for hiring, retaining and training district health systems managers in low- and middle-income countries. Cochrane Database Syst Rev 2013; 4: CD009035.
A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.
SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.
A district health manager is responsible for overseeing the operations of the health system within a particular subnational geographical area. District managers are often responsible for planning and budgeting, human resources management and service quality monitoring. Poor performance by a district manager can lead to a number of problems, such as lack of drugs and supplies, delayed repair of broken equipment, health worker absenteeism and lack of motivation among health workers.
Different approaches are used to improve the quality of district managers. Some of these approaches address the way in which managers are hired and retained, for instance by making district management positions more attractive or by giving contracts (’contractingin’) to private, nongovernmental organizations (NGOs). Other approaches focus on the training and education of managers. All of these approaches aim to improve the quality of the health system and thereby the health of the population.
| Review objectives: To assess the effectiveness of interventions to hire, retain and train district health systems managers in low- and middle-income countries. | ||
| Type of | What the review authors searched for | What the review authors found |
|---|---|---|
| Study designs & interventions |
Randomised trials, quasi-randomised trials, controlled before-after studies, interrupted time series studies. Interventions related to hiring, retaining and training managers. |
One randomised trial: district managers were hired through private contracts to work within the Ministry of Health system. One controlled before-after study: 18-month manager training program. |
| Participants | District health systems managers in low- and middle-income countries. | District health systems managers. |
| Settings | Districts in low- and middle-income countries. | Cambodia (1); Mexico, Colombia, El Salvador (1). |
| Outcomes | Health systems: population health outcomes; access; utilization; quality; efficiency; equity. Operational: job-posting vacancy rates, skills. | Health facility staffing and supervision, maternal and child health service use (e.g. immunization, antenatal care), and population health outcomes (e.g. diarrhea incidence). Managers’ competencies. |
| Date of most recent search: December 2011 | ||
| Limitations: This is a well-conducted systematic review with only minor limitations. | ||
Rockers PC, Bärnighausen T. Interventions for hiring, retaining and training district health systems managers in low- and middle-income countries. Cochrane Database Syst Rev 2013; 4: CD009035.
Rockers PC, Bärnighausen T. Interventions for hiring, retaining and training district health systems managers in low- and middle-income countries. Cochrane Database Syst Rev 2013; 4: CD009035.
High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.
Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.
Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.
Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.
* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.
† Substantially different = a large enough difference that it might affect a decision.
See last page for more information.
Two studies were included in the review. One in Cambodia evaluated private contracting of district health managers. The other evaluated training programs conducted in Mexico, Colombia, and El Salvador.
1) Private contracts for district health managers
In the intervention districts, managers were hired through private contracts to work within the Ministry of Health system (“contractin” districts), while management of control districts remained the responsibility of managers employed directly by the Ministry of Health. The contractin districts were managed by international NGOs, formalized and monitored user fees, had competitive bidding, had performance based incentives, and received a total public spending that was 60% higher.
Private versus public contracts of district health managers |
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| People: District health managers Settings: Cambodia Intervention: Private contracts (“contracting in”) Comparison: Managers employed directly by the Ministry of Health |
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| Outcomes | Impact | Certainty of the evidence (GRADE) |
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| Population health outcomes | The effect of private contracts on illness reporting, diarrhea incidence, and the probability of infant death is uncertain. | Very Low | |
| Access to health care | Contracting-in district management increased the probability that a health facility would be open 24-hours by 83% (95% CI: 61 to 105). Further, contracting-in district management increased the probability that medical equipment and supplies would be available. |
Low |
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| Utilization of health care | Contracting-in district management increased use of antenatal care by 28% (95% CI: 16 to 40) and use of public facilities by 14% (95% CI: 6 to 22). |
Low |
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| GRADE: GRADE Working Group grades of evidence (see above and last page) | |||
District managers in the intervention and control groups were surveyed at baseline and then again at follow up, after intervention managers took part in an 18 month training program that included five training courses lasting five days each. The training courses focused on developing managers’ skills related to “needs assessment, local planning, monitoring and evaluation, drug management, risk approach, quality assurance, resource management, program management, information systems, and community participation.”
Manager training program versus no training |
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| People: District health managers Settings: Mexico, Colombia, El Salvador Intervention: 18-month manager training program Comparison: No training |
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| Outcomes | Impact | Certainty of the evidence (GRADE) |
|
| District managers’ knowledge measured outside of practice |
Inservice district manager training increased knowledge of planning processes. |
Low |
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| District managers’ skills measured outside of practice | Inservice district manager training increased monitoring and evaluation skills. |
Low |
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| GRADE: GRADE Working Group grades of evidence (see above and last page) | |||
| Findings | Interpretation* |
|---|---|
| APPLICABILITY | |
|
The two included studies were conducted in low and middle income countries. |
The capacity and strength of the government to oversee and supervise districts with private contracts could be an important issue to consider.
|
| EQUITY | |
| No equity considerations were addressed in the review. |
Impacts on equity of policies regarding hiring, retaining, and training of district health managers depend on the nature of the policies (e.g. effective policies targeted at underserved populations could reduce inequities, whereas universal policies that do not take into account differences across districts might increase inequities. |
| ECONOMIC CONSIDERATIONS | |
| No economic considerations were addressed in the review. |
Hiring, retaining and training policies for district health managers could potentially have important impacts on the use of resources, depending on how much authority district managers have and the resources at their disposal. |
| MONITORING & EVALUATION | |
| Private contracts (contract-in) and training for district health managers were evaluated by the studies included in the review. |
Well designed randomised trials evaluating policies for hiring, retaining, and training district health managers are needed.
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*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgements were made see: http://www.support-collaboration.org/summaries/methods.htm |
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Engelbrecht, Beth. Financial management: an overview and field guide for district management teams. Durban: Health Systems Trust, 2002. http://www.hst.org.za/publications/financial-management-overview-and-field-guide-district-management-teams
Segall M. District health systems in a neoliberal world: a review of five key policy areas. Int J Health Plann Man-age 2003;18(Suppl 1):5–26.
The Health Managers Tool Kit: Organizational Sustainability. Web page: http://erc.msh.org/toolkit/
Cristian A. Herrera. Unit for Health Policy and Systems Research, School of Medicine, Pontificia Universidad Católi-ca de Chile. Santiago, Chile.
None declared. For details, see: www.supportsummaries.org/coi
This summary has been peer reviewed by Airton Stein. We did not receive any comments from the
review authors.
Rockers PC, Bärnighausen T. Interventions for hiring, retaining and training dis-trict health systems managers in low- and middle-income countries. Cochrane Database Syst Rev 2013; 4: CD009035.
Cristian A. Herrera. What are the impacts of policies regarding hiring, retaining and training district health system managers? A SUPPORT Summary of a sys-tematic review. February 2017. www.supportsummaries.org
All Summaries:
evidence-informed health policy, evidence-based, systematic review, health sys-tems research, health care, low and middle-income countries, developing coun-tries, primary health care, district health managers, training, hiring, retaining.
The Health Policy and Systems Research Unit (UnIPSS) is a Chilean research collaboration for the generation, dissemination and synthe-sis of relevant knowledge about health policy and systems based at the School of Medicine of the P. Universidad Católica de Chile.
Engelbrecht, Beth. Financial management: an overview and field guide for district management teams. Durban: Health Systems Trust, 2002. http://www.hst.org.za/publications/financial-management-overview-and-field-guide-district-management-teams
Segall M. District health systems in a neoliberal world: a review of five key policy areas. Int J Health Plann Manage 2003;18(Suppl 1):5–26.
The Health Managers Tool Kit: Organizational Sustainability. Web page: http://erc.msh.org/toolkit/
Cristian A. Herrera. Unit for Health Policy and Systems Research, School of Medicine, Pontificia Universidad Católica de Chile. Santiago, Chile.
None declared. For details, see: www.supportsummaries.org/coi
This summary has been peer reviewed by Airton Stein. We did not receive any comments from the
review authors.
Rockers PC, Bärnighausen T. Interventions for hiring, retaining and training district health systems managers in low- and middle-income countries. Cochrane Database Syst Rev 2013; 4: CD009035.
Cristian A. Herrera. What are the impacts of policies regarding hiring, retaining and training district health system managers? A SUPPORT Summary of a systematic review. February 2017. www.supportsummaries.org
Keywords
All Summaries:
evidence-informed health policy, evidence-based, systematic review, health systems research, health care, low and middle-income countries, developing countries, primary health care, district health managers, training, hiring, retaining.
This summary was prepared with additional support from:
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The Health Policy and Systems Research Unit (UnIPSS) is a Chilean research collaboration for the generation, dissemination and synthesis of relevant knowledge about health policy and systems based at the School of Medicine of the P. Universidad Católica de Chile. |
