The World Bank Group Health, Nutrition and Population Global Practice, Washington, DC, USA.
Centre for Petroleum, Energy Economics and Law, University of Ibadan, Ibadan, Nigeria.
Health Policy Plan. 2018 Jan 1;33(1):41-58. doi: 10.1093/heapol/czx146.
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.
发展中国家基层卫生机构绩效的决定因素尚未得到充分研究。研究最少的领域之一是卫生机构管理。本研究调查了尼日利亚试点绩效为基础的融资（PBF）计划下的卫生机构，旨在了解哪些因素将绩效好的基层医疗保健中心（PHCC）与绩效差的 PHCC 区分开来，重点是卫生机构管理实践。我们使用了多案例研究，对每个 PBF 目标州的两个高绩效 PHCC 和两个低绩效 PHCC 进行了比较。两组各两名经过培训的当地研究人员在每个 PHCC 各工作一周，收集半结构化访谈、观察和文件数据。使用框架方法对访谈数据进行转录、翻译和编码。对每个 PHCC 的数据进行综合分析，以了解每个案例中不同要素的动态相互作用。然后，我们比较了高绩效和低绩效者的特征。高绩效和低绩效者之间出现关键差异的领域是：社区参与和支持；以及绩效和员工管理。我们还发现，（i）背景和卫生系统因素，特别是人员配置、获得服务的机会以及与其他提供者的竞争；（ii）卫生中心管理，包括社区参与、绩效管理和员工管理；以及（iii）社区领导支持相互作用并推动 PHCC 的绩效提升。其中，我们发现，良好的卫生中心管理可以克服一些背景和卫生系统障碍，并增强社区领导的支持。本研究结果表明，非常有必要选择有能力和积极性的卫生中心管理人员，提供长期的管理技能培训，并激励他们改进管理实践。该研究还强调，需要将与社区领导的互动作为一种关键的管理实践，并将其作为改善 PHCC 绩效的干预措施的核心要素。
