The relationship between decision-making autonomy and training on facility-level management performance of primary health care facilities in Odisha, India

Introduction

All United Nations member states have pledged to achieve universal health coverage (UHC) by 2030¹ There is general agreement that primary health care is a foundational component of UHC as it expands comprehensive service coverage while linking health to people’s homes and communities; however, primary health care delivery and quality are generally poor and improvement is slow and limited^2,3. Countries that have successfully expanded access to primary health care still struggle to improve the quality of care delivered².

Improving primary health care facility management may be one important tactic for improving quality. The World Management Survey (WMS) project has documented how managerial and organizational practices are critical for organizational productivity, and how variation in managerial quality may account for an important amount of the differences in productivity between countries and industries^4–6. In health care, recent studies have suggested that better management is associated with higher quality care and improved health outcomes at higher level facilities⁶. Although management quality has not been robustly studied at the primary health care facility level, a recent randomized experiment evaluated the effects of management consulting for primary health care centers in Nigeria [8]. The study showed short-term improvements in management practices suggesting potential for positive change, though it was not able to demonstrate an effect on long-term outcomes⁷.

A relationship between management quality and health outcomes has been demonstrated outside of primary care. A 2014 survey of over 2000 hospitals worldwide – including hospitals in India – showed lower 30-day mortality from acute myocardial infarctions in the best-managed hospitals⁸. Importantly, they found that this effect was most pronounced in countries such as the United States and United Kingdom where managers of hospitals were independent, not politically appointed, and had higher degrees of autonomy to change practices within their hospital. The study suggests that managerial autonomy may be important for achieving better health outcomes and that further study of the factors that make high quality management possible may help better target and refine future interventions.

Similarly, a study of Ugandan health facilities found some evidence of a positive relationship between the decentralization of decision-making authority and managerial performance⁹. The locus of decision-making authority can serve as a proxy for measuring autonomy; if decision-making is at the level of facility managers rather than local or national government, the facility, theoretically, has greater autonomy over its own functioning. Managerial autonomy alone may not improve overall health care performance, but it does have a role in mitigating factors including supply and staffing shortages, which ultimately impact the ability to deliver high quality care⁹. Together, literature suggests that the effectiveness of facility managers in high-autonomy settings is likely related to the management skills of individual managers and may help to achieve better health outcomes^8,9.

Like many countries, recent reforms in India are focused on improving rural care delivery and primary health care, including the introduction of a national public health insurance fund known as Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY)^10–12. Aligned with the broader Indian context, primary care in the state of Odisha is delivered through Primary Health Centers (PHC), Sub-Centers (SC), and Health and Wellness Centers (HWC), which were newly introduced by the AB PM-JAY initiative¹³. The provision of health services is centralized at the state-level, whereby states are responsible for the organization and delivery of care, resulting in wide variation across India¹³. More specifically, research in Odisha has identified variation in facility capacity for service provision; while antenatal care and immunizations are widely available, access to non-communicable disease care remains low¹⁴. Facilities report the ability to provide a wide range of primary health care services, but often lack the functional equipment and medications to deliver care consistently¹³. Additionally, there is little evidence on the state of primary health care management for both Odisha and India at large, but it is possible that existing service capacity gaps may be addressed in part by management quality.

Our previous work adapts the World Management Survey, a tool applied to hospital settings in high-income countries, into a primary health care-specific management evaluation for low- and middle income-countries known as the PRImary care facility Management Evaluation (PRIME) Tool^15,16. Use of the PRIME-Tool in Ghana found that higher management scores were associated with better supply stocks and patient-reported experiential outcomes¹⁶. In Uganda, better facility management was associated with better essential drug availability while facilities with better management scores trended towards better performance on a number of experiential quality measures¹⁷. Although the PRIME-Tool is unable to measure health outcomes, our previous studies suggest that the PRIME-Tool score is associated with patient-reported outcome and experiential quality^16,17.

Using the PRIME-Tool, we conducted a survey of managers in charge of primary care facilities across six districts within Odisha to better understand primary health care management and to determine:

Methods

Results

Our representative sample included 396 public sector facilities, of which 259 were SCs (65.4%), 130 were PHCs (32.8%), and 7 were HWCs (1.7%). HWCs were dropped from all analyses due to their limited representation within the data. The sample was assessed for outliers, and three exceptionally large facilities, based on outpatient volume per day (>5 standard deviations greater than the mean), and four facilities missing data on outpatient volume were also dropped. Altogether, 382 facilities were included in our final analysis (Table 1). The mean PRIME Score across all facilities in our final sample was 0.657 (standard deviation 0.148), and 63.6% of facilities answered “yes” to having any level of management training. For detailed information about the distribution of variables across our exposure of interest, please refer to our publicly published table “Characteristics of PHC facilities stratified by exposure.”

Decision-making autonomy in Odisha primary care facilities varied by decision type (Figure 1). The mean autonomy score across all facility types was 0.619 (standard deviation 0.305). Across all PHCs and SCs, Odisha’s Department of Health had the greatest authority over decisions regarding staff recruitment and staff promotion. For decisions surrounding facility maintenance, including ordering drugs, painting, or fixing walls, and spending internally generated funds, the decision-making authority most often rested within the health facilities themselves, although these decision categories were also controlled by central authorities in many instances.

Figure 1. The distribution of decision-making authority in PHC facilities in Odisha.

Blue indicates facility-level authority and orange indicates non-facility level authority.

After controlling for covariates, our model did not identify a significant relationship between facility-level autonomy and the PRIME-Tool score (Table 2). The coefficient on the interaction term in the second model was also not significant, suggesting that there is insufficient evidence to demonstrate that management training modifies the relationship between the autonomy score and the PRIME-Tool score. Notably, the model did measure a significant relationship between management training and the PRIME-Tool score (coefficient = 0.062, p<0.01).

Our secondary analysis also failed to measure any significant relationship between the autonomy score and the PRIME-Tool domain scores (Table 3). Our models did measure a significant relationship between completing any management training and scores in the human resources and monitoring domains of the PRIME-Tool; management training is associated with a predicted 0.160 higher Human Resources domain score and a 0.101 higher Monitoring domain score, both with p-values less than 0.0033.

Discussion

In this study, we sought to determine if decision-making autonomy is associated with primary health care facility management scores in Odisha, India, whether management training moderates that relationship, and which elements of facility management were most influenced. While our data do not support the hypothesis that autonomy positively influences the PRIME-Tool score, we found that receiving management training is associated with a higher overall score and scores in the Human Resources and Monitoring management domains.

Our hypotheses were derived from previous research in Uganda and Nigeria that studied both the impact of decision-making autonomy and the influence of management training on primary health care management performance. In Uganda, researchers found that decision-making autonomy was significantly associated with a positive increase in some management performance indicators⁹. In Nigeria, management training resulted in short term improvement in management practices but no sustained improvement past one year⁷. Contrary to evidence from Uganda, our results did not confirm a significant relationship between decision-making autonomy and management performance, but we did identify a positive relationship between management training and performance in specific management domains, as seen in Nigeria.

The statistically significant relationship between management training and management performance scores suggests that prioritizing training and skill development may help to increase overall management scores. It may be helpful to prioritize improving the quality of management training before further investigation of the role of autonomy in management performance. While autonomy and management training are likely both important components of primary health care facility management, their interdependent relationships may be more complex and multifactorial than our analyses here are capable of elucidating. There may also be components of facility-level autonomy and management that we were not able to capture with the autonomy score and PRIME-Tool score, leaving the need for a more targeted tool that can further examine this relationship and its context within a highly centralized government health system. Furthermore, these relationships may be context specific, and thus relationships present in Uganda or Nigeria may not be the same in Odisha. In the context of Odisha, decision-making autonomy varies by decision-type and rests between both the PHC-level and the regional department of health and this division in decision-making may further complexify the relationships therein.

While the PRIME-Tool summary scores may not yield clear relationships, by examining the domain scores within the tool, there is opportunity for targeted improvement initiatives specific to the Odisha context. Our study found that management training may improve performance in the Human Resources and Monitoring domains. Consequently, it may be opportune for future management training initiatives in Odisha to focus on skills related to these domains. Currently, management training in Odisha is limited to short, mandated courses provided by the state government on specific interventions and the quality of this training is not known. However, providing PHC managers with ongoing education and supportive supervision may help facilities to better support human resource management and facility monitoring and evaluation. This ultimately could increase the skill of managers at the facility level and enable more autonomous decision-making in concepts related to these domains. However, from study results alone, it remains unclear in the Odisha setting how much autonomy, and in what domains, managers should optimally be given.

Improving long-term health outcomes will require a multi-prong approach that holistically targets the broader health system, including strengthening governance and infrastructural improvements, in addition to improvement in facility autonomy and management. Given the importance of improving primary care delivery in the broader agenda of the Sustainable Development Goals and UHC, it is critical to continue studying the relationships between these different levers in order to best understand – both in Odisha and globally – how we can advance our collective goals^20,21. Ultimately, for sustainable progress towards strong primary care and achieving universal health coverage, all aspects of the system need to be supported to succeed.

Limitations

There are important limitations to this study. Firstly, our evaluation of management performance relies solely on cross-sectional technical skills assessments. Plausibly, this may discount or ignore the importance of “soft skills” of management, which include interpersonal skills such as leadership, communication, and teamwork among others. These soft skills could play a role at both the interpersonal and larger organizational levels²². The PRIME-Tool is not designed to assess these skills, and future assessments may wish to take this into account in developing more robust and nuanced tools, taking note of the differences in how these soft skills may differ across contexts. Additionally, the cross-sectional nature of the survey prevents the ability to discern any causal relationships. Moreover, the question on management training lacks a temporal and content dimension that allows for any answer regardless of time passed or extent and quality of training and may introduce a recall bias. This may have an impact on the study’s inability to find a moderating relationship of management training on the relationship between the autonomy score and the PRIME-Tool score.

Secondly, the sample included in this analysis is composed entirely of public sector facilities. We acknowledge that management in private sector primary care facilities in Odisha may have substantively different contexts, including levels of autonomy and the relationships between autonomy and performance. Similarly, given the likely differences in autonomy, it is plausible that management training may have different impacts within private sector facilities.

Finally, as previously mentioned, it is possible that these relationships differ across contexts throughout the world, and thus, these data may not be applicable outside of Odisha.

Data availability