Interventions to hire, retain and train district health systems managers

Researchers in the Cochrane Collaboration conducted a review of the effect of interventions to hire, retain and train district health systems managers in low- and middle-income countries. After searching for all relevant studies, they found only two that met their prespecified study selection criteria.

Interventions to hire, retain and train district health systems managers

In many low- and middle-income countries, the responsibility for managing important aspects of the health services are being decentralized to local governing bodies, including district health teams. As a result, district health systems managers are playing an increasingly important role.

A district manager is responsible for overseeing the operations of the health system within a particular subnational geographical area. District health systems 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 ('contracting-in') 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.

What happens when efforts are made to hire, retain and train district health systems managers?

It is difficult to draw any conclusions about the effects of these types of interventions as the review only found two relevant studies. In addition, the evidence that the review did identify was of low quality.

Training: The available evidence suggests that in-service district manager training:

·       may lead to more knowledge about planning processes 

·       may lead to better monitoring and evaluation skills

None of the studies assessed the effects of district manager training on people’s health, on their access to or use of health care, or on the quality or efficiency of care.

Contracting-in: The available evidence suggests that private contracts with international NGOs for district health systems management:

·       may not affect people’s illness reporting, diarrhea incidence or infant death

·       may increase the likelihood that a health facility is open 24 hours

·       may increase the availability of medical equipment and supplies

·       may increase people’s use of antenatal care and public facilities

None of the studies assessed the effects of contracting-in district management on the quality or efficiency of health care, on job vacancy rates, or on district manager knowledge and skills.

Authors' conclusions: 

There is low quality evidence that contracting-in may improve health care accessibility and utilization and that intermittent training courses may improve district health systems managers’ performance. More evidence is required before firm conclusions can be drawn regarding the effectiveness of these interventions in diverse settings. Other interventions that might be promising candidates for hiring and retaining (e.g., government regulations, professional support programs) as well as training district health systems managers (e.g., in-service workshops with on-site support) have not been adequately investigated.

Read the full abstract...
Background: 

District managers are playing an increasingly important role in determining the performance of health systems in low- and middle-income countries as a result of decentralization.

Objectives: 

To assess the effectiveness of interventions to hire, retain and train district health systems managers in low- and middle-income countries.

Search strategy: 

We searched a wide range of international databases, including the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE. We also searched online resources of international agencies, including the World Bank, to find relevant grey literature. Searches were conducted in December 2011.

Selection criteria: 

District health systems managers are those persons who are responsible for overseeing the operations of the health system within a defined, subnational geographical area that is designated as a district. Hiring and retention interventions include those that aim to increase the attractiveness of district management positions, as well as those related to hiring and retention processes, such as private contracting. Training interventions include education programs to develop future managers and on-the-job training programs for current managers. To be included, studies needed to use one of the following study designs: randomized controlled trial, nonrandomized controlled trial, controlled before-and-after study, and interrupted time series analysis.

Data collection and analysis: 

We report measures of effect in the same way that the primary study authors have reported them. Due to the varied nature of interventions included in this review we could not pool data across studies.

Main results: 

Two studies met our inclusion criteria. The findings of one study conducted in Cambodia provide low quality evidence that private contracts with international nongovernmental organizations (NGOs) for district health systems management ('contracting-in') may improve health care access and utilization. Contracting-in increased use of antenatal care by 28% and use of public facilities by 14%. However, contracting-in was not found to have an effect on population health outcomes. The findings of the other study provide low quality evidence that intermittent training courses over 18 months may improve district health system managers’ performance. In three countries in Latin America, managers who did not receive the intermittent training courses had between 2.4 and 8.3 times more management deficiencies than managers who received the training courses. No studies that aimed to investigate interventions for retaining district health systems managers met our study selection criteria for inclusion in this review.

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