February, 2017 - SUPPORT Summary of a systematic review | print this article |

What are the impacts of policies regarding hiring, retaining, and training district health system managers?

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.

 
Key messages

  • Private contracts (“contracting in”) of district health managers compared to direct employment by the Ministry of Health may improve access and utilization of healthcare. It is uncertain whether contracting in improves health outcomes.
  • Intermittent training programs may increase knowledge of planning processes and monitoring and evaluation skills of district managers.
  • The effects of other interventions are uncertain, including changes in how district managers are hired, strategies for retaining district managers such as making the positions more attractive, and other training programs such as inservice workshops with onsite support.

 

Background

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.

 



About the systematic review underlying this summary

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.  

Summary of findings

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 contracts (contracting in) of district health managers compared to direct employment by the Ministry of Health may improve access and utilization of health care. The certainty of this evidence is low.
  • It is uncertain whether contracting in improves population health outcomes. The certainty of this evidence is very low.

 

Private versus public contracts of district health managers

People: District health managers
Settings
:  Cambodia
Intervention
: Private contracts (“contracting in”)
Comparison
: Managers employed directly by the Ministry of Health
Outcomes Impact Certainty of the evidence
(GRADE)
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

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

GRADE: GRADE Working Group grades of evidence (see above and last page)

2) Manager training program

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 programs may increase knowledge of planning processes and monitoring and evaluation skills. The certainty of this evidence is low

 

Manager training program versus no training

People: District health managers
Settings
: Mexico, Colombia, El Salvador
Intervention
: 18-month manager training program
Comparison
: No training
Outcomes Impact Certainty of the evidence
(GRADE)
District managers’ knowledge measured outside of practice
Inservice district manager training increased knowledge of planning processes.

Low

District managers’ skills measured outside of practice Inservice district manager training increased monitoring and evaluation skills.

Low

GRADE: GRADE Working Group grades of evidence (see above and last page)

 

 

 

Relevance of the review for low-income countries

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.

 

  • The extent of decentralization might change the impact of policies related to health managers.

 


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.

 

  • Consideration should be given to piloting changes in policies before implementing them on a large scale, or to conducting impact evaluations.

 


*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

 

Additional information

Related literature

 

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/

 

This summary was prepared by

Cristian A. Herrera. Unit for Health Policy and Systems Research, School of Medicine, Pontificia Universidad Católi-ca de Chile. Santiago, Chile.

 

Conflict of interest

None declared. For details, see: www.supportsummaries.org/coi

 

Acknowledgements

This summary has been peer reviewed by Airton Stein. We did not receive any comments from the

review authors.

 

This review should be cited as

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.

 

The summary should be cited as

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

 

Keywords

 

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.

 

This summary was prepared with additional support from:

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.

 

 

 

 

Related literature

 

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/

 

This summary was prepared by

Cristian A. Herrera. Unit for Health Policy and Systems Research, School of Medicine, Pontificia Universidad Católica de Chile. Santiago, Chile.

 

Conflict of interest

None declared. For details, see: www.supportsummaries.org/coi

 

Acknowledgements

This summary has been peer reviewed by Airton Stein. We did not receive any comments from the

review authors. 

 

This review should be cited as

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.    

 

The summary should be cited as

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:

Home :  

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.

 

 

 



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