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Interventions for hiring, retaining and training district health systems managers in low- and middle-income countries

  1. Peter C Rockers1,*,
  2. Till Bärnighausen1,2

Editorial Group: Cochrane Effective Practice and Organisation of Care Group

Published Online: 30 APR 2013

Assessed as up-to-date: 24 FEB 2012

DOI: 10.1002/14651858.CD009035.pub2


How to Cite

Rockers PC, Bärnighausen T. Interventions for hiring, retaining and training district health systems managers in low- and middle-income countries. Cochrane Database of Systematic Reviews 2013, Issue 4. Art. No.: CD009035. DOI: 10.1002/14651858.CD009035.pub2.

Author Information

  1. 1

    Harvard University, Department of Global Health and Population, Harvard School of Public Health, Boston, Massachusetts, USA

  2. 2

    University of KwaZulu-Natal, Africa Centre for Health and Population Studies, Mtubatuba, South Africa

*Peter C Rockers, Department of Global Health and Population, Harvard School of Public Health, Harvard University, 667 Huntington Ave., Boston, Massachusetts, 02115, USA. prockers@hsph.harvard.edu.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 30 APR 2013

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Characteristics of included studies [ordered by study ID]
Bloom 2006

MethodsRandomized Controlled Trial


ParticipantsCountries: Cambodia

Participants: District health systems managers.

Sample: Three districts were randomized to receive a contracting-in treatment while four districts served as controls.


InterventionsIn districts receiving the contracting-in treatment, district managers were hired through private contracts to work within the Ministry of Health system.

Management of control districts remained the responsibility of managers employed directly by the Ministry of Health


OutcomesHealth facility staffing and supervision, maternal and child health service use (e.g., immunization, antenatal care), and population health outcomes (e.g., diarrhea incidence)


NotesNone


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskRandomization was quasi-stratified by province; the provincial health systems director randomly drew districts to assign them to the three experimental groups.

Allocation concealment (selection bias)High riskAllocation performed centrally at start of study. However, one district randomized to receive the contracting-in treatment was unsuccessful in establishing a working contractual relationship.

Baseline outcome measurementsLow riskAt baseline, one outcome differed between treatment and control (at 5% significance), but that was expected by chance with 22 outcomes.

Baseline characteristic measurementsUnclear riskNot reported.

Incomplete outcome data (attrition bias)
All outcomes
Low riskNo missing data.

Blinding (performance bias and detection bias)
All outcomes
Low riskPrimary outcomes were objective.

Contamination of experimental groupsLow riskUnlikely that control group received the intervention.

Selective reporting (reporting bias)Low riskAll relevant outcomes in the methods section are reported in the results section.

Other biasHigh riskEffect of contracting-in may be confounded by the 60% higher public spending for health care in the contracting-in districts compared to the control districts.

Diaz-Monsalve 2004

MethodsControlled before-and-after study


ParticipantsCountries: Mexico, Colombia, El Salvador.

Participants: District health systems managers.

Sample at baseline: 85 intervention managers; 71 control managers.

Sample at follow-up: 74 intervention managers; 66 control managers.


Interventions18-month manager training program.


OutcomesManagers’ competencies, including knowledge, job performance, co-ordination and communication skills, and use of monitoring and evaluation methods.

Measured outside of practice.


NotesNone


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskNo randomization for CBA design.

Allocation concealment (selection bias)High riskIt is not clear how managers were allocated to treatment and control groups.

Baseline outcome measurementsLow riskSimilar competencies between treatment and control groups at baseline.

Baseline characteristic measurementsLow riskSimilar demographic characteristics between treatment and control groups.

Incomplete outcome data (attrition bias)
All outcomes
High riskControl managers interviewed at baseline not the same as control managers interviewed at follow-up; substantial loss to follow-up in the intervention group in El Salvador.

Blinding (performance bias and detection bias)
All outcomes
High riskMain outcome measure largely relied on self report.

Contamination of experimental groupsLow riskUnlikely that control group received the intervention.

Selective reporting (reporting bias)Low riskAll relevant outcomes in the methods section are reported in the results section.

Other biasLow riskNone.

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Agyepong 1999Not an RCT, QRCT, CBA or ITS; a qualitative description.

Ambegaokar 2004Not an RCT, QRCT, CBA or ITS; a case study.

Ayaya 2007Not an RCT, QRCT, CBA or ITS; a cross-sectional survey.

Basri 2009Inappropriate target population; targeted TB program managers.

Briggs 2010Not an RCT, QRCT, CBA or ITS; a program description.

Byskov 2009Not an RCT, QRCT, CBA or ITS; a case study.

Bärnighausen 2009Not an RCT, QRCT, CBA or ITS; a review paper.

Clark 2001Not an RCT, QRCT, CBA or ITS; a program description.

Comolet 1997Not an RCT, QRCT, CBA or ITS; an uncontrolled before-and-after study.

Conn 1996Not an RCT, QRCT, CBA or ITS; a case study.

De Brouwere 1996Not an RCT, QRCT, CBA or ITS; a program description.

Dieleman 2009Inappropriate target population; targeted clinical professionals.

Djibuti 2009Inappropriate target population; targeted immunization program managers.

Egger 2007Not an RCT, QRCT, CBA or ITS; a case study.

Enkhtuya 2009Inappropriate target population; targeted immunization program managers.

Espino 2004Inappropriate target population; targeted clinical professionals.

Fonn 2011Not an RCT, QRCT, CBA or ITS; a qualitative description.

Grobler 2009Inappropriate target population; targeted clinical professionals.

Israr 2006Inappropriate target population; targeted program managers.

Jack 2003Inappropriate target population; targeted health facility managers.

Jain 1999Inappropriate target population; targeted family planning officers.

Jones 2008Inappropriate intervention; building a support system.

Kahindo 2011Not an RCT, QRCT, CBA or ITS; a case study.

Kalita 2009Not an RCT, QRCT, CBA or ITS; a program description.

Koehlmoos 2009Inappropriate target population; targeted health facility managers.

Krishnamurthy 2007Inappropriate target population; targeted clinical professionals (community health workers).

Lagarde 2009Inappropriate target population; targeted health facility managers.

Liu 2007Inappropriate target population; targeted health facility managers.

Liu 2008Inappropriate target population; targeted health facility managers.

Loevinsohn 2005Inappropriate target population; targeted health facility managers.

Loevinsohn 2009Not an RCT, QRCT, CBA or ITS; a case-control study.

MacFarlane 2006Inappropriate target population; targeted disaster program managers.

Mansour 2010Not an RCT, QRCT, CBA or ITS; a case study.

McEwan 2001Inappropriate target population; targeted management trainers.

McPake 1994Inappropriate target population; targeted health facility managers.

McPake 1995Inappropriate target population; targeted health facility managers.

Mills 1998Inappropriate target population; targeted health facility managers.

Mills 2004Not an RCT, QRCT, CBA or ITS; a case study.

Mugisha 2009Inappropriate target population; targeted health facility managers.

Mutabaruka 2010Inappropriate target population; targeted immunization program managers.

Naimoli 2003Not an RCT, QRCT, CBA or ITS; a case study.

Nankumbi 2011Inappropriate intervention; introduction of HIV clinical services.

Newbrander 2011Not an RCT, QRCT, CBA or ITS; a qualitative description.

Nigenda 2009Inappropriate target population; targeted health facility managers.

Okamoto 2009Not an RCT, QRCT, CBA or ITS; a case study.

Omar 2009Inappropriate outcome; measured participants’ perceptions of training course.

Omaswa 1997Inappropriate target population; targeted clinical professionals.

Palmer 2006Not an RCT, QRCT, CBA or ITS; a case study.

Pappaioanou 2003Not an RCT, QRCT, CBA or ITS; a case study.

Perry 2008Not an RCT, QRCT, CBA or ITS; a program description.

Sandiford 1994Not an RCT, QRCT, CBA or ITS; uncontrolled before-and-after.

Siddiqi 2006Not an RCT, QRCT, CBA or ITS; a qualitative description.

Sinha 2007Inappropriate target population; targeted insurance program managers.

Soeters 2003Not an RCT, QRCT, CBA or ITS; a case study.

Talbot 2009Inappropriate target population; targeted clinical professionals.

Tanaka 1999Not an RCT, QRCT, CBA or ITS; a case study.

Tarimo 1989Not an RCT, QRCT, CBA or ITS; a qualitative description.

Topçuoğlu 2004Not an RCT, QRCT, CBA or ITS; a case study.

Trap 2001Inappropriate target population; targeted clinical professionals (pharmacists).

USAID 2009Not an RCT, QRCT, CBA or ITS; a case study.

Van den Broucke 2010Inappropriate intervention; building a support system.

Varpilah 2011Inappropriate target population; targeted clinical professionals.

Vian 2007Inappropriate target population; targeted local non-governmental organizations.

WGIHSPT 1995Not an RCT, QRCT, CBA or ITS; a program description.

Yaping 2002Inappropriate outcome; measured participants’ perceptions of a training course.

 
Summary of findings for the main comparison.

Intervention: Training

OutcomesRelative effect
(95% CI)
Quality of the evidence
(GRADE)
Comments

Population health outcomesNo evidence

Access to health careNo evidence

Utilization of health careNo evidence

Quality of health careNo evidence

Efficiency of health careNo evidence

Equity of health careNo evidence

District manager job-posting vacancy ratesNo evidence

District managers’ knowledge measured within a practice environmentNo evidence

District managers’ skills measured within a practice environmentNo evidence

District managers’ knowledge measured outside of practiceIn one study (CBA), in-service district manager training significantly increased knowledge of planning processes.⊕⊕⊝⊝
low
1 CBA; downgraded due to serious risk of bias; upgraded due to large effect.

District managers’ skills measured outside of practiceIn one study (CBA), in-service district manager training significantly increased monitoring and evaluation skills.⊕⊕⊝⊝
low
1 CBA; downgraded due to serious risk of bias; upgraded due to large effect.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 
Summary of findings 2.

Intervention: Hiring

OutcomesRelative effect
(95% CI)
No of Participants
(studies)
No of Participants
(studies)
Quality of the evidence
(GRADE)

Population health outcomesIn one study (RCT), contracting-in district management did not significantly affect illness reporting, diarrhea incidence or the probability of infant death.1 RCT⊕⊕⊝⊝
low
Downgraded due to serious risk of bias; downgraded due to serious indirectness

Access to health careIn one study (RCT), 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.1 RCT⊕⊕⊝⊝
low
Downgraded due to serious risk of bias; downgraded due to serious indirectness

Utilization of health careIn one study (RCT), 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).1 RCT⊕⊕⊝⊝
low
Downgraded due to serious risk of bias; downgraded due to serious indirectness

Quality of health careNo evidence

Efficiency of health careNo evidence

Equity of health careNo evidence

District manager job-posting vacancy ratesNo evidence

District managers’ knowledge measured within a practice environmentNo evidence

District managers’ skills measured within a practice environmentNo evidence

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 
Table 1. Characteristics of contracting-in versus control districts in Bloom (2006)

 CharacteristicContracting-in districtsControl districts

Private versus public managementManagement by international NGOsManagement by the government

Competitive biddingCompetitive bidding based in part on prior experience of contractor and quality of key staffNone

ContractsContract targeting improvements; subcontracts implementedNo contracts

Hiring of district managersHiring of expatriates as district managers (presumably with higher salaries)Political allegiance (corruption) played a role, otherwise not described

IncentivesPerformance-based incentivesNot specified

User feesFormalization and monitoring of user fees; not a statistically significant difference in the amount collectedInformal fees

Public spendingTotal public spending 60% higher 

Consulting services and trainingNot specifiedHealth care management consulting services and management training

Supplemental fundingEligible to receive an operating supplement after submitting an acceptable plan

 
Table 2. Potential interventions for future research

Types of interventionsPrimary outcomesSecondary outcomes


Population healthAccess to and utilization of health careQuality and efficiency of health carePatient satisfactionDistrict manager knowledge and skill

Hiring and retaining

Direct financial incentives (e.g., signing bonuses)-----

Bonding (e.g., service-requiring scholarships)-----

Professional development opportunities (e.g., future program placement priorities)-----

Improvements to the work environment (e.g., facility infrastructure)-----

Training

Off-site in-service training--1 study

Low quality evidence
-1 study

Low quality evidence

On-site in-service training-----

Pre-career education-----

Mid-career education-----

Packages

Contracting-in1 study

Low quality evidence
1 study

Low quality evidence
-1 study

Low quality evidence
-