Quantifying the intangible: Evidence from Nigeria on the impact of supervision, autonomy, and management practices on PHC performance in the context of Direct Facility Financing

Key messagesO_LISecondary analysis of data from the Nigeria States Health Investment Project showed improvements in facility autonomy, budget control, and management practices in experimental (PBF and DFF) districts much more so than in control districts. C_LIO_LISupportive supervision, including use of a quantified checklist, contributed to improvements in facility readiness to provide services and clinical productivity. C_LIO_LIPrimary healthcare facilities with better management practices had improved service readiness and offered more services than those with worse management practices. C_LI Previous studies have shown that facility autonomy, especially control over budget allocation, can have a modest positive effect on performance, but the findings depend on the context. Similarly, management practices are often cited as important contributors to facility performance, but the evidence is limited and usually qualitative. Data from the large-scale randomized evaluation of the Nigeria States Health Investment Project (NSHIP) offers an opportunity to quantitatively examine these relationships in the context of a lower middle-income country. We utilize non-parametric statistics to test for difference in means and apply regression analysis to test the hypothesis that autonomy and management affected facility performance. Our results show that facilities with greater autonomy, more budget control, and better management practices generally outperform their peers on a range of facility readiness and service delivery measures. For example, regression results found that facilities with high autonomy held on average 2.1 more outreach sessions per month than those without, and facilities with an annual business plan offered 1.8 additional outreach services. Supervision practices, such as more frequent visits and use of a quantitative checklist, are associated with 26% higher productivity and up to a 28.6% increase in equipment availability (percentage points), respectively. We conduct sensitivity analyses on our variable selection and use a random forest approach to validate that results are robust to changes in the model structure. We conclude that facility-level autonomy and especially budget control can improve primary healthcare facility readiness and service availability, even in resource-constrained contexts, Further, this can be achieved through good management practices that are reinforced through supportive supervision and routine performance monitoring to maximize the gains that result from incremental financing. This shows that these policies and practices can be critical contributors to efficiently achieving the goals of universal healthcare policies in the context of limited resources.