A framework to assess management performance in district health systems: a qualitative and quantitative case study in Iran

Tabrizi, Jafar Sadegh; Gholipour, Kamal; Iezadi, Shabnam; Farahbakhsh, Mostafa; Ghiasi, Akbar

doi:10.1590/0102-311X00071717

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ARTICLE • Cad. Saúde Pública 34 (4) • 2018 • https://doi.org/10.1590/0102-311X00071717 copy

A framework to assess management performance in district health systems: a qualitative and quantitative case study in Iran

Um modelo para avaliar a gestão dos distritos sanitários no Irã: um estudo de caso qualitativo e quantitativo

Un marco para evaluar el desempeño de la gestión en el área de sistemas de salud: un estudio de caso cualitativo y cuantitativo en Irán

Authorship SCIMAGO INSTITUTIONS RANKINGS

The aim was to design a district health management performance framework for Iran’s healthcare system. The mixed-method study was conducted between September 2015 and May 2016 in Tabriz, Iran. In this study, the indicators of district health management performance were obtained by analyzing the 45 semi-structured surveys of experts in the public health system. Content validity of performance indicators which were generated in qualitative part were reviewed and confirmed based on content validity index (CVI). Also content validity ratio (CVR) was calculated using data acquired from a survey of 21 experts in quantitative part. The result of this study indicated that, initially, 81 indicators were considered in framework of district health management performance and, at the end, 53 indicators were validated and confirmed. These indicators were classified in 11 categories which include: human resources and organizational creativity, management and leadership, rules and ethics, planning and evaluation, district managing, health resources management and economics, community participation, quality improvement, research in health system, health information management, epidemiology and situation analysis. The designed framework model can be used to assess the district health management and facilitates performance improvement at the district level.

Keywords:
Local Health Systems; Health Systems; Health Evaluation; Efficiency

Variable	Qualitative phase		Quantitative phase
Variable	n	%	n	%
Gender
Male	39	86.7	16	72.7
Female	6	13.3	5	27.3
Education
MSc	-	-	2	9.5
MD	38	84.5	15	71.4
PhD	7	15.5	4	19.1
Job position
Head of department	10	22.2	9	42.8
District health manager	30	66.7	8	38.1
Faculty member	5	11.1	4	19.1
Years at current job
5-10	5	11.1	2	9.5
10-15	7	15.5	4	19.1
15-20	8	17.8	6	28.6
> 20	25	55.6	9	42.8

Row	Category/Indicator	CVR	CVI	Status
	Human resources and organizational creativity
1.	Employee job satisfaction ratio	0.90	0.70	Accepted
2.	The proportion of vacant positions	0.24	0.65	Rejected
3.	The proportion of employees in their organizational positions	0.71	0.86	Accepted
4.	The proportion of employees who havr used recreational services	0.62	0.71	Accepted
5.	The proportion of applicant’s employees early retirement	0.33	0.65	Rejected
6.	The proportions of employees who have over the yaers encouragement	0.62	0.83	Accepted
7.	The proportion of staff involvement in-service training courses	0.71	0.79	Accepted
8.	Job burnout status	0.71	0.86	Accepted
9.	Staff presence compliance to the district helath system	0.71	0.65	Rejected
	Management leadership
10.	The implementation of subordinate units monitoring and evaluation programs (health centers, hospitals, etc.)	0.81	0.86	Accepted
11.	The ratio of office staff to line staff	0.62	0.86	Accepted
12.	The program of managerial rounds that were carried out last year	0.52	0.76	13*Merged
13.	Management rounds performed in program in subsidiaries	0.90	0.87	Accepted
14.	Ratio of managers that hold a degree in management (participation in manager training courses)	0.62	0.83	Accepted
15.	Hold district coordination council meetings on a regular basis	0.71	0.90	Accepted
	Rules and ethics
16.	Systems and clear rules for appointment and dismissal of employees	0.90	0.73	Accepted
17.	Comply with employing position requirement	0.33	0.62	Rejected
18.	Active polls system in district	0.81	0.81	Accepted
19.	Feedback system for handling complaints is in place	1.00	0.84	Accepted
20.	The proportion of financial statements approved by the official auditors	0.24	0.78	Rejected
	Planning and evaluation
21.	A strategic plan for the district health system is in place	0.62	0.83	Accepted
22.	The ratio of units that havr operational programs in the district	0.33	0.76	Rejected
23.	Implementation of district health system action plans	0.90	0.90	Accepted
24.	Coordinate program(s) development with Provincial health authorities	0.90	0.62	Rejected
25.	Have written plans for health promotion through participation with district stakeholders in place	0.33	0.62	Rejected
26.	Percentage of indicators that achieved operational program goals	0.33	0.65	Rejected
27.	Have monitoring and evaluation programs in place	0.33	0.65	Rejected
28.	Have subordinate units monitoring checklist in place	0.90	0.90	Accepted
29.	The ratio of units have been monitored on a regular basis	0.24	0.76	Rejected
	Managing the district
30.	Have maps of health care centers in the district	1.00	0.90	Accepted
31.	Availability of healthcare centers’ information	1.00	0.75	Accepted
32.	Completion of distric health system development program(s)	0.81	0.90	Accepted
33.	Proportions of the population covered by the Family Physician Program	0.90	0.95	Accepted
34.	Have an organizacional structure of district health management in place	0.33	0.75	Rejected
35.	Have a list of district healthcare	1.00	0.84	Accepted
36.	District referral system performance	0.90	0.83	Accepted
37.	The proportions of districts holding health system committees	0.33	0.78	Rejected
38.	The proportion of districts committee holding	0.78	0.76	Accepted
	Health resources management and economics
39.	Have revenue and budget control plans in place	0.90	1.90	Accepted
40.	Financial analysis of units (unit costs)	0.81	0.90	Accepted
41.	Expenditures in compliance with budget plans	0.90	0.86	Accepted
42.	Have maintenance plans for equipment and buildings in place	0.81	0.94	Accepted
43.	Insurance deductibles rates in health centers	0.81	0.92	Accepted
44.	Rate of achievements predicted budget	0.24	0.62	Rejected
45.	Have an equipment purchasing plan for district health centers in place	0.33	0.76	Rejected
46.	Trend of health centers and facilites reconstruction	0.81	0.84	Accepted
47.	Proportion of the population exposed to catastrophic costs	0.24	0.76	Rejected
48.	The ratio of operating costs to capital costs	0.62	0.76	Accepted
49.	Have transparent processes for resource allocation in place	0.81	0.90	Accepted
50.	District health centers have budgeting program in place	0.14	0.76	Rejected
	Community participation
51.	NGO have information availabel locally	0.90	0.87	Accepted
52.	Analysis of NGO and public participation	0.52	0.62	Rejected
53.	How frequently the Board of Trustees of each district meet	0.71	0.81	Accepted
54.	The number of programs implemented with the participation of people or other organizations	0.81	0.86	Accepted
55.	The number of collaborative programs with NGOs in the region in accordance with relevant guidelines	0.81	0.90	Accepted
56.	The number of joint programs with other regional organizations	0.62	0.76	54*Merged
57.	Coverage ratio of health volunteers	0.90	0.81	Accepted
58.	The ratio of people who participated in health promotion programs	0.71	0.79	Accepted
59.	The proportion of health donors’ assistance to the total budget of district health centers	1.00	0.89	Accepted
60.	Guidelines and programs for cooperation with NGOs are in place	0.62	0.76	55*Merged
	Quality improvement
61.	The number of quality improvement projects performed in one year	0.81	0.78	Accepted
62.	The ratio of documented processes	0.81	0.76	Accepted
63.	The ratio of employees who have completed quality improvement courses	0.90	0.94	Accepted
64.	The ratio of health centers that lack essential drugs	0.24	0.65	Rejected
	Research in health system
65.	The number of research projects implemented in district health centers	0.43	0.76	Accepted
66.	The number of articles published in scientific journal by employees	0.71	0.76	Accepted
67.	The number of articles presented in congress by employees	0.24	0.76	Rejected
68.	The number of problems solved by research	0.52	0.76	Accepted
69.	Research priorities are in place at the district level	0.71	0.84	Accepted
	Health and information management
70.	The completion of a health data panel	0.90	0.78	Accepted
71.	Tracking of district health indicators and trend data	0.71	0.81	Accepted
72.	The number of inquiry of expert groups indicators in the technical/coordination committee of district	0.71	0.76	Accepted
73.	District data is stored usisng eletronic health records	0.24	0.76	Rejected
74.	Mangers’ ability to analysis and interpret health data	0.43	0.62	Rejected
75.	Health centers have performance feedback system in place	0.81	0.92	Accepted
	Epidemiology and situations analysis
76.	Tracking and recording prevalence and incidence data for various diseases per year	0.62	0.76	79*Merged
77.	Identification of important health risk factors in the district	0.90	0.90	Accepted
78.	Extraction of defined populations burden of disease	0.33	0.65	Rejected
79.	Tracking and recording information about trends of common diseases in the region during past decade	0.90	0.89	Accepted
80.	Have a district epidemiological data panelk in place	0.90	0.92	Accepted
81.	Have instrutions and guidelines for disease control in the district health centers in place	0.24	0.81	Rejected

Category	S-CVI/Ave
Human resources and organizational creativity	0.79
Management, leadership	0.86
Rules and ethics	0.79
Planning and evaluation	0.88
Managing the district	0.85
Health resources management and economics	0.88
Community participation	0.85
Quality improvement	0.83
Research in health system	0.78
Health information management	0.82
Epidemiology and situation analysis	0.90
Total framework	0.84

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[1] * Correspondence K. Gholipour Tabriz Health Services Management Research Center, Tabriz University of Medical Sciences. University Rd, EAZN 5166614711, Tabriz, Iran. gholipourk@tbzmed.ac.ir