District Health Management and Public Service Delivery: Evidence from India's Flagship Health Programme

There is now a strong body of evidence of what interventions are most effective in improving health in low- and middle-income countries but little is known about how to ensure widespread coverage in the population. Weak public service delivery has long been regarded as the key obstacle, particularly in countries with the greatest gaps in service coverage. Nowhere is the issue more salient than India, where the state has struggled to deliver basic public services to its population, despite the presence of elite national institutions and a highly educated top brass of civil servants. One reason for the current status quo is possibly poor managerial quality in the civil service, yet there is almost a complete absence of evidence linking practices in civil service organisations to effective service delivery and outcomes.

The research aims to study the relationship between the management practices civil servants in district health offices operate under and the delivery of health services in Madhya Pradesh, India. We examine this question in the context of the National Rural Health Mission (NRHM), India's flagship health programme. Three phases of work are envisaged. The first phase (9 months) builds on previous research in economics to develop a tool that will ultimately provide a quantitative measure of managerial quality in our particular setting. The development of the tool will rely on qualitative methods of research to get perspectives from key informants on what dimensions of management are most important for staff productivity, as well as to provide a rich understanding of the bureaucracy in place. The second phase (3 months) involves the collection of management data from health bureaucrats in the 45 districts of Madhya Pradesh. The primary method of data collection will be phone interviews, in which interviewers score districts across a number of different dimensions of management. These will be complemented with face-to-face interviews in a subset of districts for the purposes of validation. In the third phase (6 months), the management practices data will be linked to household and health facility data from the District Level Health Survey to examine whether managerial quality is linked to better implementation of the NRHM and higher coverage of maternal and child health services.

The research has the potential to improve health outcomes by informing government policy on ways to ensure more effective health service delivery. It will lead to greater understanding of management practices in India's civil service and ultimately better implementation of key government health programmes.

The research comprises three objectives. The first objective is to develop a tool to measure quantitatively the quality of management in district health offices of Madhya Pradesh, India. Activities under this objective build on pioneering work in economics to measure management in private manufacturing firms, and subsequent adaptations made in a study of the Nigerian civil service. The development of the tool will be underpinned by theoretical insights (eg. from the new performance management literature) and a rich understanding of India's district bureaucracy (eg. the organisational structure, appointment processes, culture, language and protocol). The latter will be informed by qualitative research. In-depth interviews of bureaucrats will shed light on what dimensions of management are most important in making staff more productive and what questions can be used to score practices.

The second objective is to collect data on the management practices from bureaucrats working in all 45 district health offices of Madhya Pradesh. Two data collection approaches will be tested. The first involves phone interviews and an established double-blinding technique. The second approach is face-to-face interviews in a subset of randomly selected districts to test the reliability of the phone interview technique. Various weighting schemes will be used to generate an overall measure of management quality from the data on individual practices.

The final objective will link the management practice data to micro household and facility data from the fourth round of the District Level Health Survey to examine whether managerial quality is correlated with better programme implementation and population uptake of health services. Econometric analysis will examine the robustness of the relationship through the inclusion of various fixed effects (for district, type of project and interviewer), individual characteristics and respondent noise controls.

The research offers real potential to affect health outcomes by informing government policy on how to improve the effectiveness of public health service delivery. There are three pathways through which the research could ultimately achieve this goal. First, the outputs from this research grant are expected to have an impact through their influence on government policy and research practice. Second, the research will inform the development of a full-scale research proposal. The outputs from such the subsequent research will seek to inform government efforts on how to improve managerial quality. Third, the management tool has the potential to be used by government as a rapid appraisal tool to identify strengths and weaknesses in current management practices in the civil service. If widely adopted, the tool itself may influence public service delivery.

The research team has already engaged with the government in the State of Madhya Pradesh (MP) on this research to ensure that it will be nested within ongoing efforts by the government to improve service delivery in the health sector. We have buy-in at the highest level as demonstrated by the support of the National Health Systems Resource Centre (NHSRC) which is the lead national technical agency guiding the National Rural Health Mission. This relationship will be vital for research uptake. Consultation meetings to sensitise the government of the research plans and disseminate findings have been budgeted. These will be instrumental in providing an opportunity for the research to influence policymaking around management and public service delivery.

Our research team has for many years engaged closely with the development community both in India and internationally through consultancies, previous research grants and the provision of technical advice on health systems. PHFI and LSHTM have strong links with health advisors in numerous international agencies. In particular, providing DFID with high quality evidence and influencing their work is one of our priorities, given their commitment to improving health systems and public service delivery.

We are determined to realise the potential for the research to influence the next generation of health professionals and decision makers in India, the UK and beyond. LSHTM and PHFI are leading public health training institutions in their respective countries with global reach. Members of the research team will integrate the findings of the research into course material. We intend to capitalise on an existing Wellcome Trust capacity building grant held at PHFI by involving a few junior researchers in the collection of data and training them in research skills relevant to this proposal.