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

Previous studies have shown that facility autonomy, especially control over budget allocation, and management practices can have a modest positive effect on health facility performance, but the evidence is limited and often qualitative. Data from the evaluation of the Nigeria States Health Investment Project (NSHIP), a study that examined the effects of direct facility and performance-based financing, offers a novel opportunity to quantitatively examine these relationships in the context of a lower middle-income country. We utilize non-parametric statistics and regression methods to test the hypothesis that autonomy, supervision, and management affected facility performance. 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, regressions show that facilities with high autonomy held an additional 2.1 outreach sessions per month and facilities with a business plan offered 1.8 additional outreach services (<i>p</i> < 0.05). Supervision practices, including visit frequency and a quantitative checklist, are associated with 26% higher productivity and up to a 29% increase in equipment availability (<i>p</i> < 0.05). Sensitivity analyses validated that results are robust. We conclude that facility-level autonomy and especially budget control can improve primary healthcare facility readiness and service availability. Further, management practices that are reinforced through supportive supervision and routine monitoring can maximize the benefits that accrue from even small amounts of incremental financing. This shows that these policies and practices can contribute critically to efficiently achieving the goals of universal healthcare policies in the context of limited resources.