How to incentivise public health managers: Lessons from India

30-second summary Covid-19 has intensified the need to recognise, incentivise and reward public health managers. Managers need to be supported with relevant knowledge, skills, tools and resources to build their capacity as leaders. Managerial performance is also contingent on adequate staff, finance, supplies, infrastructure and an overall enabling policy environment and culture.

Public health managers form the backbone of a well-performing health system. Yet policymakers in low and middle-income countries (LMICs) struggle to design appropriate performance management levers for them. How do you incentivise and motivate health managers to keep delivering in an overburdened and under-resourced system? How do you distinguish the contribution of individual managers when their duties are intrinsically linked with colleagues and their performance is contingent on resource availability? What are the essential competencies that are required to develop health managers into leaders?

In this blog series, we provide key insights on individual performance measurement and management based on a recent comprehensive assessment of the leadership and management capabilities of block-level public health managers in a low-resource state in India. Questions of incentivisation become even more significant in the light of the Covid-19 pandemic. Public health managers are shouldering higher responsibilities in an environment of greater risk.

We make a case for policymakers and practitioners to design more holistic performance drivers at an individual level and to recognise the capacity development needs of managers. The design of appropriate and innovative performance mechanisms is critical, but how these are enforced is equally important. Moreover, a performance management system is not a silver bullet. There are several systemic factors that need to be aligned for a manger to be able to perform well.

The design of performance incentives. Insights from OPM’s assessment

Individual performance criteria should align with a manager’s role: We found that the performance metrics of health managers are often designed around outdated job descriptions and are not reflective of their actual work. In practice, managers take on additional and ad hoc responsibilities which crowd out their pre-defined duties. This could be due to varying reasons such as the introduction of new public health programmes or the pressing demands from higher authorities. As a first step, policymakers would do well to clearly map out the roles and responsibilities of health managers and to update performance metrics correspondingly, on a periodic basis. Process and quality indicators should also be mapped and assessed than relying solely on quantitative target achievement.

Performance metrics should be set only for areas that managers can control or deliver: Health managers are often the implementers of top-down bureaucratic strategies and decisions, with limited autonomy and decision space. Our assessment found that the performance criteria for managers are not set proportionate to what they control. For example, health managers are expected to ensure 100% routine immunisation coverage, though they often have limited or no control over key programme delivery aspects such as the supply chains, availability of community health workers or immunisation schedules. Performance metrics need to be reformed into a clear responsibility-accountability matrix.

Integrate behavioural competencies for leadership development: We found that public health managers are often a predominantly male cadre that oversees female community health workers. Our assessment revealed routine gendered biases within health systems that are rooted in deep socio-cultural contexts. These are demonstrated by disrespectful behaviour, insensitive language, lack of equal access to space, and apathy towards supervisees. Current performance management mechanisms, however, rarely incorporate or address behavioural characteristics. To create stronger and more equitable health systems, policymakers need to enhance behavioural competencies. Instilling accountability is also essential to correct structural inequities. Evidence has shown that promoting traits such as trust, team building, active communication, distributed decision making and collective problem solving are also key enablers for developing quality service delivery. These could be long-drawn-out and complex processes requiring sustained political commitment .

Managing performance in under-resourced systems

Recognise systemic barriers: Public health managers are a cog in the wheel of a complex and constantly shifting health system. Their behaviors, decisions and actions are influenced by the dynamics of other stakeholders and the resources made available to them including staff, medicines, essential supplies and infrastructure. Those evaluating the performance of health managers need to recognise not only their knowledge, skills and attitudes, but also the organisational and institutional environment in which they work. Policymakers need to clearly define what good performance for a particular health facility is, and the functions of an individual manager towards these organisational goals. Managers could then be assessed on whether they delivered their functions and demonstrated favorable behaviors, with an appreciation for the difficult geographies they operate in, the political pressures they often face, and the systemic constraints and social norms they grapple with.

Performance appraisals as a capacity development tool, rather than only an accountability measure: The public health managers we interviewed had a poor understanding of how performance appraisals determined their career prospects. They often lacked clarity on the link between their performance on the job, the annual appraisal process, and career progression. As is typical of many administrative systems in LMICs, even these paper exercises were often conducted erratically and were highly influenced by patronage relationships.

Such a fundamental shift in how appraisals are managed would firstly need substantial political and bureaucratic support. Health systems could benefit from well-defined competency frameworks for the managerial cadre to clearly set out the expectations for each role. An assessment of these can clarify a manager’s current strengths and weaknesses. They can also be used as a transparent and collaborative career development and accountability tool, enabling health managers to track and improve their personal and professional development on an ongoing basis. Read about how OPM has used competency frameworks in development programmes, and more specifically in this health systems project. Equipped with specific details of managerial competency gaps, policymakers could in turn offer appropriate support. This would need to be complemented with tougher and more political systemic shifts such as proportionate pay rewards, incentives and punishment for incompetency.

Provide leadership development support: For managers to be good leaders, they need to be provided with the relevant knowledge, skills, tools and resources required to perform their functions. Our assessment found that health managers were often overworked, held dual roles and worked in conditions characterised by acute shortage of supplies and equipment. Training was scarce and often limited only to the basic awareness of diseases or new health programmes and it rarely tackled leadership competencies. Evidence has shown that leadership development tools such as training, coaching and mentoring, peer exchanges and job aids empower managers, even in resource constrained settings, and enhance their ability to navigate difficult environments. Empowered managers can innovate and shift individual and team behaviours, in turn, to improve health service delivery.

This is the first in a two-part blog series on strengthening performance mechanisms and incentives for public health managers in highly under-resourced LMICs. In the next blog, read about a 360-degree approach we developed for assessing managerial capabilities to deliver their functions.

About the authors:

Madhavi Rajadhyaksha leads the India hub for Public Sector Governance. She is an experienced public policy professional supporting institutional reform across sectors. She is particularly interested in how multi-level governments function. [email protected]k

Rajiv Bhardwaj is a Research Coordinator working on a health systems project in India @email

Pratima Singh is an Assistant Consultant in the Health portfolio at OPM and specialises in quantitative evaluations of health systems strengthening programs with a focus on family planning and sexual reproductive healthcare. @email