Ways to measure managerial performance in health: Lessons from India

30-second summary Collecting 360-degree data helps generate learnings on aspects such as job satisfaction or motivation which are hard to quantify. Putting in place mechanisms to cross verify performance data from multiple sources increases confidence of the analysis. Using innovative measurement techniques and incorporating contextualized assessment tools captures the nuances adequately and is a robust way to assess performance. .

The importance of measuring intangible leadership elements

Managerial competency, widely understood to be a combination of managers’ knowledge, skills and attitudes, can largely be measured in two ways: i) quantitatively, which is a summary of core tasks managers must undertake for their roles; and ii) qualitatively, or the mapping of soft skills and motivational methods public health managers use to lead and manage the providers they supervise.

Measuring the qualitative aspect of management practice, as well as its determinants, is not a straightforward task, and is often ignored in practice. A growing body of literature shows that these intangible aspects of a manager’s work are as important as their other competencies when it comes to improving the performance of a health facility. These include leadership styles as well as a manager’s preference for encouraging providers to work in teams and promoting decentralised decision making, decentralised decision making,

Our assessment confirms that the type of leadership demonstrated by health managers impacts the motivation and job satisfaction of those whom they supervise significantly. Penalising actions take a toll on the levels of job satisfaction and motivation of community health workers’ (henceforth providers). Unsurprisingly, supportive actions lead to positive increases in the same. There are similar positive relationships between teamwork and decentralised decision making, and job satisfaction and motivation as well.

Our approach

We collected 360-degree data on leadership styles by asking managers what they perceived as their usual style and compared it with similar questions posed to providers about how they are managed.

We bucketed these questions into three common leadership styles found in health systems literature including:

• Transactional leadership refers to using the ‘hard power’ and formal and informal management mechanisms conferred upon managers by the system. Hard power is indeed hard to come by in public health facilities where managers often lack the authority to hire, fire, promote or reward their providers.
• Transformational leadership enables individuals in teams to feel intrinsically motivated to work together by motivating team members to solve problems, empowering them to take decisions, and encouraging them to be innovative and creative.
• Laissez-faire leadership is simply the absence of any leadership.

We tested the impact of these leadership styles by capturing simple measures of motivation/amotivation as well as proxy measures of job satisfaction.

Motivation pertains to an individual’s intent to achieve personal and organizational goals. We realised that motivation levels as assessed by individuals themselves can be misleading. This is because when asked directly how motivated one is to do one’s job there is social desirability bias to exaggerate and say that one is very motivated. Motivation could also vary with circumstances and other systemic influences such as interactions with co-workers and supervisors in the workplace. Job satisfaction, in our opinion, is a better and more nuanced measure of increased inclination to achieve organisational goals.

Job satisfaction is a positive emotional state resulting from facets of organizational setting as well as from achieving collective goals. For our study we measured satisfaction through different aspects of work such as job responsibilities and compensation, job feedback, job empowerment, team composition, team spirit and decision making and confidence in leadership and management. These indicators better reflect the impact of leadership styles and functions on providers’ motivation to perform better and ultimately on health service delivery. We then statistically checked for relationships between these different indicators.

We found that job satisfaction and motivation had a significant impact on provider performance so factors such as adopting a leadership style should be prioritised in any reform initiative.

Three Lessons for practitioners to develop performance metrics:

1. Build in proxy measures to increase confidence in data used for performance management– Motivation is hard to describe and even harder to quantify. Using measures such as job satisfaction or satisfaction with different aspects of the work climate are good proxies for feeling motivated to achieve organisational goals. For example, asking an employee if they are motivated to work may give biased results vulnerable to observational effects, but asking an employee how satisfied they are with the specific important aspects of their jobs such as pay, work-life balance etc. could help construct more robust measures for actual motivation levels of the individual.

2. Collect multiple points of view on intangible aspects such as perceived behaviours - Collecting information from a singular point of view would limit the relevance of the data points. For instance, whether managers think of themselves as supportive towards their supervisees is only relevant when they are also perceived as such by the latter.

3. Avoid blanket labelling of leadership behaviours. Consider a more balanced approach – We found that different types of leadership are not mutually exclusive, but rather simply distinct methods that are effective in different scenarios. While there are good vs. bad leadership and management practices, it is not possible for managers to always be one way or the other. Managers could be transformational in some respects and transactional in others. Their leadership styles are often influenced by the resource constraints in public health settings as well as the increasingly complex and dynamic relationships between different cadres, genders, and technical proficiency levels of individuals. To be effective leaders, managers need to use leadership styles appropriately, to effectively improve the performance of and to improve service delivery at the facility level.

Managerial performance and its determinants will remain tricky to measure in complex systems. Early consideration of some of these learnings during programme inception and tool design could increase the robustness of performance measurement. In fact, assessments of similar nature, which are limited by the accessibility of certain intangible metrics such as those involving psychosomatic indicators for instance, could benefit from using the learnings laid out above to ensure conclusive results.

About the authors:

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

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

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