Use of Balanced Scorecard Methodology for Performance Measurement of the Health Extension Program in Ethiopia

How to Engage Health Care Workers in the Evaluation of Hospitals: Development and Validation of BSC-HCW1-A Cross-Sectional Study

Organizations worldwide utilize the balanced scorecard (BSC) for their performance evaluation (PE). This research aims to provide a tool that engages health care workers (HCWs) in BSC implementation (BSC-HCW1). Additionally, it seeks to translate and validate it at Palestinian hospitals. In a cross-sectional study, 454 questionnaires were retrieved from 14 hospitals. The composite reliability (CR), interitem correlation (IIC), and corrected item total correlation (CITC) were evaluated. Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were used. In both EFA and CFA, the scale demonstrated a good level of model fit. All the items had loadings greater than 0.50. All factors passed the discriminant validity. Although certain factors' convergent validity was less than 0.50, their CR, IIC, and CITC were adequate. The final best fit model had nine factors and 28 items in CFA. The BSC-HCW1 is the first self-administered questionnaire to engage HCWs in assessing the BSC dimensions following all applicable rules and regulations. The findings revealed that this instrument's psychometric characteristics were adequate. Therefore, the BSC-HCW1 can be utilized to evaluate BSC perspectives and dimensions. It will help managers highlight which BSC dimension predicts HCW satisfaction and loyalty and examine differences depending on HCWs' and hospital characteristics.

A systematic review: the dimensions to evaluate health care performance and an implication during the pandemic

BACKGROUND

The balanced scorecard (BSC) has been implemented to evaluate the performance of health care organizations (HCOs). BSC proved to be effective in improving financial performance and patient satisfaction.

AIM

This systematic review aims to identify all the perspectives, dimensions, and KPIs that are vital and most frequently used by health care managers in BSC implementations.

METHODS

This systematic review adheres to PRISMA guidelines. The PubMed, Embase, Cochrane, and Google Scholar databases and Google search engine were inspected to find all implementations of BSC at HCO. The risk of bias was assessed using the nonrandomized intervention studies (ROBINS-I) tool to evaluate the quality of observational and quasi-experimental studies and the Cochrane (RoB 2) tool for randomized controlled trials (RCTs).

RESULTS

There were 33 eligible studies, of which we identified 36 BSC implementations. The categorization and regrouping of the 797 KPIs resulted in 45 subdimensions. The reassembly of these subdimensions resulted in 13 major dimensions: financial, efficiency and effectiveness, availability and quality of supplies and services, managerial tasks, health care workers' (HCWs) scientific development error-free and safety, time, HCW-centeredness, patient-centeredness, technology, and information systems, community care and reputation, HCO building, and communication. On the other hand, this review detected that BSC design modification to include external and managerial perspectives was necessary for many BSC implementations.

CONCLUSION

This review solves the KPI categorization dilemma. It also guides researchers and health care managers in choosing dimensions for future BSC implementations and performance evaluations in general. Consequently, dimension uniformity will improve the data sharing and comparability among studies. Additionally, despite the pandemic negatively influencing many dimensions, the researchers observed a lack of comprehensive HCO performance evaluations. In the same vein, although some resulting dimensions were assessed separately during the pandemic, other dimensions still lack investigation. Last, BSC dimensions may play an essential role in tackling the COVID-19 pandemic. However, further research is required to investigate the BSC implementation effect in mitigating the pandemic consequences on HCO.

Improving health and social systems for all children in LMICs: structural innovations to deliver high-quality services

Despite health gains over the past 30 years, children and adolescents are not reaching their health potential in many low-income and middle-income countries (LMICs). In addition to health systems, social systems, such as schools, communities, families, and digital platforms, can be used to promote health. We did a targeted literature review of how well health and social systems are meeting the needs of children in LMICs using the framework of The Lancet Global Health Commission on high-quality health systems and we reviewed evidence for structural reforms in health and social sectors. We found that quality of services for children is substandard across both health and social systems. Health systems have deficits in care competence (eg, diagnosis and management), system competence (eg, timeliness, continuity, and referral), user experience (eg, respect and usability), service provision for common and serious conditions (eg, cancer, trauma, and mental health), and service offerings for adolescents. Education and social services for child health are limited by low funding and poor coordination with other sectors. Structural reforms are more likely to improve service quality substantially and at scale than are micro-level efforts. Promising approaches include governing for quality (eg, leadership, expert management, and learning systems), redesigning service delivery to maximise outcomes, and empowering families to better care for children and to demand quality care from health and social systems. Additional research is needed on health needs across the life course, health system performance for children and families, and large-scale evaluation of promising health and social programmes.

Scoping review of balanced scorecards for use in healthcare settings: development and implementation

Objective

Balanced scorecards (BSCs) were developed in the early 1990s in corporate settings as a strategic performance management tool that emphasised measurement from multiple perspectives. Since their introduction, BSCs have been adapted for a variety of industries, including to healthcare settings. The aim of this scoping review was to describe the application of BSCs in healthcare.

Methods

Medline, Embase and CINHAL databases were searched using keywords and medical subject headings for ‘balanced scorecard’ and related terms from 1992 to 17/04/2020. Title and abstract screening and full text review were conducted in duplicate by two reviewers. Studies describing the development and/or implementation of a BSC in a healthcare setting were included. Data were abstracted using pilot-tested forms and reviewed for key themes and findings.

Results

8129 records were identified and 841 underwent a full text review. 87 articles were included. Over 26 countries were represented and the majority of BSCs were applied at a local level (54%) in hospital settings (41%). While almost all discussed Kaplan and Norton’s original BSC (97%), only 69% described alignment with a strategic plan. Patients/family members were rarely involved in development teams (3%) which typically were comprised of senior healthcare leaders/administrators. Only 21% of BSCs included perspectives using identical formatting to the original BSC description. Lessons learnt during development addressed three main themes: scorecard design, stakeholder engagement and feasibility.

Conclusions

BSC frameworks have been used in various healthcare settings but frequently undergo adaptation from the original description in order to suit a specific healthcare context. Future BSCs should aim to include patients/families to promote patient-centred healthcare systems. Considering the heterogeneity evident in development approaches, methodological guidance in this area is warranted.

Health system responsiveness: a systematic evidence mapping review of the global literature

BACKGROUND

The World Health Organisation framed responsiveness, fair financing and equity as intrinsic goals of health systems. However, of the three, responsiveness received significantly less attention. Responsiveness is essential to strengthen systems' functioning; provide equitable and accountable services; and to protect the rights of citizens. There is an urgency to make systems more responsive, but our understanding of responsiveness is limited. We therefore sought to map existing evidence on health system responsiveness.

METHODS

A mixed method systemized evidence mapping review was conducted. We searched PubMed, EbscoHost, and Google Scholar. Published and grey literature; conceptual and empirical publications; published between 2000 and 2020 and English language texts were included. We screened titles and abstracts of 1119 publications and 870 full texts.

RESULTS

Six hundred twenty-one publications were included in the review. Evidence mapping shows substantially more publications between 2011 and 2020 (n = 462/621) than earlier periods. Most of the publications were from Europe (n = 139), with more publications relating to High Income Countries (n = 241) than Low-to-Middle Income Countries (n = 217). Most were empirical studies (n = 424/621) utilized quantitative methodologies (n = 232), while qualitative (n = 127) and mixed methods (n = 63) were more rare. Thematic analysis revealed eight primary conceptualizations of 'health system responsiveness', which can be fitted into three dominant categorizations: 1) unidirectional user-service interface; 2) responsiveness as feedback loops between users and the health system; and 3) responsiveness as accountability between public and the system.

CONCLUSIONS

This evidence map shows a substantial body of available literature on health system responsiveness, but also reveals evidential gaps requiring further development, including: a clear definition and body of theory of responsiveness; the implementation and effectiveness of feedback loops; the systems responses to this feedback; context-specific mechanism-implementation experiences, particularly, of LMIC and fragile-and conflict affected states; and responsiveness as it relates to health equity, minority and vulnerable populations. Theoretical development is required, we suggest separating ideas of services and systems responsiveness, applying a stronger systems lens in future work. Further agenda-setting and resourcing of bridging work on health system responsiveness is suggested.

Association between umbilical cord hygiene and neonatal sepsis among neonates presenting to a primary care facility in Nairobi County, Kenya: a case-control study

Background: Three-quarters of all annual neonatal deaths in developing countries are attributable to neonatal sepsis. In primary care settings, poor cord hygiene due to improper handling of the infant's cord is a major contributor to the occurrence of neonatal sepsis. The objective of this study was to describe the umbilical cord practices among mothers attending a primary care facility, assess the relationship between umbilical cord hygiene and neonatal sepsis, its impact on the population, as well as the influence of other neonatal and maternal factors on this relationship. Methods: A case-control study was conducted to assess the umbilical cord hygiene-neonatal sepsis relationship among neonates attending a primary care facility between August and October 2018. All cases were selected, while controls were systematically random sampled, as per study eligibility criteria. Exposure variables were summarized using descriptive statistics. A multivariable logistic regression model was fitted to evaluate the association between umbilical cord hygiene and neonatal sepsis adjusting for the effect of potential confounders. Subsequently, a population attributable fraction (PAF) was estimated. Results: The proportion of mothers with improper hygiene was 35.3%: 72.1% among the cases and 16.3% among the controls' caregivers. The odds of neonatal sepsis were 13 times higher (OR=13.24; 95% CI: [7.5; 23.4]) among infants whose caregivers had improper hygiene compared to those who had proper hygiene. None of the neonatal and maternal covariates confounded the umbilical cord hygiene-neonatal sepsis association. This odds ratio gave a PAF of 66.7% (95% CI: 62.5; 69.03). Conclusions: Improper cord hygiene is prevalent in this low resource setting. Improper cord hygiene has a strong positive association with neonatal sepsis. Observing good cord care practices could avert up to 67% of newborn infections. This calls for inclusion of good cord care practices in the antenatal care educational package.

Association between umbilical cord hygiene and neonatal sepsis among neonates presenting to a primary care facility in Nairobi County, Kenya: a case-control study

Background: Three-quarters of all annual neonatal deaths in developing countries are attributable to neonatal sepsis. In primary care settings, poor cord hygiene due to improper handling of the infant's cord is a major contributor to the occurrence of neonatal sepsis. The objective of this study was to describe the umbilical cord practices among mothers attending a primary care facility, assess the relationship between umbilical cord hygiene and neonatal sepsis, its impact on the population, as well as the influence of other neonatal and maternal factors on this relationship. Methods: A case-control study was conducted to assess the umbilical cord hygiene-neonatal sepsis relationship among neonates attending a primary care facility between August and October 2018. All cases were selected, while controls were systematically random sampled, as per study eligibility criteria. Exposure variables were summarized using descriptive statistics. A multivariable logistic regression model was fitted to evaluate the association between umbilical cord hygiene and neonatal sepsis adjusting for the effect of potential confounders. Subsequently, a population attributable fraction (PAF) was estimated. Results: The proportion of mothers with improper hygiene was 35.3%: 72.1% among the cases and 16.3% among the controls' caregivers. The odds of neonatal sepsis were 13 times higher (OR=13.24; 95% CI: [7.5; 23.4]) among infants whose caregivers had improper hygiene compared to those who had proper hygiene. None of the neonatal and maternal covariates confounded the umbilical cord hygiene-neonatal sepsis association. This odds ratio gave a PAF of 66.7% (95% CI: 62.5; 69.0). Conclusions: Improper cord hygiene is prevalent in this low resource setting. Improper cord hygiene has a strong positive association with neonatal sepsis. Observing good cord care practices could avert up to 67% of newborn infections. This calls for inclusion of comprehensive cord care practices in the antenatal care educational package.

Administrators, health service providers, and consumers perspectives of functions of district health-care systems in Oromia region, Ethiopia: A qualitative study

The practice of functions of district health-care systems in Ethiopia is not clear. The aim of this study was to investigate the perspectives of administrators, health service providers, and health-care consumers regarding functions of district health-care systems as currently practiced. Grounded theory approach was applied using interviews and desk review of documents. This study was set up in Oromia National Regional State, Ethiopia. Inductive analysis of interviews was done. Interviews and document reviews were mirrored. Eleven functions of district health-care systems emerged in this study organized by level with relationships and commonality of few activities. The 11 functions of district health-care systems were creating capacity of health centers and health professionals for the provision of health care; creating access for the provision of health care; ensuring equitable access to health care; regulation of private health-care providers; disaster preparedness; monitoring risk factors and diseases in the district; provision of health promotive, preventive, and curative health care for communicable diseases and maternal health conditions; monitoring intermediate outcomes of care; developing capacity of health post and villagers toward demand creation for health care; provision of maternal and child health services; and helping health posts in reaching mothers and sick individuals.

Contractual health services performance agreements for responsive health systems: from conception to implementation in the case of Qatar

Objective

Despite their use worldwide, strategy-based performance management is limited in the Eastern Mediterranean Region. This article explores Qatar's experience, the first from the Region, in implementing contractual agreements between healthcare providers and the regulator-Ministry of Public Health-to align strategy, performance and accountabilities.

Design

mixed-methods including tools development and pilot-testing, guided by performance management cycle with a focus on knowledge translation and key principles: feasibility; mandatory participation; participatory approach through Steering Committee.

Setting

All public, private and semi-governmental hospitals and primary healthcare centers.

Intervention(s)

(i) semi-structured interviews; (ii) review of 4982 indicators; (iii) Delphi technique for selecting indicators with > 80% agreement on importance and > 60% agreement on feasibility; (iv) capacity-building of providers and Ministry staff and 2-month pilot assessed by questionnaire with indicators scoring > 3 considered valid, reliable and feasible; and (v) 1-year grace period assessed by questionnaire.

Main Outcome Measure(s)

Approach strengths and challenges; Data collection and healthcare quality improvements.

Results

Contracts mandate reporting 25 hospital and 15 primary healthcare indicators to the regulator, which delivers confidential benchmarking reports to providers. Scorecards were discussed with the regulator for evidence-informed policymaking. The approach uncovered system-related challenges and learning for public and private sectors: providers commended the participatory approach (82%) and indicated that contracts enabled collecting valid and timely data (64%) and improved healthcare quality (55%).

Conclusion

This experience provides insights for countries implementing performance management, responsive regulation and public-private partnerships. It suggests that contractual agreements can be useful, despite their mandatory nature, if clear principles are applied early on.