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Assessing the technical efficiency of health posts in rural Guatemala: a data envelopment analysis
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.ORCID iD: 0000-0001-7234-3510
2014 (English)In: Global health action, ISSN 1654-9880, E-ISSN 1654-9880, Vol. 7, 23190- p.Article in journal (Refereed) Published
Abstract [en]

Introduction : Strengthening health service delivery to the rural poor is an important means of redressing inequities. Meso-level managers can help enhance efficiency in the utilization of existing resources through the application of practical tools to analyze routinely collected data reflecting inputs and outputs. This study aimed to assess the efficiency and change in productivity of health posts over two years in a rural department of Guatemala.

Methods : Data envelopment analysis was used to measure health posts' technical efficiency and productivity change for 2008 and 2009. Input/output data were collected from the regional health office of Alta Verapaz for 34 health posts from the 19 districts comprising the health region.

Results : Technical efficiency varied widely across health posts, with mean scores of 0.78 (SD=0.24) and 0.75 (SD=0.21) in 2008 and 2009, respectively. Overall, productivity increased by 4%, though 47% of health posts experienced a decline in productivity. Results were combined on a bivariate plot to identify health posts at the high and low extremes of efficiency, which should be followed up to determine how and why their production processes are operating differently.

Conclusions : Assessing efficiency using the data that are available at the meso-level can serve as a first step in strengthening performance. Further work is required to support managers in the routine application of efficiency analysis and putting the results to use in guiding efforts to improve service delivery and increase utilization.

Place, publisher, year, edition, pages
Umeå: Umeå University, Centre for Global Health Research , 2014. Vol. 7, 23190- p.
Keyword [en]
data envelopment analysis; efficiency; Malmquist; primary health care; health services management; Guatemala
National Category
Public Health, Global Health, Social Medicine and Epidemiology
URN: urn:nbn:se:umu:diva-85680DOI: 10.3402/gha.v7.23190ISI: 000329933800001PubMedID: 24461356OAI: diva2:695074
Available from: 2014-02-10 Created: 2014-02-10 Last updated: 2015-04-29Bibliographically approved
In thesis
1. Enabling the performance of nurses in rural Guatemala: the role of relationships
Open this publication in new window or tab >>Enabling the performance of nurses in rural Guatemala: the role of relationships
2014 (English)Doctoral thesis, comprehensive summary (Other academic)
Alternative title[sv]
Att stödja sjuksköterskors arbetsprestation i landsbygdens Guatemala : Betydelsen av mänskliga relationer
Abstract [en]

Background: Enhancing the performance of front-line health workers serving vulnerable populations is crucial for redressing inequities. Traditional approaches have focused on introducing technical solutions, such as guidelines and incentives, to modify performance outcomes. Recognition of the complex social nature of health system function draws attention to the intangible software elements that shape performance, including the values, ideas, interests, and norms that guide human behavior and interactions. Insight into the operation of software elements can provide a base for people-focused solutions to support health workers and enable them to confront constraints in low resource settings. This study examines the social environment of the practice of front-line auxiliary nurses (AN) in rural Guatemala, in order to understand the role of health system software elements in enabling their performance and to gain insight into how organizational support can be strengthened through locally-relevant actions.

Methods: A mixed methods approach provided a multi-level view of the AN practice environment, situated in the regional health system of the rural department of Alta Verapaz. Interviews with ANs and observations of practice were conducted to understand the values orienting them and how these shaped their relationships with patients and communities. A theory-driven case study of AN supervision was conducted in selected health posts to understand the values orienting supervisors in their role and examine how these shaped their relationships with ANs. The participatory method of concept mapping was used to examine the views of health workers, district and regional managers on actions to strengthen organizational support for the performance of ANs.

Results: The values of nursing vocation and community connectedness were prominent in ANs’ interpretations of their work. In relationships, nursing principles oriented them to be attentive to understanding patient needs, and a shared ethnic identity and personal experience of local needs served as a base for engaging with local leaders in community work. The dominant orientation of supervisors in their role was managerial control, and it provided limited support. It contributed to standard-centered relationships with ANs focused on fulfillment of ministry criteria. Supervision oriented by a holistic understanding of ANs’ needs and the goal of improving patient care was more successful in enabling AN motivation. This relationship was characterized as people-centered, based in a shared interpretation of the value of work with patients and the responsive support provided to ANs’ problems. “Organizational climate of support across levels”, where working relationships are characterized by respectful treatment, attention to psycho-social well-being and responsiveness to needs, was identified by health-system actors as a top priority for improving performance.

Conclusions: To enable performance, there needs to be a balance between attention to standards and attention to the human dimensions of health worker practice. The dominant approach to supervision did not recognize or build on AN values. Supervision and management should be oriented by a more holistic view of the ANs’ work and their needs, in order to promote a people-centered approach to working relationships. Locally relevant action to strengthen district and regional management’s support for AN performance should focus on operationalizing performance goals that go beyond standards to encompass care that responds to patient and community needs.

Place, publisher, year, edition, pages
Umeå: Umeå universitet, 2014. 101 p.
Umeå University medical dissertations, ISSN 0346-6612 ; 1672
Health workers, nurses, performance, health services management, health systems research, people-centered health systems, work environment, Guatemala
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Public health
urn:nbn:se:umu:diva-95114 (URN)978-91-7601-128-7 (ISBN)
Public defence
2014-11-14, Sal 135, Allmänmedicin, Institutionen för folkhälsa och klinisk medicin, Norrlands universitetssjukhus, Umeå, 13:45 (English)
Available from: 2014-10-24 Created: 2014-10-22 Last updated: 2015-04-29Bibliographically approved

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