More than ever, the ability of health systems to deliver proven interventions is vital to reducing disease burdens and improving well-being. Goal three of the new United Nations sustainable-development agenda—ensuring healthy lives and promoting well-being for all—has raised the ante for governments and development partners. Achieving the bold targets that support this goal by 2030 will require countries to use all the healthcare-delivery tools at their disposal. One greatly underappreciated approach is investment in frontline management.
In the private sector, there is considerable evidence showing that well-managed firms have higher productivity and greater ability to survive adverse conditions. These results apply across sectors and countries.
In global health, strong management is equally critical. It enhances healthcare delivery by increasing the productivity of existing resources and the agility of health systems as they adapt to challenges and capture opportunities. This is especially important at the front line, as the vast majority of healthcare managers in low- and lower-middle-income countries work at the district level and below, playing important roles in ensuring that the interactions between people and the health system are helpful.
However, there is a tremendous management-capability gap at the front line. Few organizations focus their programs for building management capacity there. And they rarely undertake a systematic examination of frontline healthcare-managerial challenges and their root causes. Even the most basic data, such as the number of managers working at district and facility levels, are usually missing in national health-personnel databases. Moreover, the voices of frontline managers—intrinsic to any effort to improve their performance—are mostly absent from discussions of policy or interventions.
We aim to shine a light on the “invisible army” of frontline managers in developing countries and propose practical actions to unlock their potential. We carried out a survey—the first of its kind, as far as we know—to hear directly from frontline managers. The survey responses suggest that the typical frontline manager is time strapped, multitasking, and lacking critical elements needed for success: an understanding of priorities, management skills, motivation, autonomy, and information.
We also sought to explore the root causes of frontline-management challenges, drawing from McKinsey’s knowledge and frameworks on organizational design and health. We found that improving frontline management requires a coordinated approach comprising six parts:
clearly defined roles and responsibilities, especially highlighting the role of frontline managers as coaches
optimal “boxes and lines,” including reporting relationships and spans and layers, that facilitate accountability and enable supportive supervision
strong talent orientation and talent-management functions to recruit, develop, reward, and retain frontline managers
empowering culture that fosters collaboration and trust among frontline managers and their teams, their supervisors, and the communities they serve
disciplined performance-management practices that motivate frontline managers to pursue a narrow set of targets, regularly reviewed during routine performance dialogues
functioning data and information systems oriented to support frontline decision making
Few programs exist for strengthening frontline management; still, some of those in place have had considerable impact. Consider a few examples:
In Kenya, coverage rates rose from 38 percent to 51 percent for key maternal-, newborn-, and child-health interventions just six months after the start of a leadership-development program targeting frontline health workers.
In rural Upper Egypt, the maternal-mortality rate dropped from 85 to 35.5 per 100,000 live births in two years, in a program that trained primary-health-facility leaders on important management practices and supported them in designing and executing performance-improvement projects.
In Ethiopia, hospitals that were part of a management-capability-building initiative achieved significantly lower drug stock-out days, higher patient satisfaction, and reduced inpatient-mortality costs compared with hospitals that were not part of the program.
Primary-care facilities in Pakistan experienced a 100 percent increase in drug and physician availability, as well as a 100 to 300 percent improvement in utilization after the introduction of contractual management for basic health units.
Stakeholders in the global health field have an opportunity to play significant roles in improving frontline management. For example, government leaders at the national, regional, or local level could make a visible statement that management is critical and frontline managers are valued, diagnose and prioritize the root causes of issues that constrain frontline management, set goals and design an overarching strategy aimed at enabling frontline management, and define and coordinate the roles of global and local partners to help achieve them.
Donors supporting healthcare delivery in developing countries or regions could partner with governments, local institutions, and other donors to design, demonstrate, and scale up programs for frontline-management transformation. They could also invest in knowledge, networks, and advisory capabilities to advance offerings to strengthen frontline management, especially targeting investments in implementing partners and research institutions based in developing countries. In addition, they could investigate the impact and feasibility of creating a clearinghouse for management support.
On-the-ground partners providing technical and implementation assistance could consider integrating frontline-management-strengthening approaches into existing programs, develop capacities and service offerings to provide more effective management assistance to countries, and take an active role in advancing collective knowledge of how to strengthen frontline management by sharing best practices, providing feedback, and piloting new approaches.
While there are many challenges to improving health systems, and critical gaps exist at every level, we strongly believe that bolstering frontline healthcare management is an essential approach offering a high return on investment. We urge government leaders and development partners to give attention to these often underrecognized healthcare change agents, understand what they need, and invest in effective interventions to help them succeed.