Publication: The relationship between decision-making autonomy and training on facility-level management performance of primary health care facilities in Odisha, India


Primary health care quality remains poor in many countries, despite its importance for universal health coverage. Evidence shows that better management of primary health care facilities improves service quality, and that facility managers’ autonomy and training levels can augment their management performance. In India, there is scant research in this area. Research questions include: 1) What is the effect of facility-level autonomy on management performance and is the effect modified by management training? 2) Which aspects of facility management are most sensitive to facility-level autonomy and is the effect augmented by management training?


Using a multi-stage, regionally representative survey of health facilities in Odisha (n=396), a validated tool was used to measure management performance. An “autonomy score” was created to understand which facility management decisions are within a manager’s capacity. Multivariable linear regressions were used to assess the association of decision-making autonomy and management training with performance scores.


The mean performance score across all facilities was 0.657 (SD = 0.148) on a 0-1 scale; the mean autonomy score was 0.619 (SD = 0.305). Autonomy scores were not associated with a significant difference in performance scores; however, management training had an independent positive association with the human resources and monitoring domains of facility management.


In Odisha, India management training may improve management performance, and targeted training initiatives may strengthen a primary care facility’s ability to retain staff and monitor performance. Our data did not demonstrate a significant association between decision-making autonomy and management performance, highlighting a need for further study on how decision-making autonomy may augment a manager’s ability to leverage their skills to improve facility outcomes. In summary, neither management training nor decision-making autonomy alone will sufficiently improve primary care management but targeting the improvement of management training may improve a subset of performance outcomes.


  • Desai, Eesha, Griffith Bell, Sam Woodbury, June-Ho Kim, Hannah Ratcliffe, and Dan Schwarz. “The Relationship between Decision-Making Autonomy and Training on Facility-Level Management Performance of Primary Health Care Facilities in Odisha, India.” Gates Open Research, August 24, 2022.