Health, Nutrition and Population (HNP) Discussion Paper Developing Strategies for Improving Health Care Delivery: A User’s Guide to Concepts, Determinants, Measurement, and Intervention Design

Elizabeth H. Bradley, Sarah Pallas, Chhitj Bashyal, Leslie Curry, Peter Berman


This report is a user‟s guide for defining, measuring, and improving the performance of health service delivery organizations. We define six core performance domains: quality, efficiency, utilization, access, learning, and sustainability and provide a compendium of metrics that have been used to measure organizational performance ineach of these six domains. The compendium, which includes 116 distinct categories of metrics, is based on a detailed literature review of peer-reviewed empirical studies of health care organizational performance in World Bank client countries. We include a bibliography of studies that have used these measures. Based on our reading of the literature, we define seven major strategy areas potentially useful for improving performance among health care organizations: 1) standards and guidelines, 2) organizational design, 3) education and training, 4) process improvement and technology and tool development, 5) incentives, 6) organizational culture, and 7) leadership and management. We provide illustrations of facility-level interventions within each of the strategy areas and highlight the conditions under which certain strategies may be more effective than others. We propose that the choice of strategy targeted at organizational level to improve performance should be informed by the identified root causes of the problem, the implementation capabilities of the organization, and the environmental conditions faced by the organization.

Measuring and improving organizational performance is complex because organizations are diverse and dynamic. Users of this guide should take away a toolkit of concepts and methods that can help them identify which questions to ask and how to answer them in the context of defining, measuring, and improving performance of health service delivery organizations. Having this broad set of tools with which to understand and enhance organizational performance can contribute to improving health service delivery and ultimately health outcomes.