Step 1: Literature review for tool selection and identification of management practices areas
The number of tools to measure management practices of health facilities was very limited. We found three instruments for health facilities in developed countries that had been validated, whose results were published in peer-reviewed journals – (i) the Management Practices Measurement tool [6–8]; (ii) Baldrige healthcare criteria for performance excellence ; and (iii) a questionnaire to measure organizational attributes of primary care practices . We did not find any evidence that the instruments designed for use in LMICs [26–29] had been validated. had been validated. Of the tools reviewed, we found the Management Practices Measurement tool most relevant to build on, to measure management practices of health facilities under PBF in Nigeria. It has similar components to the management areas identified by Mabuchi et al.  including, performance management, staff management and motivation, and community engagement. Also, it uses an external assessment by trained personnel based on a specific scoring grid and criteria, which addresses capacity constraints and self-reporting bias at PHCCs.
Of the about 40 publications and reports reviewed, 13 intended to define health facility managers’ practices. Table 1 synthesizes the findings from these 13 papers on management practices in health facilities. It identifies seven different management practice areas from practices requiring hard skills (such as financial management) to practices drawing upon much softer skills (such as communication and team building). In addition, the review of elements of health facility autonomy under PBF developed by Fritche et al.  and NPHCDA  highlighted one further area – pharmaceutical management. Based on these findings, we described 8 key management practice areas for the scorecard, including problem solving, communication, staff and team management, planning, performance management, relationship building and resource mobilization (which was redefined as community/client engagement), financial management and pharmaceutical management. We operationalized the 8 key management areas using relevant indicators from the original Management Practices Measurement tool identified through the literature review. We did not consider indicators that focused on hospital management because these were not relevant for PHCCs in LMICs. Based on findings from the qualitative case studies previously conducted , we subsumed communication under the staff management practice area and decided to drop the problem-solving practice as it overlaps with other areas such as planning and target setting and performance management.
Step 2: Development of scorecard
Table 2 provides the areas and indicators of the developed management scorecard (Full scorecard available in Appendix A). The scorecard included 32 indicators grouped into 6 broad management practice areas: (i) community/client engagement; (ii) stakeholder engagement; (iii) staff management; (iv) planning and target setting; (v) performance management; and (vi) use of funds and financial management. Each area was broken down into sub-areas (e.g. ‘performance tracking’ and ‘performance review’ for the performance management area) and indicators (e.g. ‘visualization of performance data’ and ‘staff attention to performance’ for the performance tracking sub-area). Ordinal responses derived for each indicator were assigned value of 1, 2 and 3 respectively, resulting of aggregate score range of 32–96 from 32 indicators for each PHCC.