Manager training plus audit-and-feedback linked to better obstetric care availability in Mozambique

Combining management training for primary care facility managers with a system-level audit-and-feedback strategy was associated with a measurable improvement in the availability of basic obstetric and neonatal services in Mozambique, according to a new study published in BMC Health Services Research. Neither intervention showed a statistically significant association with service availability on its own, but together they were linked to an average increase of 11.1 points out of 100 per survey round (95% CI: 0.7 to 21.5, p = 0.037), after adjustment for potential confounders.

The research drew on the Integrated District Evidence to Action (IDEAs) program, a system-level audit-and-feedback strategy aimed at improving the implementation of evidence-based guidelines targeting major causes of neonatal mortality in primary health care facilities. The study team asked whether prior management training for facility managers, when combined with the IDEAs program, improved basic obstetric and neonatal service availability in Mozambique.

To answer this question, the investigators used the World Health Organization’s Service Availability and Readiness Assessment survey, selecting its obstetric and neonatal module, with management training questions drawn from the Health Service Delivery Indicator survey. They analyzed three repeated annual cross-sectional facility surveys conducted between August 2019 and July 2022, covering both intervention and control facilities. Using a difference-in-differences linear mixed-effects regression, they examined the interaction between the IDEAs program and management training on service availability while accounting for facility-level clustering.

In total, 59 health facilities were included between 2019 and 2022, of which 47 (80%) had complete data across all survey rounds, with hospitals excluded. Only 23% of managers in both intervention and control facilities reported having received management training, despite having an average of eight years’ experience in the health sector. Intervention facilities consistently scored higher on service availability (65.9 to 70.9) than control facilities (64.3 to 69.2) across the survey rounds.

The central finding concerns the interaction between the two strategies. Management training alone and the IDEAs program alone did not show a statistically significant association with service availability. When both were present, however, the analysis indicated an average increase of 11.1 points per round on the 100-point availability scale, a result the authors describe as statistically significant after adjusting for potential confounders.

The study’s authors caution that these are observational findings from repeated cross-sectional surveys rather than evidence of a causal effect established through randomization. The analysis was limited to primary care facilities in Mozambique, excluded hospitals, and relied on managers’ self-reported training status. The confidence interval, ranging from 0.7 to 21.5 points, indicates considerable uncertainty around the size of the estimated association, although the interval excludes zero.

Nevertheless, the authors conclude that their findings suggest combining management training for primary health care managers with a system-level audit-and-feedback strategy could be associated with improved service availability. They propose that in sub-Saharan Africa, system-level audit-and-feedback interventions should target areas where management training already exists, or incorporate such training as part of the implementation strategy itself.

The study addresses a gap the authors identify in the literature: few studies examine how primary health care managers’ capacity determines the implementation of evidence-based interventions, particularly in sub-Saharan Africa.

Published as open access on 2 September 2026, the study was conducted by researchers including Ermyas Birru, Orvalho Augusto, Aneth Dinis and colleagues, with Kenneth Sherr among the senior authors.

Subject of Research: An observational study of whether management training combined with an audit-and-feedback program is associated with obstetric and neonatal service availability in Mozambican primary care facilities.

Article Title: Interactive association between prior management training for facility managers and an audit-and-feedback strategy with obstetric and neonatal service availability in Mozambique primary care facilities

Article References: Birru, E., Augusto, O., Dinis, A., Gremu, A., Wagenaar, B. H., Weiner, B. J., John-Stewart, G., Ramiro, I., Hirschhorn, L. R., Fernandes, Q., Gimbel, S., Gloyd, S., Tembe, S., & Sherr, K. (2026). Interactive association between prior management training for facility managers and an audit-and-feedback strategy with obstetric and neonatal service availability in Mozambique primary care facilities. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15336-x

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15336-x

Keywords: Mozambique, primary health care, audit and feedback, management training, obstetric services, neonatal health, service availability, difference-in-differences, health systems, sub-Saharan Africa, Interactive, association