EFFECTIVENESS OF THE BALANCED SCORECARD IN IMPROVING STAFF PERFORMANCE, PATIENT OUTCOMES AND RESOURCE OPTIMIZATION IN LOW- AND MIDDLE-INCOME COUNTRIES: A SYSTEMATIC REVIEW.

Introduction/background: Low- and middle-income countries (LMIC) usually have weak health systems with poor health outcomes. The Balanced Scorecard (BSC) is a strategic management tool widely used to improve healthcare services by aligning operational activities with long-term objectives across four dimensions namely patient, financial, internal process, and learning and growth. While BSC has been adopted in various high-income countries with positive impacts, its effectiveness in improving public health systems in LMIC is still unclear.

Objective: This review seeks to evaluate the effectiveness of BSC in public health settings in LMIC.

Methods: A Systematic review was carried out. The search strategy was applied across PubMed, Cochrane Library, Google Scholar, and AJOL, from 1995 to September 2024, following the PRISMA guideline. Key criteria were used in the selection of eligible studies.

Results: Of 1,159 articles retrieved from the search, 9 articles were included (3 African and 6 Asian studies). Two were in Upper-Middle, 4 in Lower-Middle, and 3 in low-income settings. One of the studies was a randomized controlled trial, 5 were pre-post and 3 were case studies. The time to evaluation of BSC implementation ranged from 10 months to 5 years. Post - implementation, change in patient satisfaction ranged between 3.7% to 16%, staff satisfaction (0.6% to 4.6%), staff training (14.8% to 35.3%), laboratory functionality (-1.0% to 45.8%), drug availability (1.9% to 17.0%), equipment functionality (11.9% to 22.8%), HMIS use (8.3% to 24.1%), and revenue generation (0.1 to 1.83%).

Discussion and conclusion: The BSC in the majority of the studies was modified and had additional perspectives to suit their context. BSC implementation was mostly led by the Ministry of (Public) Health in the countries as a system-wide approach. Implementation was by incorporating BSC indicators into the National Health Strategic Plan or accreditation standards. Some of the Ministries had funding support from partners and cost was noted as one of the limitations to its adoption. BSC implementation in LMIC generally showed positive improvements especially in staff training and resource optimization through improved capacity for service delivery. There was no appreciable increase in revenue generation but since they were public hospitals, they had less focus on financial perspective and more on patients and efficient resource utilization. It is recommended that Ministries of Health in LMIC develop or adapt and utilize the BSC to drive their health system performance by incorporating the indicators into their national performance indicators.

Acknowledgments: This review was funded by the Robert Koch Institute as part of the project 'Capacity Building in Applied Public Health Research in GHPP partner countries - CARE' from funds of the Federal Ministry of Health.