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

Few studies examine how primary healthcare (PHC) managers’ capacity determines evidence-based intervention implementation, particularly in sub-Saharan Africa (sSA). The Integrated District Evidence to Action (IDEAs) program was a system-level audit and feedback strategy aimed at improving the implementation of evidence-based guidelines targeting major causes of neonatal mortality in PHC facilities. This study explored whether prior management training for PHC managers, combined with IDEAs program, improved basic obstetric and neonatal service availability in Mozambique. We used the World Health Organization’s Service Availability and Readiness Assessment survey, selecting the obstetric/neonatal module, with management training questions selected from the Health Service Delivery Indicator survey. We analyzed three repeated annual cross-sectional facility surveys (August 2019-July 2022) from both intervention and control facilities. Using a difference-in-differences linear mixed-effects regression, we examined the interaction between the IDEAs program and management training on obstetric/neonatal service availability, while accounting for facility-level clustering. A total of 59 health facilities were included between 2019 and 2022. Of these, 47 (80%) had complete data across all rounds, excluding hospitals. Only 23% of managers in both intervention and control facilities reported receiving management training, despite having an average of eight years’ experience in the health sector. Intervention facilities consistently had higher service availability scores (65.9–70.9) than control facilities (64.3–69.2) across rounds. While management training and IDEAs program alone did not show a statistically significant association with service availability, combined, they were associated with an average increase of 11.1 points out of 100 per round (95% CI: 0.7 to 21.5, p = 0.037), after adjusting for potential confounders. Our findings suggest that combining management training for PHC managers with a system-level A&F strategy could be associated with improved service availability. In sSA, system-level A&F interventions should target areas with management training or incorporate training as part of the implementation strategy.