Health System Strengthening

 

Welcome to the programmatic area on health system strengthening (HSS) within MEASURE Evaluation’s Family Planning and Reproductive Health Indicators Database. HSS is one of the subareas found in the health systems section of the database. All indicators for this area include a definition, data requirements, data source(s), purpose, issues and—if relevant—gender implications. There has been a shift in the global health agenda from focusing on disease-specific approaches to emphasizing HSS to improve the effectiveness of health services. A "health system" is described as all the organizations, institutions, resources, and people whose primary purpose is to improve health (World Health Organization [WHO], 2010). WHO has placed additional emphasis on health systems as the means to deliver effective and affordable care and to achieve increased health equity, especially for the poor (Global Fund to Fight AIDS, Tuberculosis and Malaria, 2009). WHO and global partners developed a framework for measuring HSS that is comprised of six core components or “building blocks" (WHO, 2010): service delivery, health workforce, health information systems, access to essential medicines, financing, and leadership and governances. The core indicators presented here were selected for the six component areas of the framework. Key indicators to monitor and evaluate commodity HSS can be found in the links at left.   Full Text While significant strides have been made in global interventions designed to improve maternal and child health and reduce mortality and ill-health related to HIV/AIDS, tuberculosis, and malaria, these gains have not been sufficiently broad-based and sustainable. National level progress has not necessarily translated into improvements for the most vulnerable groups, and in some instances progress has reached a plateau or even reversed (WHO, 2010). Consequently, there’s been a shift in the global health agenda from focusing on disease-specific approaches to emphasizing health system strengthening (HSS) to improve the effectiveness of health ministries. Increasing evidence demonstrates that health systems capable of delivering services equitably, efficiently, and in a coordinated manner are essential for achieving improved health outcomes. This evidence is leading many global health initiatives to incorporate HSS in support of country and regional programs. A "health system" is described as all of the organizations, institutions, resources, and the people whose primary purpose is to improve health (WHO, 2010). WHO has placed additional emphasis on health systems as the means to deliver effective and affordable care, to facilitate meeting the Millennium Development Goals, and to achieve increased health equity, especially for the poor (The Global Fund, 2009). In order to function, a health system needs staff, funds, information, supplies, transport, communications, and overall guidance and direction and it needs to provide services that are responsive, financially fair, and that treat people with respect. Strengthening health systems means addressing key constraints in each of these areas with the goals of improving access, quality and utilization of services, as well as, developing effective approaches for monitoring and evaluating the various levels of system inputs, processes, outputs and outcomes (Global Fund, 2009; WHO, 2010). HSS Building Blocks Service delivery Health workforce Health information systems Access to essential medicines Financing Leadership governance WHO and global partners have been developing a framework for measuring HSS that is comprised of six core components or “building blocks" (WHO, 2010). Leadership/ governance and health information systems are cross-cutting components that provide the basis for the overall policy and regulation of the other system blocks. Financing and the workforce are key input components, while medical products/technologies and service delivery reflect immediate system outputs. The framework focuses on the health sector and does not include interactions with other sectors, nor does it take into account factors that influence health behaviors, underlying social and economic determinants of health, such as gender inequities and education, or links and interactions across the six components. However, by distinguishing these components, the framework provides structure for this complex system that allows identification of indicators and measurement strategies for monitoring and evaluation. Indicator Selection Indicators were selected for the six component areas of the framework, initially by a small working group of agency representatives and technical experts, then reviewed more broadly by country level experts and supported with case studies and reviews of country experiences (WHO, 2010). The final selection of indicators was guided by the need to detect changes and progress in strengthening health systems that relate to both the level and distribution of inputs and outputs. Whereas the primary focus is on low- and middle-income countries, experiences from higher income countries have also been used to guide the development of the indicators and measurement approaches. Note: For graphics and detailed discussion of the WHO Health Systems Framework, more detail on the process and criteria used in developing the WHO toolkit of indicators for HSS, and comprehensive lists of indicators with definitions, see the following resource links: WHO (2010) and The Global Fund (2009). For the purpose of this database, fourteen core indicators have been selected from the comprehensive WHO HSS toolkit that relate directly to reproductive health in terms of policy, access, management and quality of services, training, commodities, and the registration and reporting of vital statistics for births, deaths and maternal mortality. The use of these standardized indicators will allow comparisons within and between countries, regions, sectors, and programs, as well as tracking changes over time. Some of the indicators will present challenges for measurement and reporting, requiring the development and institutionalization of effective country, regional, and program level protocols, management, and training. Wherever possible, collection of relevant corresponding data is recommended for disaggregation of the indicators (e.g., by sub-populations, location, sector and types of facilities and programs, demographic and socioeconomic factors). The value of these indictors, as with all of the indicators in the WHO HSS toolkit, will be enhanced and better understood through continued research and utilization of the information that they generate. _____________ References:    The Global Fund, 2009, Monitoring and Evaluation Toolkit: HIV, Tuberculosis and Malaria and Health Systems Strengthening, http://www.theglobalfund.org/documents/me/M_E_Toolkit_P2-HSS_en.pdf. USAID, 2009, Measuring the Impact of Health Systems Strengthening: A Review of the Literature, Washington, DC. http://www.usaid.gov/our_work/global_health/hs/publications/impact_hss.pdf WHO, 2010, Monitoring the Building Blocks of Health Systems: A handbook of Indicators and their Measurement Strategies, Geneva. http://www.who.int/healthinfo/statistics/toolkit_hss/en/index.html “Global Action for Health System Strengthening, Policy Recommendations to the G8.” Task Force on Global Action for Health System Strengthening.  Japan Center for International Exchange, 2009.

Number and distribution of health facilities per 10,000 population

Definition:

 

The number of health facilities per population of 10,000 or the number of health facilities per total population living in a designated area. Health facilities include all public, private, non-governmental and community-based health facilities defined as a static facility (i.e., has a designated building) in which general health services are offered. Health posts can be counted as static facilities, but because they are generally small with minimal supplies, they may need to be disaggregated for interpretation purposes. The indicator does not include mobile service delivery points and non-formal services such as traditional healers.

Where possible, geographic mapping of sites can be used to help determine coverage. 

This indicator is calculated as:

(Number of health facilities / Total population in a designated area)

 

The ratio can be adjusted to per 10,000 population by multiplying the numerator and denominator by the same factor required for the denominator to equal 10,000.

This indicator is selected from the list of core indicators in the WHO Health System Strengthening (HSS) Handbook. For more background on the process and criteria used in developing the WHO Handbook of indicators for HSS and for details on this and related indicators, see  WHO (2010); USAID (2009); and The Global Fund (2009).

Data Requirements:

District and national databases provide the number of public facilities, often by type (hospital, health center, health post, dispensary, etc.).  Facility censuses may be required to obtain the number of private, non-governmental and community-based facilities, especially if there is no enforced registration system. Geographic locations of health facility sites using maps or computerized mapping system.  Where a full-scale census of facilities may not be feasible or in order to validate census findings, a comprehensive facility survey instrument called the Service Provision Assessment (SPA) has been developed by USAID and Macro International Inc. to be used with nationally representative samples of health facilities to provide information on the characteristics of health services, including their quality, infrastructure, utilization and availability.  The WHO service availability and readiness assessment (SARA) is specifically designed to assess, map and monitor service availability and readiness. For more details on the SPA and SARA, see WHO (2010) and MEASURE DHS (2011)

Data can be disaggregated by type of facility, districts, urban/rural location, and, where data are available, by area income median or quintiles and other relevant demographic and socioeconomic factors.

Data Sources:

District and national databases; facility censuses, maps and/or computerized mapping systems

Purpose:

This standardized indicator measures levels of access to health services by the designated populations, can be used to identify underserved areas, and will allow comparisons within and between countries, regions, sectors, and programs. Geographic mapping will allow identification of where there are coverage gaps for certain populations. Data from multiple time points allow for monitoring progress in scaling up health interventions and overall HSS (WHO, 2010). There has been a shift in the global health agenda from focusing on disease-specific approaches to emphasizing HSS to improve the effectiveness of national and district-level health ministries and programs. This indicator can contribute to monitoring progress in the Millennium Development Goals  #4. Reduce child mortality; #5. improve maternal health; and #6. combat HIV/AIDS.  The usefulness of this indicator, as with all of the indicators in the WHO HSS Handbook, will be enhanced and better understood through continued research and utilization of the information that they generate.

Issue(s):

 

Difficulties in identifying facilities that are not in the public sector or are not registered can result in undercounting. The size of health facilities may vary considerably making comparisons difficult and, when smaller geographical units such as districts are analyzed, the population may not necessarily use the facilities in the designated area. Consequently, comparisons of densities between districts and subpopulations need to be done with caution.

Indicators of service availability cannot accurately reflect access to and utilization of services. For example, clients may avoid use of local facilities or may use ones that lie outside the immediate catchment area because of travel logistics, sociocultural preferences and actual or perceived issues around quality. Urban areas present a particular challenge because, although facilities may be close in proximity, issues of affordability and acceptability become more important obstacles to access (WHO, 2010).

Poverty and Equity Considerations:

The primary aim of HSS is to improve access, quality, and utilization of health services, and growing evidence shows that health systems capable of delivering services equitably, efficiently, and in a coordinated manner are essential for achieving improved health outcomes.

References:

 

The Global Fund, 2009, Monitoring and Evaluation Toolkit: HIV, Tuberculosis and Malaria and Health Systems Strengtheninghttp://www.hivpolicy.org/Library/HPP000485.pdf

MEASURE DHS. 2011, Service Provision Assessments (SPA) Survey Overview, DHS Website. http://www.measuredhs.com/What-We-Do/Survey-Types/SPA.cfm

USAID, 2009, Measuring the Impact of Health Systems Strengthening, A Review of the Literature, Washington, DC: USAID.  https://www.k4health.org/sites/default/files/measuring%20reform%20hss.pdf

WHO, 2010, Monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies, Geneva: WHO. http://www.who.int/healthinfo/systems/WHO_MBHSS_2010_full_web.pdf

Number and distribution of inpatient beds per 10,000 population

Definition:

 

The number of inpatient beds available relative to the total population for the same geographical area. This includes total hospital beds (for long-term and acute care), maternity beds and pediatric beds, but not delivery beds. Data on maternity beds can also be used to calculate the density of maternal beds per 1000 pregnant women per year.  Public and private sectors are included.

This indicator is calculated as:

(Number of inpatient beds / Total population for the same geographical area)

The ratio can be adjusted to per 10,000 population by multiplying the numerator and denominator by the same factor required for the denominator to equal 10,000.

This indicator is selected from the list of core indicators in the WHO Health System Strengthening (HSS) Handbook. For more background on the process and criteria used in developing the WHO Handbook of indicators for HSS and for details on this and related indicators, see  WHO (2010); USAID (2009); and The Global Fund (2009).

Data Requirements:

District and national databases can provide the number of beds. Facility censuses may be required to obtain the number of private, non-governmental and community-based facilities, especially if there is no enforced registration system.  Where a full-scale census of facilities may not be feasible or in order to validate census findings, a comprehensive facility survey instrument called the Service Provision Assessment (SPA) has been developed by USAID and Macro International Inc. to be used with nationally representative samples of health facilities to provide information on the characteristics of health services, including their quality, infrastructure, utilization and availability.  The WHO service availability and readiness assessment (SARA) is specifically designed to assess, map and monitor service availability and readiness. For more details on the SPA and SARA, see WHO (2010) and MEASURE DHS (2011).  Data can be disaggregated by type of facility, districts, urban/rural location, and, where data are available, by area income median or quintiles and other demographic and socioeconomic factors.

Data Sources:

District and national databases; facility censuses; facility surveys, such as the SPA and SARA

Purpose:

 

This standardized indicator measures levels of access to hospital inpatient services by the designated populations, can be used to identify underserved areas, and will allow comparisons within and between countries, regions, sectors, and programs.  Moreover, data from multiple time points will allow for monitoring progress in scaling-up health services and overall HSS (WHO, 2010). The primary aim of HSS is to improve access, quality, and utilization, and growing evidence shows that health systems capable of delivering services equitably, efficiently, and in a coordinated manner are essential for achieving improved health outcomes. There has been a shift in the global health agenda from focusing on disease-specific approaches to emphasizing HSS to improve the effectiveness of national and district-level health ministries and programs. This indicator can contribute to monitoring progress in the Millennium Development Goals  #4. Reduce child mortality; #5. improve maternal health; and #6. combat HIV/AIDs.  The usefulness of this indicator, as with all of the indicators in the WHO HSS toolkit, will be enhanced and better understood through continued research and utilization of the information that they generate.

Two closely related inpatient indicators are (WHO, 2010):

1. Average length of stay: an indicator of quality and efficiency of health services.

2. Bed occupancy rate: an indicator of efficiency of services.

Issue(s):

 

The size of hospitals and numbers of inpatient beds may vary considerably making comparisons difficult and, when smaller geographical units such as districts are analyzed, the population may not necessarily use the hospitals in the designated area. Consequently, comparisons of numbers of available inpatient beds between districts and subpopulations need to be done with caution.

Indicators of service availability cannot accurately reflect access to and utilization of services. For example, clients may avoid use of local hospitals or may use ones that lie outside the immediate catchment area because of travel logistics, sociocultural preferences and perceptions of quality. Urban areas present a particular challenge because, although hospitals may be close in proximity, issues of affordability and acceptability become more important obstacles to access (WHO, 2010).

References:

 

The Global Fund, 2009, Monitoring and Evaluation Toolkit: HIV, Tuberculosis and Malaria and Health Systems Strengthening, http://www.hivpolicy.org/Library/HPP000485.pdf

MEASURE DHS. 2011, Service Provision Assessments (SPA) Survey Overview, DHS Website. http://www.measuredhs.com/What-We-Do/Survey-Types/SPA.cfm

USAID, 2009, Measuring the Impact of Health Systems Strengthening, A Review of the Literature, Washington, DC: USAID.  https://www.k4health.org/sites/default/files/measuring%20reform%20hss.pdf

WHO, 2010, Monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies, Geneva: WHO. http://www.who.int/healthinfo/systems/WHO_MBHSS_2010_full_web.pdf

Number of outpatient department visits per 10,000 population per year

Definition:

 

The number of outpatient visits to health facilities during one year relative to the total population of the same geographical area. Health facilities include all public, private, non-governmental and community-based health facilities in which general health services are offered.

This indicator is calculated as:

(Number of visits to health facilities for ambulant care (not including immunization) / Total population for the same geographical area)

The ratio can be adjusted to per 10,000 population by multiplying the numerator and denominator by the same factor required for the denominator to equal 10,000.

This indicator is selected from the list of core indicators in the WHO Health System Strengthening (HSS) Handbook.  For more background on the process and criteria used in developing the WHO Handbook of indicators for HSS and for details on this and related indicators, see WHO (2010); USAID (2009); and The Global Fund (2009).

Data Requirements:

Data can be collected from health facility records, health information systems (HIS), and population-based surveys. A comprehensive facility survey instrument called the Service Provision Assessment (SPA) has been developed by USAID and Macro International Inc. to be used with nationally representative samples of health facilities to provide information on the characteristics of health services, inclu(ding their quality, infrastructure, utilization and availability MEASURE DHS, 2011; WHO, 2010). The accuracy and completeness of reporting need to be consistent over time and between populations to allow assessment of trends and comparisons. Data can be disaggregated by type of facility, districts,age group and sex.

If targeting and/or linking to inequity, disaggregate by relevant demographic and socioeconomic factors related to poverty-related inequities such as location (poor/not poor, urban/rural) and income.

Data Sources:

Facility records, HIS; population-based surveys; facility sample surveys, such as the SPA.

Purpose:

 

This standardized indicator shows the levels of utilization of outpatient healthcare services and can be employed to examine trends and variations in use of services by type of facility and healthcare service, geographic districts and urban/rural locations, and will allow comparisons between countries and programs. These data can assist in planning, advocacy, and data from multiple time points will allow for monitoring progress in scaling-up health services and overall HSS (WHO, 2010). The primary aim of HSS is to improve access, quality, and utilization, and growing evidence shows that health systems capable of delivering services equitably, efficiently, and in a coordinated manner are essential for achieving improved health outcomes.

There has been a shift in the global health agenda from focusing on disease-specific approaches to emphasizing HSS to improve the effectiveness of national and district-level health ministries and programs. Strengthening outpatient service delivery and increasing utilization are fundamental to the achievement of the health-related Millennium Development Goals, which include: #4 reduce child mortality; #5 improve maternal health; and # 6 combat HIV/AIDS, tuberculosis and malaria.

Issue(s):

The number of outpatient visits does not measure actual numbers of people utilizing services since individuals may make repeated visits. The volumes of visits at outpatient facilities do not serve as a coverage indicator because the population in need is not well defined. However, low rates are indicative of poor availability and quality of services. For example, several countries have demonstrated that outpatient department rates go up when barriers to using health services are removed, such as by bringing services closer to the people or reducing user fees (WHO, 2010). On the other hand, “higher than normal” rates of outpatient visits may signify problems such as lack of available hospital beds or lack of trained staff or available commodities for providing appropriate care and treatment for clients who should actually be receiving inpatient care.

References:

 

The Global Fund, 2009, Monitoring and Evaluation Toolkit: HIV, Tuberculosis and Malaria and Health Systems Strengtheninghttp://www.hivpolicy.org/Library/HPP000485.pdf

MEASURE DHS. 2011, Service Provision Assessments (SPA) Survey Overview, DHS Website http://www.measuredhs.com/What-We-Do/Survey-Types/SPA.cfm

USAID, 2009, Measuring the Impact of Health Systems Strengthening, A Review of the Literature, Washington, DC: USAID.  https://www.k4health.org/sites/default/files/measuring%20reform%20hss.pdf

WHO, 2010, Monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies, Geneva: WHO. http://www.who.int/healthinfo/systems/WHO_MBHSS_2010_full_web.pdf

Government health expenditure on reproductive health

Definition:

 

The total per capita annual government expenditure on reproductive health (RH) services and programs.

Areas for RH expenditures include family planning, maternal, newborn and child health care, treatment and prevention of STDs and HIV/AIDS and other RH conditions, infertility, abortion and postabortion care, RH and sexuality counseling, information, and education, and treatment and prevention for sexual abuse, gender-based violence and harmful practices, such as female genital cutting (WHO/UNFPA, 2008). 

This indicator is calculated as the sum of annual expenditures by government ministries and agencies for RH services and programs divided by the total population.

This indicator is a subcategory for RH from the core indicator for Total Expenditure on Health in the WHO Health System Strengthening (HSS) Handbook.  For more background on the process and criteria used in developing the WHO Handbook of indicators for HSS and for details on this and related indicators, see WHO (2010) and USAID (2009).

Data Requirements:

Data are collected through reporting by the ministries of finance and health and other relevant ministries and agencies. If public expenditure reviews that track whether government expenditures correspond with budget plans are available, these can be a helpful source of information. The best source of health expenditure data is from national health accounts (NHA), which combine expenditure data from all sources and through all types of financial agents. NHA data include all health service expenditures and can be disaggregated by government versus other sources and by the target areas of the expenditures. WHO, World Bank and USAID have jointly developed a guide to undertake NHA that has been adapted to meet the needs of low-income countries. Ideally, health expenditures should be calculated on an annual basis. Government RH expenditure data can be further disaggregated by type of RH service or program. For more information on NHA, see WHO (2010) and WHO/World Bank/USAID (2003)

Data Sources:

Reports from government ministries (i.e., finance, health, etc.) and agencies; NHA data; public expenditure reviews

Purpose:

 

This indicator provides information on the overall availability of funds for and level of government commitment to RH services and programs. Whether expenditures are considered sufficient requires estimates of the amounts needed to ensure access to the desired level of RH services.  The indicator will also allow per capita comparisons with other countries with similar and/or higher levels of gross domestic product (GDP).  Health financing is fundamental to the ability of health systems to maintain and improve human welfare and is basic to achieving Millennium Development Goals for health: #4. reduce child mortality; #5. improve maternal health; and #6. combat HIV/AIDs . In 2005, WHO Member States endorsed a resolution urging governments to develop health financing systems aimed at universal coverage, which is described as raising sufficient health funds to allow access to needed services without the risk of a financial catastrophe for households. Despite substantial increases in external assistance for health since 2000, the available resources are still insufficient in most low-income settings to assure universal coverage with even a very basic set of interventions (WHO, 2010).

Informed health financing policy decision-making requires reliable information on the quantity of financial resources used for health, their sources and the way they are used. The use of complied data on expenditures, such as the NHA, provides for monitoring progress in HSS, specifically health spending for all public and private sectors, different healthcare activities, providers, diseases, population groups and regions in a country.  It helps in developing national strategies and in raising funds for effective health financing.  Moreover, the information can be used to make financial projections of a country’s health system requirements and compare its experiences with those in the past or with those of other countries.

Issue(s):

In most countries, information on government health expenditures directed through the ministry of health is typically available through the ministry of finance or regional authorities in decentralized systems. However, information on government health expenditures that are directed through non-health ministries, such as military or police health services, are sometimes more difficult to obtain. While budget information is available in ‘real time’, there is often a delay of about one year in the production of consolidated expenditure accounts. Breaking down expenditures for RH services and programs may be complicated when these services overlap with health services that are not specifically defined as RH (e.g., nutrition care and adolescent health). Data on total expenditures for RH services cannot show how efficiently or effectively resources are being utilized.  

References:

 

The Global Fund, 2009, Monitoring and Evaluation Toolkit: HIV, Tuberculosis and Malaria and Health Systems Strengtheninghttp://www.hivpolicy.org/Library/HPP000485.pdf

USAID, 2009, Measuring the Impact of Health Systems Strengthening, A Review of the Literature, Washington, DC: USAID. https://www.k4health.org/sites/default/files/measuring%20reform%20hss.pdf

WHO/World Bank/USAID, 2003, Guide to producing national health accounts with special applications for low-income and middle-income countries. Geneva: WHO. http://www.who.int/health-accounts/documentation/publication_nha_guide/en/

WHO, 2010, Monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies, Geneva: WHO. http://www.who.int/healthinfo/systems/WHO_MBHSS_2010_full_web.pdf

WHO/UNFPA, 2008, National-level monitoring of the achievement of universal access to reproductive health: conceptual and practical considerations and related indicators, Geneva: WHO. http://whqlibdoc.who.int/publications/2008/9789241596831_eng.pdf   

WHO, 2011, National Health Accounts (NHA), Website, Geneva: WHO. http://www.who.int/nha/en/

The ratio of household out-of-pocket payments for healthcare to household income

Definition:

 

The number or percent of households in each region where direct out-of-pocket payments to providers for health during the past 12 months was more than 40 percent of their household income net of subsistence needs or 10 percent of their total income. The World Bank defines out-of-pocket expenditures as any direct outlay by households, including gratuities and in-kind payments, to health practitioners and suppliers of pharmaceuticals, therapeutic appliances, and other goods and services the primary intent of which is to contribute to the restoration or enhancement of health status (World Bank, 2011a). This definition can include transport costs for accessing healthcare and over-the-counter medicines and supplies, but does not include pre-paid fees for health-related taxes or insurance.  

WHO has defined financial catastrophe as direct out-of-pocket payments exceeding 40 percent of household income net of subsistence needs (calculated as total household income minus the cost for subsistence needs). Subsistence needs are determined as the median of household food expenditure in the country (WHO, 2010). The World Bank uses a more recent definition of financial catastrophe, where out-of-pocket payments exceed 10 percent of total household income. This approach is simpler to estimate and the results are similar to those derived by the WHO method.

This indicator is calculated as:

(Household out-of-pocket expenditure for health during the past 12 months / Total household income (or total income - subsistence needs) in past 12 months) x 100

 

In settings where self-reported total expenditure on health is a more reliable indicator of household purchasing power than self-reported income, the closely related indicator, the Ratio of household out-of-pocket payments for health to total health expenditures, can be calculated as: Annual household out-of-pocket payments for health care divided by total household health expenditures (i.e., out-of pocket plus prepaid expenditures, such as health-related taxes and insurance). 

This indicator is selected from the list of core indicators in the WHO Health System Strengthening (HSS) Handbook.  For more background on the process and criteria used in developing the WHO Handbook of indicators for HSS and for details on this and related indicators, see WHO (2010) and USAID (2009).

Data Requirements:

 

Information on household out-of-pocket expenditures is only available from household surveys. The World Bank has sponsored Living Standards Measurement Surveys (LSMS) since 1980 from which information on household health expenditures can be extracted (World Bank, 2011b) and World Health Surveys (WHS) sponsored by WHO in 2000-2001 also contain a household expenditure module (WHO, 2011). Demographic and Health Surveys and Multiple Indicator Cluster Surveys include modules on household assets, but not expenditures. There is considerable variability in the types of questions used to obtain household health expenditures, making it important to choose a standard instrument that would enhance comparability across time and countries. Data can be disaggregated by income or wealth quintiles, districts, urban/rural location, and relevant demographic and socioeconomic factors.

Data Sources:

 

Household surveys with income and expenditure data (e.g., LSMS or WHS)

Purpose:

 

This indicator measures the percent of the population at risk of impoverishment as a result of out-of-pocket payments.  Expenditures in excess of the WHO threshold (40 percent of income net of subsistence needs) commonly require households to reallocate expenditures from basic needs, such as food, clothing, and even children’s education. To examine questions of equity, the risk of impoverishment or financial catastrophe can be estimated by income or wealth quintile, if a separate wealth or asset index can be constructed from the same household survey. Optimally, total government expenditure on health should be increasing both in absolute terms and as a proportion of GDP in low-income countries, while the proportion of households facing financial catastrophe as a result of out-of-pocket payments should be decreasing.
Health financing is basic to maintaining health systems and protecting households from impoverishment, thereby contributing toward the Millennium Development Goals for health: #4. reduce child mortality; #5. improve maternal health; and #6. combat HIV/AIDS, as well as MDG #1. eradicate extreme poverty and hunger. In 2005, WHO Member States endorsed a resolution urging governments to develop health financing systems aimed at universal coverage, which is described as raising sufficient health funds to allow access to needed services without the risk of a financial catastrophe for households. Despite substantial increases in external assistance for health since 2000, the available resources are still insufficient in most low-income settings to assure universal coverage with even a very basic set of interventions (WHO, 2010).

In countries where self-reported total expenditure is regarded as a more reliable indicator of resources than self-reported income, the related indicator for the ratio of household out-of-pocket health payments to total health expenditures can be used. Comparisons are usually made in terms of total expenditure quintiles.

Issue(s):

Data collection for household income and expenditures is subject to reporting error and well-trained interviewers using standardized instruments can help reduce this source of error. Comparisons of the indicator by income quintiles need to be interpreted carefully.  In many countries the quintile with the lowest income (or total expenditures) also has a lower incidence of catastrophic payments than richer quintiles. People who are very poor often do not use services for which they have to pay, and thus do not experience a financial catastrophe (although they may suffer health consequences if they have inadequate care).  As people have slightly more income, they may begin to use services and experience adverse financial consequences linked to paying for care.

Poverty and Equity Considerations:

Compared to other areas of health spending, the poor are proportionally higher consumers of public health goods and services (depending on the location of service delivery and other factors affecting access). When government's take on a greater responsibility for public health spending, this directly contributes to poverty reduction through improved health status and protection from catastrophic losses due to treatment costs (Becker, Wolf, Levine, 2006).

References:

 

Becker L, Wolf J, Levine R, 2006. Measuring commitment to health. Center for Global Development. http://www.cgdev.org/doc/ghprn/Final%20Indicators%20Consultation%20Report.pdf

The Global Fund, 2009, Monitoring and Evaluation Toolkit: HIV, Tuberculosis and Malaria and Health Systems Strengtheninghttp://www.hivpolicy.org/Library/HPP000485.pdf

USAID, 2009, Measuring the Impact of Health Systems Strengthening, A Review of the Literature, Washington, DC: USAID.  https://www.k4health.org/sites/default/files/measuring%20reform%20hss.pdf

WHO, 2010, Monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies, Geneva: WHO. http://www.who.int/healthinfo/systems/WHO_MBHSS_2010_full_web.pdf

WHO, 2011, World Health Survey, Website, Geneva: WHO. http://www.who.int/healthinfo/survey/en/index.html

World Bank, 2011a, World Development Indicators, Website. http://data.worldbank.org/indicator/SH.XPD.OOPC.ZS

World Bank, 2011b, Living Standards Measurement Study (LSMS), Website. http://econ.worldbank.org/WBSITE/EXTERNAL/EXTDEC/EXTRESEARCH/EXTLSMS/0,,menuPK:3359053~pagePK:64168427~piPK:64168435~theSitePK:3358997,00.html

Number of health workers per 10,000 population by type of health worker

Definition:

 

The number of health workers available in a country relative to the total population subset by type of health worker.

Health workers are defined as all persons eligible to participate in the national health labor market by virtue of their training, accreditation, skills, and, where required, by age. The most complete and comparable data currently available on the health workforce globally pertain to physicians, nurses and midwives. However, the health workforce includes a wide range of other categories of service providers (e.g., dentists, pharmacists, physiotherapists, community health workers), as well as management and support workers. Information should be captured on all of these categories of human resources for health. Optimally, data on health occupations should be classified according to the latest International Standard Classification of Occupations (ISCO) revision or its national equivalent.  For guidelines on using ISCO for classification of healthcare workers, see WHO (2011).

This indicator is calculated as:

(The number of health workers at a given time in a given country or region / Total population for the same geographical area)

 

The ratio can be adjusted to per 10,000 population by multiplying the numerator and denominator by the same factor required for the denominator to equal 10,000.

This standardized indicator is selected from the list of core indicators in the WHO Health System Strengthening (HSS) Handbook.  For more background on the process and criteria used in developing the WHO handbook of indicators for HSS and for details on this and related indicators, see WHO (2010); USAID (2009); and The Global Fund (2006).

Data Requirements:

The numerator can be assessed through routine administrative records on numbers of active health workers compiled, updated and submitted regularly (e.g. quarterly) by district health officers, payroll registrars, individual health facilities (public, private, non-governmental and community-based) and/or health professional regulatory bodies. These data can be collated into a centralized human resource information system (HRIS) or database maintained by the ministry of health or other mandated agency. Information on the supply of health workers and on the total population should be periodically validated and adjusted against data from a population census and other nationally representative source. A comprehensive facility survey instrument called the Service Provision Assessment (SPA) has been developed by USAID and Macro International Inc. to be used with nationally representative samples of health facilities to provide information on the characteristics of health services, including their quality, infrastructure, utilization and availability.  The WHO service availability and readiness assessment (SARA) is specifically designed to assess, map and monitor service availability and readiness, including human resources. For more details on the SPA and SARA, see WHO (2010) and MEASURE DHS (2011).

Data Sources:

Health facility records; HRIS; census data; facility surveys, such as the SPA and SARA

Purpose:

This indicator provides information on the stock of health workers relative to the population.  It can be used to monitor whether the size and specialties of the current workforce meets a given threshold that should allow the most basic levels of healthcare coverage in a country. The advantages include that it is simple to calculate, may be used for comparative analyses across countries and over time, and is easy to understand among a wide range of audiences, making it useful for policy and advocacy purposes. The primary aim of HSS is to improve access, quality, and utilization, and growing evidence shows that health systems capable of delivering services equitably, efficiently, and in a coordinated manner are essential for achieving improved health outcomes. Globally, there is increasing attention to equity in health and the pathways by which inequities arise and are perpetuated or exacerbated.  Imbalance or uneven distribution in the supply, deployment and composition of human resources for health can lead to inequities in the effective provision of health services and is an issue of social and political concern in many countries. Attaining and maintaining sufficient numbers of well-trained health workers is basic to HSS and contributes to achieving progress in the Millennium Development Goals for health #4. Reduce child mortality; #5. improve maternal health; and #6. combat HIV/AIDs.   

Issue(s):

 

Counts of workers outside the public sector (i.e., private, non-governmental, community-based) are likely to be less accurate, particularly if these sectors are not required to regiser and/or provide reports on staff and services. While this indicator measures the availability of service providers, it does not take into account all of a health system's objectives, particularly with regard to accessibility, equity, efficiency, and quality of training and services.

References:

 

The Global Fund, 2006, Monitoring and Evaluation Toolkit: HIV, Tuberculosis and Malaria and Health Systems Strengtheninghttp://www.hivpolicy.org/Library/HPP000485.pdf

MEASURE DHS. 2011, Service Provision Assessments (SPA) Survey Overview, DHS Website. http://www.measuredhs.com/What-We-Do/Survey-Types/SPA.cfm

USAID, 2009, Measuring the Impact of Health Systems Strengthening, A Review of the Literature, Washington, DC: USAID.  https://www.k4health.org/sites/default/files/measuring%20reform%20hss.pdf

WHO, 2010, Monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies, Geneva: WHO. http://www.who.int/healthinfo/systems/WHO_MBHSS_2010_full_web.pdf

WHO, 2011, Classifying health workers: Mapping occupations to the international standard classification, Geneva: WHO. http://www.who.int/hrh/statistics/Health_workers_classification.pdf

Distribution of health workers, by occupation/specialization, region, place of work and sex

Definition:

 

The distribution or percent of health workers according to selected characteristics, notably by occupation, geographical region, place of work and sex.

Health workers are defined as all persons eligible to participate in the national health labor market by virtue of their training, accreditation, skills, and, where required, by age. The most complete and comparable data currently available on the health workforce globally pertain to physicians, nurses and midwives. However, the health workforce includes a wide range of other categories of service providers (e.g., dentists, pharmacists, physiotherapists, community health workers), as well as management and support workers. Information should be captured on all of these categories of human resources for health. Optimally, data on health occupations should be classified according to the latest International Standard Classification of Occupations (ISCO) revision or its national equivalent.  For guidelines on using ISCO for classification of healthcare workers, see WHO (2011).

Where possible, geographic mapping of sites can be used to help determine coverage. 

This indicator is calculated as:

(The number of health workers with a given characteristic / Total number of health workers in a designated area) x 100

This indicator is selected from the list of core indicators in the WHO Health System Strengthening (HSS) Handbook. For more background on the process and criteria used in developing the WHO Handbook of indicators for HSS and for details on this and related indicators, see  WHO (2010) ; USAID (2009); and The Global Fund (2009).

Data Requirements:

The HSS indicator for stock of health workers can be subset according to the selected characteristics (see indicator in this section Number of health workers per 10,000 population by type of health worker). Geographic locations of health facility sites using maps or computerized mapping system. The WHO service availability and readiness assessment (SARA) is specifically designed to assess, map and monitor service availability and readiness, including human resources. For more details on the SARA, see WHO (2010).  Data can be disaggregated by occupation (and subset within a given occupation or medical specialization), by geographical typology (e.g. urban or rural, within or outside the capital city, by province/state or district), by place of work (e.g. hospital or primary health-care facility, public or private), by main work activities (e.g., preventive, curative, rehabilitative healthcare versus teaching or research), and by sex.

Data Sources:

Health facility records; human resource information system (HRIS); database maintained by the ministry of health or other mandated agency; maps and/or computerized mapping systems; facility surveys, such as the SARA

Purpose:

 

This indicator provides information on the distribution of health workers by their occupations and areas of specialty and can be subset by district, sex, age and other categories to examine coverage and demographics of the health care workforce.  The additional information on health workers’ demographic characteristics may be important for policy and planning, for instance, the age distribution can lend insights into the numbers of workers approaching retirement age and whether sufficient numbers of younger health workers are coming into the system. At least four main typologies for monitoring the distribution of health workers should be considered: imbalances in occupation/specialty; geographical representation; institutions and services; and demographics. The impact on the health system varies for these different types of imbalances and, consequently, there is a need to monitor and assess each of these dimensions of workforce distribution (WHO, 2010).

Issue(s):

Counts of workers outside the public sector (i.e., private, non-governmental, community-based) are likely to be less accurate, particularly if these sectors are not required to register and/or provide reports on staff and services. Private sector providers are often less accessible to low-income populations, compared with public and community- based providers making it important to disaggregate this indicator by employment sector.  While this indicator measures the availability and distribution of service providers by occupations and other categories, it does not take into account all of a health system's objectives, particularly with regard to accessibility, equity, efficiency, and quality of training and services.

Poverty and Equity Considerations:

Globally, there is increasing attention to equity in health and the pathways by which inequities arise and are perpetuated or exacerbated. Imbalance or uneven distribution in the supply, deployment and composition of human resources for health can lead to inequities in the effective provision of health services and is an issue of social and political concern in many countries. Attaining and maintaining sufficient numbers and distribution of well-trained health workers by occupations and specialties is basic to HSS and contributes to achieving progress in the Millennium Development Goals for health #4. Reduce child mortality; #5. improve maternal health; and #6. combat HIV/AIDS.

References:

 

The Global Fund, 2009, Monitoring and Evaluation Toolkit: HIV, Tuberculosis and Malaria and Health Systems Strengtheninghttp://www.hivpolicy.org/Library/HPP000485.pdf

USAID, 2009, Measuring the Impact of Health Systems Strengthening, A Review of the Literature, Washington, DC: USAID. https://www.k4health.org/sites/default/files/measuring%20reform%20hss.pdf

WHO, 2010, Monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies, Geneva: WHO. http://www.who.int/healthinfo/systems/WHO_MBHSS_2010_full_web.pdf

WHO, 2011, Classifying health workers: Mapping occupations to the international standard classification, Geneva: WHO. http://www.who.int/hrh/statistics/Health_workers_classification.pdf

Existence of designated mechanisms charged with analysis of RH statistics

Definition:

 

There is a designated and functioning institutional mechanism charged with analysis of reproductive health (RH) statistics, synthesis of data from different sources and validation of data from population-based and facility-based sources (WHO, 2010). The body charged with these functions should be administratively separate from programs responsible for delivery of interventions and should adhere to fundamental principles of handling official statistics.

This indicator is a subset for RH of one of the core indicators for general health statistics in the WHO Health System Strengthening (HSS) Handbook and is also one of 26 indicators in the Health Information Systems Performance Index (HISPIX), which can be summed into a composite score (WHO, 2010). For more background on the process and criteria used in developing the WHO Handbook of Indicators for HSS and for details on this and related indicators, see WHO (2010); USAID (2009); and WHO (2007).

Data Requirements:

 

Reviews of ministry of health (MOH) and national health sector reports on designated infrastructure, staff, and procedural guidelines for health statistics analysis and reporting.  A number of tools have been developed for assessing information systems including: the HIS indicators in the WHO HSS Handbook and the HISPIX (WHO, 2010); the self-assessment indicators in the WHO Health Metrics Network (HMN) toolkit (WHO, 2007); the Organization for Economic Cooperation and Development (OECD, 2003) statistical standards, guidelines and best practices on development indicators; and the United Nations Fundamental Principles of Official Statistics (UN, 1994), which is often used as a general framework to assess the performance of national statistics offices.

The HMN toolkit recommends scoring the responses for this and related indicators on a four-level scale: highly adequate; adequate; present but not adequate; and not adequate at all. The crucial difference between the HISPIX approach and the HMN self-assessment tool is that the HISPIX indicators and summary score can be assessed on the basis of information that is largely available in the public domain.

Data Sources:

National MOH and health sector reports

Purpose:

This indicator reflects the national capacity for synthesis, analysis and validation of health data, specifically RH data, and can be used to establish a baseline and to monitor progress. A well-functioning national health information system (HIS) that provides sound and reliable information is the foundation of decision-making across all aspects of the health system.  The HIS collects data from health and other relevant sectors, analyses the data, ensures overall quality, relevance and timeliness, and converts the data into information for decision-making and planning. Quality health statistics analysis and reporting are essential for all aspects of HSS, from health system policy development and implementation, governance and regulation, health research, human resources development, health education and training, to service delivery and financing.  Few developing countries have sufficiently strong and effective health information systems to meet all the varied needs for health information. New technologies can contribute to improving data generation, compilation and information exchange, however, these technologies also require detailed quality standards to be of optimal value. Strengthening national HIS capacity and RH health data quality and utilization are fundamental to the achievement of the health-related Millennium Development Goals: #4 reduce child mortality; #5 improve maternal health; and # 6 combat HIV/AIDS, tuberculosis and malaria.

Issue(s):

The existence of a mechanism for RH data analysis does not necessarily mean that the body charged with the task is operating effectively and efficiently. In many countries, health sector reform and decentralization have brought about shifts in functions between the central, district and local levels that have created new information needs with changing requirements for data collection, processing, analysis and dissemination. Moreover, health sector reforms can increase the need for standardization and quality information.

References:

 

Organization for Economic Cooperation and Development (OECD), 2003, Quality dimensions, core values for OECD statistics and procedures for planning and evaluating statistical activities. Paris: OECD. http://www.oecd.org/dataoecd/26/38/21687665.pdf (accessed 1 April 2010).

United Nations Statistics Division. Fundamental principles of official statistics. New York: United Nations, 1994. http://unstats.un.org/unsd/dnss/gp/fundprinciples.aspx

USAID, 2009, Measuring the Impact of Health Systems Strengthening, A Review of the Literature, Washington, DC: USAID. https://www.k4health.org/sites/default/files/measuring%20reform%20hss.pdf

WHO, 2010, Monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies, Geneva: WHO. http://www.who.int/healthinfo/systems/WHO_MBHSS_2010_full_web.pdf

WHO, 2007, Strengthening Country Health Information Systems: Assessment and Monitoring Tool Version 2.0, Geneva: WHO Health Metrics Network http://www.hrhresourcecenter.org/node/747

Two or more population-based data points for maternal mortality in the last 10 years

Definition:

The country has collected population-based data for maternal mortality at two or more time points in the past 10 years, including one in the past five years.

This indicator is one of the 26 indicators in the WHO Health Systems Strengthening (HSS) Handbook of indicators Information Systems Performance Index (HISPIX), which can be summed to form a composite score (WHO, 2010). For more background on the process and criteria used in developing the WHO Handbook of Indicators for HSS and for details on this and related indicators, see WHO (2010) and USAID (2009).

Data Requirements:

Reviews of country reports can ascertain when and how often population-based surveys have been conducted that include measures of maternal mortality, such as Demographic and Health surveys (DHS), the UNICEF Multiple Indicator Cluster Surveys (MICS), or the WHO World Health Survey (WHS).

Data Sources:

Country reports; population-based surveys providing information on maternal mortality, such as DHS, MICS, and WHS

Purpose:

 

This indicator assesses the country’s commitment to conducting   population-based surveys that include measures of core reproductive health (RH) outcome indicators, such as maternal mortality, and are frequent and recent enough to be useful for RH policy, planning, and program evaluation purposes. Data from multiple time points permit evaluators to establish baselines and track changes. A well-functioning national health information system (HIS) that provides sound and reliable information is the foundation of decision-making across all aspects of the health system. Collection and analysis of accurate and timely data on RH outcomes, such as maternal mortality, are essential for informing health system policy development, allocation of funds, and implementation of programs and interventions.

WHO recommends that countries fund and implement surveys that provide at least the following information (WHO, 2010):

Strengthening national HIS capacity for collection of data on maternal mortality and other RH outcomes is fundamental to the achievement of the health-related Millennium Development Goals: #4 reduce child mortality; #5 improve maternal health; and # 6 combat HIV/AIDS, tuberculosis and malaria.

Issue(s):

While this indicator demonstrates if the country has been collecting periodic and timely survey data on RH outcomes, it does not capture how the information is used for policy decision-making, planning and programs.

References:

 

USAID, 2009, Measuring the Impact of Health Systems Strengthening, A Review of the Literature, Washington, DC: USAID.  https://www.k4health.org/sites/default/files/measuring%20reform%20hss.pdf

WHO, 2010, Monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies, Geneva: WHO. http://www.who.int/healthinfo/systems/WHO_MBHSS_2010_full_web.pdf

Percent of births registered in the country

Definition:

 

The percent of births registered during a specified time period for a country or designated region. This should be at least 90 percent of all births. An intermediate goal is 50 percent.  WHO recommends scoring this indicator as <50 percent = 0; 50 to 89 percent = 1; and ≥ 90 percent = 2 (WHO, 2010).

This indicator is calculated as:

(Number of births registered/ Total births for the same time period and geographical region)  x 100

This indicator is one of the 26 indicators in the WHO Health Systems Strengthening (HSS) Handbook of Indicators Health Information Systems Performance Index (HISPIX), which can be summed to form a composite score (WHO, 2010). For more background on the process and criteria used in developing the WHO Handbook of Indicators for HSS and for details on this and related indicators, see WHO (2010); USAID (2009); and The Global Fund (2009).

Data Requirements:

Reports of births by civil or sample registration systems, hospitals, and community-based reporting systems. Where information on total births is not available because of incomplete civil registration, total births can be estimated by extrapolating from the census or on the basis of information about birth rates derived from population-based surveys, such as Demographic and Health surveys (DHS), the UNICEF Multiple Indicator Cluster Surveys (MICS); WHO World Health Survey (WHS).  Data can be disaggregated by type of source (e.g., hospital or community-based) and by district, urban/rural location.

Data Sources:

 

Birth registration systems; hospital and community-based reporting systems; estimates from population-based surveys (e.g., DHS, MICs, WHS)

Purpose:

 

This indicator assesses the country’s capacity to design and implement an effective civil registration system to report vital statistics including births and deaths. A well-functioning national health information system (HIS) that provides sound and reliable information is the foundation of decision-making across all aspects of the health system. Collection and analysis of accurate and timely data on vital statistics are essential for informing health system policy development, allocation of funds, and the implementation of programs and interventions. Comparisons between regions and across time can help identify regional or localized problems in reporting or breakdowns in the HIS system.

WHO recommends that countries fund and implement an HIS that, at minimum, can track these vital statistics (WHO, 2010):

The United Nations Statistics Division provides guidelines and support for national governments in establishing and maintaining reliable civil registration systems (UN, 1998). Strengthening national HIS capacity for collection of vital statistics is fundamental to the achievement of the health-related Millennium Development Goals: #4 reduce child mortality; #5 improve maternal health; and # 6 combat HIV/AIDS, tuberculosis and malaria.

Issue(s):

The quality of reporting may vary between sources, for instance, hospitals may provide more complete reporting than community-based sources. Thus, disaggregation of the indicator by type of reporting source may be important for identifying these differences, particularly where the overall percent of reported births is low. While this indicator can show if the country has developed an effective vital registration system, it does not capture whether and how the information generated by this system is used for policy decision-making, planning and programs. 

References:

 

The Global Fund, 2009, Monitoring and Evaluation Toolkit: HIV, Tuberculosis and Malaria and Health Systems Strengtheninghttp://www.hivpolicy.org/Library/HPP000485.pdf

United Nations Statistics Division, 1998, Principles and recommendations for a vital statistics system, revision 2. New York, NY, United Nations. http://unstats.un.org/unsd/demographic/standmeth/handbooks/default.htm   

USAID, 2009, Measuring the Impact of Health Systems Strengthening, A Review of the Literature, Washington, DC: USAID.  https://www.k4health.org/sites/default/files/measuring%20reform%20hss.pdf

WHO, 2010, Monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies, Geneva: WHO. http://www.who.int/healthinfo/systems/WHO_MBHSS_2010_full_web.pdf

Percent of deaths registered in the country

Definition:

The percent of deaths registered during a specified time period for a country or designated region. This should be at least 90 percent of all deaths. An intermediate goal is 50 percent.  WHO recommends scoring this indicator as <50 percent = 0; 50 to 89 percent = 1; and ≥ 90 percent = 2 (WHO, 2010).

This indicator is calculated as:

(Number of deaths registered / Total deaths for the same time period and geographical region) x 100

This indicator is one of the 26 indicators in the WHO Health Systems Strengthening (HSS) Handbook of Indicators Health Information Systems Performance Index (HISPIX), which can be summed to form a composite score (WHO, 2010). For more background on the process and criteria used in developing the WHO Handbook of Indicators for HSS and for details on this and related indicators, see WHO (2010); USAID (2009); and The Global Fund (2009).

Data Requirements:

Reports of deaths by civil or sample registration systems, hospitals, and community-based reporting systems. Where information on total deaths is not available because of incomplete civil registration, total deaths can be estimated by extrapolating from the census or on the basis of information about death rates derived from population-based surveys, such as Demographic and Health surveys (DHS), the UNICEF Multiple Indicator Cluster Surveys (MICS); WHO World Health Survey (WHS).  Data can be disaggregated by type of source (e.g., hospital or community-based) and by district, urban/rural location.

Data Sources:

Death registration systems; hospital and community-based reporting systems; estimates from population-based surveys (e.g., DHS, MICs, WHS)

Purpose:

This indicator assesses the country’s capacity to design and implement an effective civil registration system to report vital statistics including births and deaths. A well-functioning national health information system (HIS) that provides sound and reliable information is the foundation of decision-making across all aspects of the health system. Collection and analysis of accurate and timely data on vital statistics are essential for informing health system policy development, allocation of funds, and the implementation of programs and interventions. Comparisons between regions and across time can help identify regional or localized problems in reporting or breakdowns in the HIS system.

WHO recommends that countries fund and implement an HIS that, at minimum, can track these vital statistics (WHO, 2010):

The United Nations Statistics Division provides guidelines and support for national governments in establishing and maintaining reliable civil registration systems (UN, 1998). Strengthening national HIS capacity for collection of vital statistics is fundamental to the achievement of the health-related Millennium Development Goals: #4 reduce child mortality; #5 improve maternal health; and # 6 combat HIV/AIDS, tuberculosis and malaria.

Issue(s):

The quality of reporting may vary between sources, for instance, hospitals may provide more complete reporting than community-based sources. Thus, disaggregation of the indicator by type of reporting source may be important for identifying these differences, particularly where the overall percent of reported deaths is low. While this indicator can show if the country has developed an effective vital registration system, it does not capture whether and how the information generated by this system is used for policy decision-making, planning and programs.

References:

The Global Fund, 2009, Monitoring and Evaluation Toolkit: HIV, Tuberculosis and Malaria and Health Systems Strengthening, http://rbm.who.int/toolbox/tool_MEtoolkit.html

United Nations Statistics Division, 1998, Principles and recommendations for a vital statistics system, revision 2. New York, NY, United Nations. http://unstats.un.org/unsd/demographic/standmeth/handbooks/default.htm  

USAID, 2009, Measuring the Impact of Health Systems Strengthening, A Review of the Literature, Washington, DC: USAID. http://www.usaid.gov/our_work/global_health/hs/publications/impact_hss.pdf

WHO, 2010, Monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies, Geneva: WHO. http://www.who.int/healthinfo/systems/WHO_MBHSS_2010_full_web.pdf

Average availability of 14 selected essential medicines in public and private health facilities

Definition:

 

The average percent of public and private medicine outlets in sample areas where a selection of the 14 essential medicines are found on the day of the survey. The medicines should be present and not expired on the day of visit (or during a specified reference period, e.g., last month or last 3 months). The 14 drugs in the global core list of tracer medicines can be found in (WHO 2010; Table 4.1).  Non-governmental and community-based facilities providing medicines can also be included in the calculation.   

A closely related indicator Percent of facilities that have all tracer medicines and commodities in stock on the day of visit (and last three months) includes additional medicines plus commodities and vaccines. This indicator uses a composite index of 61 essential medicines, commodities, and vaccines and is available in (WHO, 2010; Chapter 4 Annex). For additional information on assessing and tracking commodities, see the database section on Commodity Security and Logistics.

This indicator is calculated as an average of percentages from sample areas:

(The number of facilities with all 14 essential medicines in stock (present and not expired) on the day of visit / Total number of facilities surveyed in sample area) x 100

This indicator is selected from the list of core indicators in the WHO Health System Strengthening (HSS) Handbook. For more background on the process and criteria used in developing the WHO Handbook of indicators for HSS and for details on this and related indicators, see  WHO (2010); USAID (2009); and The Global Fund (2009).

Data Requirements:

 

National surveys of medicine price and availability ideally are conducted using a standard methodology developed by WHO and Health Action International (HAI).  WHO/HAI (2008) protocols recommend collecting data from medicine outlets in six sample geographic or administrative areas of a country (or for large countries - a state or province). Data are collected on the availability and price of the essential 14 medicines from all public, private, and other sector outlets that serve as important medicine dispensing points. The full list of 50 survey medicines includes 14 essential medicines in use worldwide, 16 regionally specific medicines and countries are encouraged to collect data on an additional 20 medicines of national importance. 

For each medicine, information is collected on the originator brand, the lowest priced generic equivalent found at each medicine outlet, government procurement prices, and any add-on costs that are charged to medicines as they proceed through the supply and distribution chain. In the absence of routine monitoring, a national survey of medicine prices and availability should be conducted every three to five years using the WHO/HAI standard methodology.

Data Sources:

Surveys of health care facilities and other medicine outlets using standardized instruments (e.g., WHO /HAI survey)

Purpose:

This indicator can be used to examine access in terms of availability of essential medicines in addition to practices and trends over time in selection and procurement of these medicines.  Moreover, it can serve as a proxy for service quality, as represented by the presence of non-expired stock. Various WHO disease prevention and treatment programs have proposed maintaining lists of medicines in stock for assessment of service availability and readiness. Essential medicines satisfy priority health care needs of the population and are intended to be available within the context of functioning health systems at all times, in adequate amounts, in the appropriate dosage, with assured quality, and at a price that individuals and the community can afford. Access to medicines is included in the Millennium Development Goals under MDG 8 to develop global partnerships for development,  specifically Target 8.E to provide access to affordable essential drugs in developing countries. For the purpose of monitoring the MDGs, access has been defined as “having medicines continuously available and affordable at public or private health facilities or medicine outlets that are within one hour’s walk of the population” (United Nations Development Group, 2003). Recent United Nations reports assessing progress towards MDG target 8.E found that low availability, high prices and poor affordability of medicines are key impediments to access to treatment in low- and middle-income countries (UN, 2009).

Issue(s):

This indicator measures availability of essential, non-expired medicines, but the overall access to, distribution of, and quality of services with medicines can only be measured using a range of indicators that provide data on medicine procurement, storage, affordability, travel time to medicine outlets, and rational use including appropriate prescribing, dosages, and dispensing practices.

References:

 

The Global Fund, 2009, Monitoring and Evaluation Toolkit: HIV, Tuberculosis and Malaria and Health Systems Strengthening. http://www.hivpolicy.org/Library/HPP000485.pdf

USAID, 2009, Measuring the Impact of Health Systems Strengthening, A Review of the Literature, Washington, DC: USAID.  https://www.k4health.org/sites/default/files/measuring%20reform%20hss.pdf

WHO, 2010, Monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies, Geneva: WHO. http://www.who.int/healthinfo/systems/WHO_MBHSS_2010_full_web.pdf

WHO/Health Action International (HAI), 2008, Medicine Prices, Availability, and Price Components, Amsterdam: HAI. http://www.haiweb.org/medicineprices/manual/documents.html

United Nations, 2009, Strengthening the global partnership for development in a time of crisis. MDG gap task force report 2009. New York; UN. http://www.un.org/millenniumgoals/pdf/MDG_Gap_%20Task_Force_%20Report_2009.pdf

United Nations Development Group, 2003, Indicators for monitoring the Millennium Development Goals, New York, United Nations. http://www.armstat.am/file/doc/99465263.pdf

Median consumer price ratio of 14 selected essential medicines in public and private health facilities

Definition:

 

The consumer price ratios for 14 essential medicines calculated as the ratio between median unit prices and the median international reference prices for that same product for the year preceding the survey.

The 14 drugs in the global core list of tracer medicines can be found in (WHO 2010; Table 4.1).  Non-governmental and community-based facilities providing medicines can also be included in the calculation.  

The median international reference prices for the essential medicines (as price per tablet or therapeutic unit) are available through Management Sciences for Health (MSH, 2011). The MSH international reference prices have been selected for comparison as they are widely available, updated frequently, and relatively stable over time.

This indicator is calculated as:

(Median unit price paid by consumers for a specific medicine during previous year / Median international reference price for same medicine during previous year)

This indicator is selected from the list of core indicators in the WHO Health System Strengthening (HSS) Handbook. For more background on the process and criteria used in developing the WHO Handbook of indicators for HSS and for details on this and related indicators, see  WHO (2010);  USAID (2009); The Global Fund (2009).

Data Requirements:

 

National surveys of medicine price and availability ideally are conducted using a standard methodology developed by WHO and Health Action International (HAI).  WHO/HAI (2008) protocols recommend collecting data from medicine outlets in six sample geographic or administrative areas of a country (or for large countries - a state or province).  Data are collected on the availability and price of the essential 14 medicines from all public, private and other sector outlets that serve as important medicine dispensing points. The full list of 50 survey medicines includes 14 essential medicines in use worldwide, 16 regionally specific medicines and countries are encouraged to collect data on an additional 20 medicines of national importance. 

For each medicine, information is collected on the originator brand, the lowest priced generic equivalent found at each medicine outlet, government procurement prices, and any add-on costs that are charged to medicines as they proceed through the supply and distribution chain. In the absence of routine monitoring, a national survey of medicine prices and availability should be conducted every three to five years using the WHO/HAI standard methodology.

Data Sources:

Surveys of health care facilities and other medicine outlets using standardized instruments (e.g., WHO /HAI survey)

Purpose:

This indicator can be used to examine access in terms of affordability of essential medicines at the time of survey and to compare trends over time. Essential medicines satisfy priority health care needs of the population and are intended to be available within the context of functioning health systems at all times, in adequate amounts, in the appropriate dosage, with assured quality, and at a price that individuals and the community can afford. Access to medicines is included in the Millennium Development Goals under MDG 8 to develop global partnerships for development, specifically Target 8.E to provide access to affordable essential drugs in developing countries. For the purpose of monitoring the MDGs, access has been defined as “having medicines continuously available and affordable at public or private health facilities or medicine outlets that are within one hour’s walk of the population” (United Nations Development Group, 2003). Recent United Nations reports assessing progress towards MDG target 8.E found that low availability, high prices and poor affordability of medicines are key impediments to access to treatment in low- and middle-income countries (UN, 2009).

Issue(s):

 

This indicator measures affordability of essential medicines, but the overall access to, distribution of, and quality of services with medicines can only be measured using a range of indicators that provide data on medicine procurement, availability, storage, travel time to medicine outlets, and rational use including appropriate prescribing, dosages, and dispensing practices (WHO, 2010).

References:

 

The Global Fund, 2009, Monitoring and Evaluation Toolkit: HIV, Tuberculosis and Malaria and Health Systems Strengthening, http://www.hivpolicy.org/Library/HPP000485.pdf

Management Sciences for Health (MSH), 2011, International Drug Price Indicator Guide, Cambridge, MA: MSH. https://www.msh.org/resources/international-drug-price-indicator-guide

USAID, 2009, Measuring the Impact of Health Systems Strengthening, A Review of the Literature, Washington, DC: USAID.  https://www.k4health.org/sites/default/files/measuring%20reform%20hss.pdf

WHO, 2010, Monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies, Geneva: WHO. http://www.who.int/healthinfo/systems/WHO_MBHSS_2010_full_web.pdf

WHO/Health Action International (HAI), 2008, Medicine Prices, Availability, and Price Components, Amsterdam: HAI. http://www.haiweb.org/medicineprices/manual/documents.html

United Nations, 2009, Strengthening the global partnership for development in a time of crisis. MDG gap task force report 2009. New York; UN. http://www.un.org/millenniumgoals/pdf/MDG_Gap_%20Task_Force_%20Report_2009.pdf

Existence of a comprehensive reproductive health policy consistent with the ICPD action plan

Definition:

 

Recorded evidence of a national reproductive health (RH) policy or strategy that is comprehensive and consistent with the recommendations in the action plan of the 1994 International Conference on Population and Development (ICPD) exists as a stand-alone document or has been integrated into health policies or strategies. 

For the policy to be considered comprehensive, it should cover the RH domains included in the ICPD plan, such as family planning, reproductive rights, women’s empowerment and gender equality, male involvement in RH, essential medicines and commodities, sexually transmitted infections (STIs), HIV/AIDS, TB, malaria, maternal health, child health and immunization (UNFPA, 1973).

This indicator is selected from the list of core indicators in the WHO Health System Strengthening (HSS) Handbook. For more background on the process and criteria used in developing the WHO Handbook of Indicators for HSS and for details on this and related indicators, see  WHO (2010) and USAID (2009).

Data Requirements:

Review of national health policies on RH including reviews of the respective RH domains listed above. The reviewed policies and strategies can be compared to see if they are consistent with the stated goals of the ICPD Programme of Action (UNFPA, 1973).

Data Sources:

Review of national health policies or strategies

Purpose:

 

This indicator measures government support for RH programs and services based on the existence of policies that are both comprehensive and consistent with the ICPD plan of action. The 1994 ICPD in Cairo articulated a vision of the relationships between population, development and individual well-being. At the Conference, 179 governments adopted a 20-year plan of action, including RH and rights in addition to women’s empowerment and gender equality, as the cornerstone of population and development programs.  The Millennium Development Goals (MDG) have built upon the ICPD action plan and this indicator can be used to evaluate progress in policies supporting the MDGs: # 3 promote gender equity and empower women: #4 reduce child mortality; #5 improve maternal health; and # 6 combat HIV/AIDS, tuberculosis and malaria.

The WHO Handbook on HSS (WHO, 2010) includes this indicator as a measure of good governance and policy related to maternal health and it serves as one of ten indicators that can be used to calculate a composite governance policy index. The index provides a summary measure of governance quality from a rules-based perspective and assesses whether countries have policies, regulations and strategies in place to promote good leadership and governance in the health sector.

Issue(s):

Although a country’s stated policies may capture the intent of the ICPD action plan, if the policies have not been revised for five or more years or have not been costed for implementation, they may not accurately reflect current needs and resources of the country. Evaluators may wish to determine if the policies and plans are current and relevant, and if they have been systematically costed and, optimally, budgeted for implementation. Evidence of comprehensive RH policies does not ensure that the policies have been successfully adopted.  Evaluators may also wish to follow up with a complementary output indicator, evidence of RH policies implemented, resources allocated and subsequently used in relation to the same RH policy.

References:

 

The Global Fund, 2009, Monitoring and Evaluation Toolkit: HIV, Tuberculosis and Malaria and Health Systems Strengthening, http://rbm.who.int/toolbox/tool_MEtoolkit.html

UNFPA, 1995, International Conference on Population and Development - ICPD - Programme of Action, New York: UNFPA. http://www.unfpa.org/public/publications/pid/1973   

USAID, 2009, Measuring the Impact of Health Systems Strengthening, A Review of the Literature, Washington, DC: USAID.  https://www.k4health.org/sites/default/files/measuring%20reform%20hss.pdf 

WHO, 2010, Monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies, Geneva: WHO. http://www.who.int/healthinfo/systems/WHO_MBHSS_2010_full_web.pdf