Monitoring health systemsHealth system metrics

Health Metrics Network

1st Steering Committee Meeting

March 21 2006

Overall goalOverall goal

Develop a common strategy to monitor health systems in countries that:1. Guides and advocates for investment in a data generation

strategy that provides accurate statistics for health system indicators

2. Includes a core set of health system indicators, if possible with baselines and targets or thresholds

3. Promotes the incorporation of health system monitoring in planning cycles (e.g. PRSP, annual health sector reviews, strategic plans etc.)

4. Contributes to effectively communicating about health systems

Demand SideDemand Side

Communication: Make health systems tangible by focusing on actionable (measurable) items

Global Health Partnerships: enhance accountability of investments in health systems, directly related to core mandate of the respective partnerships

Performance-based disbursement: systems performance using relatively simple reliable set of statistics that can be reported on frequently (e.g. EC)

Composite measures of health system performance (effective coverage, responsiveness)

Demand for human resources statistics

Health Metrics Network in coordination role

Supply SideSupply Side

WHO: World Health Statistics 2005 (9 indicators) and World Health Report annexes (financing)

OECD, developed countries indicators: extensive lists of indicators of clinical services for reporting

Global Health Partnerships (GAVI, GFATM), WHO departments, HR: developing shortlist of indicators for (suggested) reporting

Co-coverage of interventions of child health (equity, Countdown)

WHO / World Bank meeting in 2004 First step towards defining a set of core health system metrics

(health system inputs, outputs)

WHO / World Bank meeting in 2004 First step towards defining a set of core health system metrics

(health system inputs, outputs)

Financing– Total health expenditure per capita– Total health expenditure as % of GDP– General government expenditure on health as % of total government expenditure

Human resources– Health workers per 1,000 population (physicians, assistance doctors, nurses, midwives) – Nurse physician ratio (skills mix) Annual output of health workers by training institutions per

1,000 population Information

– % of estimated deaths that are 'counted' Service delivery

– Hospital (in-patient) beds

Policy / governance – CPIA

Additional (OECD list)

Under development

Health systemInputs Outputs OutcomesPolicyFinancingHuman resources

InformationService delivery

Service coverageUtilization

Human resource data availability end 2004: percent distribution of countries by year and WHO region,

World Health Statistics 2005

Human resource data availability end 2004: percent distribution of countries by year and WHO region,

World Health Statistics 2005

0

10

20

30

40

50

60

70

80

90

100

Before

2000

2001

2002+

Quality concerns!

GAVI – Health System StrengtheningGAVI – Health System Strengthening

Process indicators (short term)– N of people trained, N of vehicles purchased, etc.

Output and capacity indicators (medium term)– N of facilities with trained health workers in place, % of districts

with vehicles operational etc.

Outcome indicators (long term)– District level DPT 3 coverage (equity indicator)– Measles coverage, – Under 5 mortality

Global FundM&E toolkit, Jan 2006 edition

Global FundM&E toolkit, Jan 2006 edition

Service delivery– 4 output (facilities with specific services), 3 outcome indicators (% of population covered by GF

interventions)

Human resources– 4 output (HW density, training output), 2 outcome (patient satisfaction)

Community systems strengthening– 4 output (training community workers), 1 outcome (availability basic package community

services)

Information system & operational research– 4 output (reporting facilities), 4 outcome (surveys, HIV prevalence)

Infrastructure– 2 output (health facilities with specific arrangements), 1 outcome (geographic access)

Procurement and supply management– 3 output (trained technicians, stock out days TB drugs), 1 outcome (facility supply status)

Co-coverage of 8 MCH interventions(mean, concentration index >6 interventions)

Co-coverage of 8 MCH interventions(mean, concentration index >6 interventions)

0

1

2

3

4

5

6

7

Bangladesh Benin Brazil Cambodia Eritrea Haiti Malawi Nepal Nicaragua

Mean N of interventions Concentration index for >6 interventions

Immunization • -Child; BCG, DTP, measles

• -Mother: TT

•Vitamin A supplementation

Antenatal care

Skilled delivery

Safe water

Areas of Health SystemsAreas of Health Systems

1. Financing

2. Human resources

3. Information

4. Policy, governance, stewardship

5. Infrastructure, procurement, logistics and supplies

6. Service delivery (availability, quality)

7. Coverage of services (effective coverage)

(Health outcomes)

Areas of health system monitoring (1)Areas of health system monitoring (1)

FinancingFinancing

Consensus around 10 or so indicators

NHA

established method

moderate

implementation rate

Exp survey

established method

Poor

Implementationrate

InformationInformation

No consensus HMN work ongoing

Data production assessment

VR coverageStatistics

HIS index

PoliciesPracticesProducts

Use

Human resourcesHuman resources

Some consensus ,norms and standards

CensusLabour force survey

Administrative databases)Passive / active(

What are the obstacles ?How to increase investment

in measurement strategies

HMN assessment tool opportunity to develop comparable statistics

and be local management tool

Classification issues Consensus on measurement strategies, databases ,

Indicators; investment

Areas of health system monitoring (2)Areas of health system monitoring (2)

Policy / stewardshipPolicy / stewardship

No consensus around indicators

CPIA

Limited

)Int Health regulation(

Infrastructure, drugs & logistics / Service delivery

Infrastructure, drugs & logistics / Service delivery

WHO list drug policies monitoring (113 ind.)

Key informantsurveys

2-3 year intervals

CoverageCoverage

Consensus ,norms and standards

Pop surveys

Good dataLong intervals

Service statistics

Poor dataShort intervals

Admindatabases

Passive/Active

Brainstorming onindicator and reporting Universal access; key indicator(s) and

)Sub(national measurement strategy

Components co-coverage indicator, data issues:

Child health, maternal health, TB control, HIV/AIDS, water & sanitation ,

chronic disease treatment

Overall presence of basic equipment and basic drugs & commodities, preliminary data, Mwanza region, SAM 2005

Overall presence of basic equipment and basic drugs & commodities, preliminary data, Mwanza region, SAM 2005

86

81

94

65

80

82

89

82

0 20 40 60 80 100

Ilemela

Nyamagana

Geita

Kwimba

Magu

Misungwi

Sengerema

Ukerewe

Percent of basic equipment available

83

70

84

79

81

83

84

83

0 20 40 60 80 100

Ilemela

Nyamagana

Geita

Kwimba

Magu

Misungwi

Sengerema

Ukerewe

Percent of basic drugs in stock

Availability of 8 items*(Region: 84%)

Availability of 11 drugs & commodities(Region: 81%)

*Blood pressure meter, stethoscope, thermometer, weighing scale forunder-fives, scale for adults, disposable gloves in stock, refrigerator,environmental disinfectant

* Antibiotics (oral and injectable), contraceptives (oral/injectable), irontablets, condoms, vitamin A capsules, measles vaccine, 1st and 2nd line antimalarials, ORS

Public 83%Private non-profit 86%Private for profit 88%

Public 82%Private non-profit 79%Private for profit 75%

Areas of health system monitoring (2)Areas of health system monitoring (2)

Policy / stewardshipPolicy / stewardship

No consensus around indicators

CPIA

Limited

)Int Health regulation(

Infrastructure ,drugs & logistics

Infrastructure ,drugs & logistics

WHO list drug policies monitoring (113 ind.)

Key informantsurveys

2-3 year intervals

CoverageCoverage

Consensus ,norms and standards

Pop surveys

Good dataLong intervals

Service statistics

Poor dataShort intervals

Admindatabases

Passive/Active

Brainstorming onindicator and reporting Universal access; key indicator(s) and

)Sub(national measurement strategy

Components co-coverage indicator, data issues:

Child health, maternal health, TB control, HIV/AIDS, water & sanitation ,

chronic disease treatment

DiscussionDiscussion

Strong demand, big topic

Lots of supply – will be hard to come up with small set

Focus on measurement strategies and comparable statistics at least as important as indicators

Working groups: draft papers

Country case studies: review of practices and issues

Consensus meeting planning