Decentralize Health Systems Strengthening Approach at a Glance

Definition of indicators

Facilitators’ Workshop on DistrictHealth Performance Improvement

Lilongwe, 25th – 27th March 2015

Steps

Diagnose

•Select interventions

•Define indicators

•Identify information sources and collect data

•Identify the bottlenecks

•Identify areas lagging behind

•Analyse the root causes of bottlenecks

Intervene

•Prioritize solutions with all stakeholders

•Define an implementation and monitoring plan

•Support implementation

Verify

•Monitor frequently using existing opportunities

Adjust

•Take corrective actions to ensure impact

Define coverage determinantindicators

•Indicators are standardized at country level, based onthe data available in the information system and ondata that are easy to collect

•Some rare exceptions can occur for which a specificindicator may be changed at district level (e.g. smallunderserved population that require a particular sampling)

Indicators to identifypossible bottlenecks

Determinants

from supply

Determinants

from demand

Determinants

from quality

Information used to identifypossible bottlenecks

•Availability of commodities (drugs, equipment, diagnosis kits, trainingmaterials…)

•Availability of trained human resources (community workers, doctors,nurses, midwives…)

•Geographic access through delivery points (health facilities, outreachactivities, community care points…)

•Initial utilization (measures the demand barriers to initiate theutilization of a service, e.g. DPT/Pentavalent 1, ANC visit 1…)

•Continuous Utilization (measures the demand barriers to completeutilization of a service and the follow up/drop outs, e.g. DPT/Pentavalent3, ANC visit 4…)

•Quality/effective coverage (measures the effectiveness of theintervention by assessing the quality of the service provided, usually interms of adherence to guidelines)

Exercise in groups

Discussion after exercise

Antenatal care

Commodities

Proportion of health centres with zero absolute stock-outs of essential commodities lasting more than 1week in the past 3 months

Human Resources

Proportion of facilities with availability of nurses andmidwives compared to need (national standard)

Geographic Access

Proportion of pregnant women not reporting distanceas a problem for access to health care

Utilization

Proportion of pregnant women who attended at least1 ANC visits

Continuity

Proportion of pregnant women who attended at least4 ANC visits

Effective Coverage

Proportion of pregnant women who had their BPmeasured or urine analyzed during ANC

Indicators used to identifypossible bottlenecks

•Availability of commodities  stock outs (absolute or use of bufferstock)

•Availability of trained human resources  vacancies of trained staff(defined according to national standards)

•Geographic access through delivery points  physical distance, timeto reach the delivery point, direct assessment from target population

•Initial utilization  first measure of coverage, people using the servicesat least once

•Continuous Utilization  only for relevant interventions, for whichcontinuity is a condition for effectiveness (we use knowledge in behavioralinterventions)

•Quality/effective coverage  adherence to guidelines, often a proxy

How to measurethe determinants of coverage (1)

•Commodities availability:

–Ideally: percentage of the target population forwhich commodities are available for a givenintervention

–More often: percentage of delivery points withoutstock outs of such commodities

–Challenges: difficulty obtaining data from privatesector and other sources of info on commodities

How to measurethe determinants of coverage (2)

•Trained human resources availability:

–Ideally: percentage of the target population forwhich appropriately trained health professionalsare available

–More often: percentage of delivery points withinsufficient human resources compared withnational norms (vacancies and training)

How to measurethe determinants of coverage (3)

•Geographic access:

–Ideally: percentage of the target population ableto access a delivery point for a given intervention

–Usually measured in terms of: percentage oftarget population that lives within a certaindistance from the delivery points (5 km, or 30 min.trip). Subjective assessment very reliable.

How to measurethe determinants of coverage (4)

•Initial utilization:

–Concept: percentage of the target populationwhich has accessed a given service at least once

–Usually measured in terms of: percentage oftarget population that used a given service.

How to measurethe determinants of coverage (5)

•Continuous utilization:

–Concept: percentage of the target populationwhich has used a given service as recommended

–Usually measured in terms of: percentage oftarget population that used a given service therecommended number of times.

* Not usually necessary for interventions that are provided onceonly (e.g. early HIV diagnosis for HIV exposed children - EID)

How to measurethe determinants of coverage (6)

•Effective coverage:

–Concept: percentage of the target populationwhich received a given service in an effective wayand on time

–Usually measured in terms of: percentage oftarget population that received a given servicewith good quality.

Additional indicators

Sometimes is useful to collect indicators beyond the sixdeterminants of coverage:

•To better interpret the determinants of coverage (e.g. earlybooking of ANC,

•To better understand key aspects of an intervention (e.g. careseeking behaviors)