1. Monitoring health systems Health system metrics Health Metrics Network 1 st Steering Committee Meeting March 21 2006

2. Overall 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

3. Demand 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

4. Supply 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)

5. 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 system Inputs Outputs Outcomes Policy Financing Human resources Information Service delivery Service coverage Utilization

6. Human resource data availability end 2004: percent distribution of countries by year and WHO region, World Health Statistics 2005 Quality concerns!

7. GAVI – 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

8. Global Fund M&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)

9. Co-coverage of 8 MCH interventions (mean, concentration index >6 interventions) Immunization - Child; BCG, DTP, measles - Mother: TT Vitamin A supplementation Antenatal care Skilled delivery Safe water

10. Areas 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)

11. Areas of health system monitoring (1) Financing Consensus around 10 or so indicators NHA established method moderate implementation rate Exp survey established method Poor Implementation rate Information No consensus HMN work ongoing Data production assessment VR coverage Statistics HIS index Policies Practices Products Use Human resources Some consensus, norms and standards Census Labour 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

12. Areas of health system monitoring (2) Policy / stewardship No consensus around indicators CPIA Limited (Int Health regulation) Infrastructure, drugs & logistics / Service delivery WHO list drug policies monitoring (113 ind.) Key informant surveys 2-3 year intervals Coverage Consensus, norms and standards Pop surveys Good data Long intervals Service statistics Poor data Short intervals Admin databases Passive/Active Brainstorming on indicator 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

13. Overall presence of basic equipment and basic drugs & commodities, preliminary data, Mwanza region, SAM 2005 Availability of 8 items* (Region: 84%) Availability of 11 drugs & commodities (Region: 81%) *Blood pressure meter, stethoscope, thermometer, weighing scale for under-fives, scale for adults, disposable gloves in stock, refrigerator, environmental disinfectant * Antibiotics (oral and injectable), contraceptives (oral/injectable), iron tablets, condoms, vitamin A capsules, measles vaccine, 1 st and 2 nd line antimalarials, ORS Public83% Private non-profit86% Private for profit88% Public82% Private non-profit79% Private for profit75%

14. Areas of health system monitoring (2) Policy / stewardship No consensus around indicators CPIA Limited (Int Health regulation) Infrastructure, drugs & logistics Infrastructure, drugs & logistics WHO list drug policies monitoring (113 ind.) Key informant surveys 2-3 year intervals Coverage Consensus, norms and standards Pop surveys Good data Long intervals Service statistics Poor data Short intervals Admin databases Passive/Active Brainstorming on indicator 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

15. Discussion 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