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Monitoring health system performance - s ynthesis of some experiences from low-income countries Dina Balabanova, Tim Powell-Jackson, Richard Coker, Kara.

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Presentation on theme: "Monitoring health system performance - s ynthesis of some experiences from low-income countries Dina Balabanova, Tim Powell-Jackson, Richard Coker, Kara."— Presentation transcript:

1 Monitoring health system performance - s ynthesis of some experiences from low-income countries Dina Balabanova, Tim Powell-Jackson, Richard Coker, Kara Hanson & Anne Mills London School of Hygiene and Tropical Medicine Health System Metrics, Glion sur Montreux, September 2006

2 Overview n Background n Complexity n Objectives and methods n Measurement n Health financing n Health care delivery n Emerging issues n Conclusions

3 Background n Commitment to invest in health systems is unprecedented, but will not last unless it is possible to show results n Currently poor health information available but demand for improved health system metrics (national / international) n Opportunities –Health System Metrics and other initiative seeking to strengthen HIS –Commitment to the health MDGs – need to measure progress –Growing consensus of importance of measurement strategies & monitoring & evaluation built into programme planning cycles n Threats –Limited resources for health information and sustainability –Capacity constraints (in the health and social sectors)

4 Objectives & Methods n Purpose of the study: a review of some low-income countries experiences with health system performance monitoring and use of data n Case study countries: –Georgia –Rwanda –Uganda –West Bengal, India –Material from other countries n Selection criteria n Analytical approaches: –uses the WHO health system performance framework –synthesis around common themes and issues –identifying unique lessons in each type of context

5 Complexity n How should health system performance be measured? –Increasingly multiple contacts with the system, chronic diseases –Outcomes determined by different care components, sectors –Need for system-wide and inter-sectoral indicators n Tension between international (donor-driven) demands and country-level agendas and needs n Use of normative approaches imply causality n To what extent monitoring influences policy? n Impact of measurement on health systems, e.g. Indicators that are measured often improve n Monitoring information may be complex to interpret where a range of interventions co-exist.

6 Measurement What approaches are taken to measure health system performance in the study countries?

7 What is measured ? DataGeorgiaRwandaUgandaWest Bengal Demographic Census (2002) Census (2001) Health financing NHA (2004)NHA (2003) NHA (2001), public expenditure reviews, Tracking Study (2001)NHA (2001) Health outcomes incl. births and deaths RHS (2005) & MICS (2006), Vital registration & HMIS DHS (2005), HMIS (facility)DHS (2004)DHS (2005) Co-coverage of interventions MICS (2006) & RHS (2005)DHS (2005)DHS (2004)DHS (2005) Human resources HMISHR inventory HMIS Service provision HMIS & SAM ( ) HMIS, SAM (2004) & Service Provision Assessment Survey (2001) HMIS, SAM (2004), Area Team assessmentsHMIS Quality n/a Various / accreditationn/a Vertical programme monitoring Immunisation, TB, HIV/AIDS Immunisation, malaria, HIV/AIDS, TB etc. Malaria, RCH, TB, Leprosy, Polio, HIV/AIDS etc. Disease surveillance IDRS Sentinel sites (HIV), early warning system, IDRS Sentinel sites (HIV)HMIS

8 Health financing How has information been used? Where are the gaps? What challenges remain?

9 Use of health financing information n Identification of financing gaps and advocacy for increased allocation of funds to health (Rwanda) n Health sector leadership and management of funds (Tanzania, Rwanda) n Equity of health financing in the health system (South Africa, Rwanda) n Protection against the financial burden of ill health (Mexico) n Resource allocation with the health sector (Rwanda)

10 Gaps in health financing information n Private health expenditures – difficult to collect compared to public and external health financing sources n Coverage of NHA relatively low in developing countries but expanding n Health financing data at decentralised levels for local decision- making n Financial burden of ill health and impact on impoverishment at the household level

11 National Health Accounts in Africa Number of NHA Rounds 1994 – 2004

12 Remaining challenges n Institutionalisation of NHA into the routine activities of Government n Underlying problems in Public Expenditure Management systems and data reliability n Timeliness of data (NHAs and household surveys) n Collection of private expenditure health financing data n Tension between disease expenditure and general health expenditure financial tracking n Addressing the needs of in-country policy makers vis-à-vis that of external agencies

13 Health care delivery How has information been used? Where are the gaps? What challenges remain?

14 Use of information: country examples West Bengal, India Aim: to monitor the performance of public sector programmes. Improve accountability and planning at national level n Standard service use indicators & regular meetings in PHC facilities Uganda Aim: to link health system performance monitoring to SWAPs and national policy process. Allows policy adjustment. n Data used in the annual health sector review process and to inform the development of annual plans n District league tables to rank performance of districts & motivate districts to improve indicators. n Tracking surveys – at the start of SWAP, to assess Govt systems (financial procedures, drug distribution, HR deployment)

15 Major gaps in measurement n Private sector – service use, service availability (infrastructure, human resources, services offered) n Vital events n Efficiency of health system n Quality of health care n Effective coverage

16 Remaining challenges n Low capacity and motivation to use data: –Locally –For decision-making or for policy initiatives n Lack of ownership by health providers, who are not involved in designing of monitoring procedure and indicators n Capacity for analysis concentrated at central level n Feedback to lower levels is limited, poor internal feedback n HMIS is often mistrusted n Selection of indicators often creates distortions n Information systems do not reflect move from project to system performance –India: critical milestones & vertical project indicators

17 Emerging issues

18 Data quality and reliability n Existing information systems, but data inaccessible or inappropriate to needs and policy process n Developing parallel monitoring frameworks rather than adapting & use of existing data: concerns for complexity and data reliability n HIS not always reflecting reform developments n Limited external data audit and reliance on single data sources (Rwanda, Uganda) n Technology involved in data collection, analysis and use often rely on bespoke software.

19 Parallel systems n Donor agenda regarding data collection, unsustainable n Data collection, analysis and use for policy is fragmented –Uganda/Nepal: lack of unified data linked to SWAPs –Private sector is often not covered (India/Uganda) n Multiple reporting requirements (Rwanda/India). n Lack of inter-sectoral information systems and unified quality standards. (Uganda/ Rwanda) n Vertical donors-supported programmes often function well in the short-term but may distort wider systems (e.g. Georgia & Angola)

20 Information flows & level of use n One-way traffic for information –Disaggregated data not available at sub-national level –Information intended to be used locally, is used at national level, or for different purpose reflecting governance & aid coordination n Information that is not aggregated nationally, less useful internationally n Governance and stewardship at local level needs to be able to draw effectively on aggregate & disaggregate data –Disaggregated data feeds effectively into local planning when linked to decentralised decision-making (TEHIP) n Peer comparisons at district level – productive vs unhelpful

21 Factors facilitating measurement & use of data n Health system monitoring embedded within reform process –SWAPs/ PRSP in Uganda, Rwanda; district autonomy (TEHIP) n Unintended consequences (Afghanistan) –Selective use of data internationally (user fees/HIV, in Uganda) n In post-conflict settings, the aid influx promotes monitoring health systems & early warning systems. Possible inefficiencies. n The importance of governance –Channels for policy exist (annual reviews, SWAPs meetings) & comparable timelines. –Communities and non-health system stakeholders involved n Large-scale data collection exercises are resource-intensive and not synchronised with the policy process (some In-DEPTH/ LSMS). n Technology, appropriate to context

22 Conclusions Effective health systems monitoring requires: n Capacity: to collect or use existing data, analyse, inform policy n Ownership n Coherence between domestic and external demands n Coherence between external agencies n Coherence between system-wide monitoring and vertical programmes performance measurement n Coherence between assessing the performance of different system elements n Domestic governance n Impact measurement to ensure sustainability/reform (scaling up) n Foster partnership between stakeholders

23 Acknowledgements GeorgiaGeorge Gotsadze IndiaBarun Kanjilal Rwanda Vianney Nizeyimana TanzaniaGraham Reid UgandaValeria Oliveira-Cruz Freddy Ssengoba

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