OVERVIEW OF THE APPROACH

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CHAPTER 2
OVERVIEW OF THE APPROACH
2.1 Introduction
The health systems assessment approach presented in this manual is an indicator-based approach
for rapid assessment of the health system, using secondary data, document review, and
stakeholder interviews. It is designed to allow you to diagnose health system performance by
identifying system strengths and weaknesses and then developing strategies and
recommendations based on an understanding of priorities and programming gaps in the country.
The approach attempts to fill a gap in assessment approaches by providing a structured tool that
examines a wide range of health system components, synthesizes information, and transforms
findings into recommendations and strategies for action. Whereas other tools examine in detail
specific components of the health system1 or describe the health system,2 no tools, this tool
provides for a rapid or comprehensive assessment of the overall health system of a developing
country.
The primary client and audience for this assessment and its ensuing recommendations is the U.S.
Agency for International Development (USAID) Mission in the assessment country.
Recommendation development is outlined with the Mission’s interests and objectives in mind.
With minor modifications in emphasis and presentation, however, this approach can also be used
for other primary audiences, such as the Ministry of Health. Note too that the assessment does
not have a disease-specific focus, but you may have to address disease-specific issues in
developing recommendations for the Mission, based on its priorities.
This manual provides guidelines for planning and conducting the assessment, synthesizing
findings, generating recommendations, and preparing an assessment report. It is broken down
into a general description of the health system environment (Chapter 5 “Core Module”) and six
technical areas that include indicators and guiding
questions. (See Box 2.1) In addition, the manual itself may
serve as an educational and reference tool.
You may decide to work through all or only a subset of the
technical modules, depending on the assessment
objectives. The core module (Chapter 5) is mandatory and
should be completed in all cases. It allows you to
understand the country-specific contextual background
before working through one of the remaining six technical
modules (Chapters 6–11). Each module is estimated to
take one to two person-weeks to complete, depending on the information available for the
assessment country. Depending on how you organize the assessment, it can be accomplished in a
1 Examples include assessment tools developed by RPMPlus for pharmaceuticals and those developed by the Health
Metrics Network for health information systems.
2 Examples include guidelines for health systems profiles developed by the Pan American Health Organization and
the European Observatory on Health Systems and Policies.
Box 2.1
The approach includes seven
modules—
• Core module
• Stewardship
• Health financing
• Service delivery
• Human resources
• Pharmaceutical management
• Health information systems
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concentrated period or spread out over a longer period, and multiple modules can be completed
simultaneously. In addition, a stakeholder workshop is recommended to validate findings,
receive feedback, prioritize results, and discuss recommendations. (See Box 2.2. Chapter 3
provides detailed guidelines for planning and
conducting the assessment.
Reading through all the chapters of the manual
before embarking on the assessment is
recommended. This step will facilitate your
understanding of the requirements and
expectations necessary for appropriate
assessment planning. In particular, read Chapter
4 along with the technical module chapters
before starting the analysis. Chapter 4 outlines
the process of synthesizing findings; assessing strengths, weaknesses, and root causes; and then
prioritizing areas for action.
2.2 Conceptual Framework for the Health Systems Assessment Approach
The conceptual framework for the assessment approach was developed based on extensive
discussions among partners and USAID staff. It builds on the World Health Organization
(WHO) definition of health systems (see Chapter 1) and its delineation of four major health
system functions: stewardship (also called governance), financing, creating resources, and
delivering services. The six technical areas (each represented by a module) fall within these
functions.
Figure 2.1 provides a visual presentation of the six technical modules integrated into WHO’s
health systems functions, presented earlier in Figure 1.1. Figure 2.1 builds on Figure 1.1 in the
same way that the conceptual framework for this assessment approach builds on the health
systems functions defined by WHO. Note that not all aspects of each of WHO’s health systems
functions have been addressed in the six technical modules in detail. These areas were chosen
based on their primary relevance to USAID investment strategies.3
3 Other factors that affect the health system, but involve other sectors, such as education, environment, water, and
sanitation, are also not included.
Tip!
This approach does not call for any primary data collection beyond stakeholder interviews.
Thus, you should apply sound judgment in quoting information and using evidence from
secondary sources for deriving conclusions. For example, it may be best not to quote or use
information that cannot be verified from multiple sources. In addition, anonymity of
interviewees may have to be preserved.
Box 2.2
Assessment Steps
1. Plan assessment, including stakeholder
workshop (Chapter 3).
2. Conduct assessment (Chapters 5–11).
3. Synthesize findings and develop
recommendations (Chapter 4).
4. Discuss and validate findings and
recommendations and develop priorities
through stakeholder workshop (Chapter 4).
5. Prepare an assessment report (Chapter 3).
Chapter 2. Overview of the Approach
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Figure 2.1 Conceptual Framework for Health Systems Performance
The approach suggests using the data collected to synthesize contributions of each technical area
to health systems performance in terms of the following performance criteria: equity, access,
quality, efficiency, and sustainability (which are defined in Annex 1A).
2.3 Overview of the Technical Modules
The approach has been developed in modular form, where each module relates to a specific
health system function, with the exception of the core module, which is designed to provide
background information relevant to all the modules. As mentioned, you can choose to do all or a
selection of the technical modules, depending on the needs of your assessment. A brief
description of each module is provided here. Annex 2A provides a full list of the indicators and
qualitative questions by topic area in each module.
• Core module covers basic sociodemographic and economic information for the
assessment country and an overview of the health system and the general health situation
of the country. It covers the topic areas of political and macroeconomic environment,
business environment and investment climate, top causes of mortality and morbidity,
structure of the main government and private organizations involved in the health care
system, decentralization, service delivery organization, donor mapping, and donor
coordination.
• Governance module addresses the information assessment capacity of the health system,
policy formulation and planning, social participation and health system responsiveness,
accountability, and regulation.
Financing:
2. Financing
Creating resources:
3. Human resources
management
4. Pharmaceuticals
management
Delivering services:
5. Service provision
6. Information systems
Criteria:
Equity
Access
Quality
Efficiency
Sustainability
Health System Functions Health System
Performance
Impact
Stewardship:
1. Stewardship/
governance
Health
impact
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• Health financing module covers sources of financial resources; the pooling and
allocation of health funds, including government budget allocation and health insurance;
and the process of purchasing and proving payments.
• Health service delivery module examines service delivery outputs and outcomes; the
availability, access, utilization, and organization of service delivery; quality assurance of
healthcare; and community participation in service delivery.
• Human resources (HR) module covers systematic workforce planning, HR policies and
regulation, performance management, training/education, and incentives.
• Pharmaceuticals management module evaluates the health system’s pharmaceutical
policy, laws, regulations; selection of pharmaceuticals; procurement, storage and
distribution; appropriate use and availability of pharmaceuticals; access to quality
pharmaceutical products and services; and financing mechanisms for pharmaceuticals.
• Health information systems (HIS) module reviews the current operational HIS
components; the resources, policies, and regulations supporting the HIS; data availability,
collection, and quality; and analysis and use of health information for health systems
management and policy making.
2.3.1 Module Components
Each module is set up in two components, both indicator-based.4
Component 1 is based on internationally comparable data. This assessment component includes
indicators for which data are available from international data sets. This provides quick
background information for each technical module with readily available data. These data (with a
listing of sources) are included in the CD that accompanies this manual (filename: Component 1
data). Instructions on how to use the data are provided in Chapter 5 (Section 5.2), and these
instructions are valid for all technical modules.
Component 2 is based on country-level document review and stakeholder interviews.
This assessment component uses multiple indicators, both quantitative and qualitative. The
assessment combines a desk-based assessment of documents with stakeholder interviews to
identify strengths and weakness in the technical area and relate them to health system
performance. The stakeholder interviews are meant to complement the desk-based assessment,
provide information on the health system performance indicators that cannot be obtained from
document review, and explore possible recommendations. A list of suggested materials to review
and stakeholders to interview is provided for each indicator, along with suggested probing
questions to be used for obtaining more detailed information.
4 Certain modules (such as, the governance module) rely more on developing a qualitative profile of that health
system function and does not rely solely only on indicators.
Chapter 2. Overview of the Approach
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2.3.2 Indicators
To the extent possible, indicators are presented in a consistent format across modules using the
standardized template below (Table 2.1). The governance module (Chapter 6) is an exception; in
that module, assessment involves analysis of different issues and does not follow the indicatorbased
approach.
Table 2.1 Format for the Indicators
Element Description of Information Covered for Each Element
Indicator title
Definition, rationale,
and interpretation
Provides a definition or description of the indicator and the reason why the
indicator is important for the assessment (the rationale for including it)
Also provides brief guidance on how to measure the indicator and how to
interpret the findings
Suggested data source Provides suggestions on the types of documents from which data on the
indicator can be obtained
Also provides cross-references to related indicators in other modules using
the clearly labeled phrase “Module link”
Stakeholders to
interview
Provides suggestions on types of stakeholders to interview for further
information related to this indicator
This element will be included with Component 2 indicators only
Issues to explore Provides suggestions on issues and topics for further probing, including the
reasons why
This element will be included with Component 2 indicators only
Notes and caveats Includes any caveats that the user should be aware of (such as, challenges in
data collection due to inconsistent definitions) and could include suggestions
on how to change or customize the indicator depending on what data is
available in the country
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Figure 2.2 provides a schematic presentation of the assessment approach.
Figure 2.2 Schematic Presentation of the Approach
Note from Figure 2.2 that the modules are designed to provide a series of findings related to
Component 1 and Component 2 indicators that allow you to gauge the functioning of that
technical area and its contribution to overall health system performance (against the five
performance criteria), and to develop a list of the area’s specific strengths and weaknesses and an
appraisal of opportunities and threats. These findings then permit you to develop possible options
for interventions to address these strengths and weaknesses, taking advantage of opportunities
and minimizing threats. After completing the individual modules, you will synthesize the results
across modules and develop overall priorities for systems strengthening (see Chapter 4). A
stakeholder workshop is strongly recommended for validating findings, identifying priorities,
and discussing recommendations (see Chapter 3 for planning the workshop).
MODULES BASED
ON HEALTH
SYSTEMS
FUNCTIONS
Human Resources
Governance
Pharmaceutical
Management
Health Information
Systems
IDENTIFY HEALTH SYSTEMS STRENGTHS AND WEAKNESSES
Responses to questions in each module will allow for
performance assessment based on performance criteria
PERFORMANCE
ASSESSMENT BASED
ON FIVE CRITERIA
Equity
Efficiency
Access Quality
Sustainability
Each module will have two assessment components:
Assessment component 1: Includes indicator-based questions
for which answers are readily available from standardized
international databases. Data for all component 1 indicators are
provided on accompanying CD (filename: “Component 1 data”).
Assessment component 2: Includes indicator-based or
qualitative questions that the user will have to answer based on
desk review of secondary resources and interviews with key
stakeholders in country.
Core module for
country background
Service Delivery
Health Financing
RECOMMEND PRIORITY INTERVENTIONS
Chapter 2. Overview of the Approach
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Implementing the assessment approach will permit you to measure the performance of the health
system being assessed, to identify health system weaknesses and strengths, and to develop
priority interventions to promote desired performance enhancements based on the criteria
defined above.
2.4 Output of the Assessment
One of the key outputs of the assessment process will be an assessment report addressed to the
assessment’s primary audience: the USAID Mission. Both the stakeholder workshop and the
health system assessment report should highlight key findings, identify health system strengths
and weaknesses, and provide recommendations for priority interventions. Recommendations
should reflect priorities and objectives of the USAID Mission, although key findings and
potential interventions could be put forth for other donors or organizations, including local
stakeholders, to address or implement. Chapter 3 discusses planning and conducting the
assessment including report preparation and provides a suggested outline for the report. Chapter
4 provides guidance for synthesizing findings across the modules and presenting results.
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Annex 2A. List of Indicators by Topic Area in Each Module
Indicator Map—Core Module (Chapter 5)
Component Topical Area Indicator Number and Content
1. Population, total
2. Population growth (annual %)
Population Dynamics
3. Rural population (% of total)
Urban population (% of total)
4. Contraceptive prevalence (% of women aged 15–
49)
5. Fertility rate, total (births per woman)
6. Pregnant women who received 1+ antenatal care
visits (%)
Pregnant women who received 4+ antenatal care
visits (%)
Reproductive Health
7. Prevalence of HIV, total (% of population aged 15–
49)
8. Life expectancy at birth, total (years)
9. Mortality rate, infant (per 1,000 live births)
10. Mortality rate, under age 5 (per 1,000)
Mortality
11. Maternal mortality ratio (per 100,000 live births)
12. GDP per capita (constant 2,000 USD)
13. GDP growth (annual %)
14. Per capita total expenditure on health at
international dollar rate
15. Private expenditure on health as % of total
expenditure on health
16. Out-of-pocket expenditure as % of private
expenditure on health
Component 1
Income and Inequity
17. GINI Index
Political and
Macroeconomic
Environment
Business Environment and
Investment Climate
Top Causes of Mortality
and Morbidity
Structure of the Main
Government and Private
Organizations Involved in
the Health Care System
Decentralization
Service Delivery
Organization
Donor Mapping
Component 2
Donor Coordination
Not applicable
Chapter 2. Overview of the Approach
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Indicator Map—Governance Module (Chapter 6)
Component Topical Area Indicator Number and Content
1. Voice and Accountability
2. Political Stability
3. Government Effectiveness
4. Rule of Law
5. Regulatory Quality
Component 1 Not applicable
6. Control of Corruption
7. Describe the general state of routine systems for
collection, reporting, and analyzing data (in terms of
efficiency, frequency, and quality) on vital
registration statistics, health status, health services,
health financing, and human resources.
8. Based on the level of decentralization, is the
information available at subnational and local levels
adequate to inform health officials at those
respective levels?
9. Is information collected, analyzed, and used at the
point of generation or merely reported up to a
higher level?
10. Describe the technical capacity of the Health
Planning Unit (or other appropriate group) to
absorb, analyze, and translate findings from the
information collected into viable, appropriate health
plans and policies.
Information/Assessment
Capacity
11. How and with what frequency are data from health
information systems presented to policy makers?
12. Inquire about the existence and implementation of
strategic health plans.
13. Does the MOH identify policy changes needed to
achieve the objectives in the strategic health plan
based on sound technical review of performance?
14. To what extent do health policy makers work
effectively with the legislative and executive
branches of government to gain approval of sound
public health and health care policies?
15. How does the government coordinate or harmonize
donor inputs (funding and policy priorities)?
16. What proportion of major external sources of
funding are coordinated with and complement an
agreed upon government health plan?
Component 2
Policy Formulation and
Planning
17. Does the MOH fulfill its public health function by
engaging in health policy development and actions
(including communication with national, local, and
special interest advocacy groups) to raise
awareness of policies that affect public health such
as legislation on tobacco use, road safety, family
planning, and HIV/AIDS prevention?
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Component Topical Area Indicator Number and Content
Policy Formulation and
Planning
(continued)
18. Does the MOH engage national, local, and special
interest advocacy groups to develop health
policies?
19. Who participates (i.e., persons or representatives of
stakeholder groups) in setting the health policy
agenda or in defining and prioritizing health needs
and services at the national level?
20. Who participates (i.e., persons or representatives of
stakeholder groups) in setting the health policy
agenda or the definition and prioritization of health
needs and services at the local level?
21. Does the MOH reach out to the general public with
information, education, and communication to raise
awareness and change behavior for priority health
issues such as tobacco use, road safety, family
planning, and HIV/AIDS prevention?
Social Participation and
System Responsiveness
22. What mechanisms are in place to track the
responsiveness of health officials to stakeholder
input (such as requests for representation on
advisory bodies, requests for a share of funding,
and incorporation of public input into health policy)?
23. Are health system goals, objectives, and
performance targets clearly articulated and
communicated to the public by the MOH?
24. Do health authorities regularly communicate with
constituencies and partners at the national,
subnational, and local levels on priority health
issues?
25. Does a national health policy or legislation exist to
define the role and responsibilities of the public
health sector?
26. Has the government provided and published
guidance for prioritizing health expenditures based
on available resources and assessed need?
27. Is an adequate system in place to monitor and
evaluate progress toward stated health objectives
as well as changes in performance resulting from
changes in policies and priorities?
28. Are reports on government health sector
performance produced and made available to the
general public and civil society?
29. Inquire about financial accountability of public
authorities.
Component 2
(continued)
Accountability
30. Is information from research, media, opinion polls,
advocacy, and watchdog groups available to public
and private stakeholders?
Chapter 2. Overview of the Approach
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Component Topical Area Indicator Number and Content
31. To what extent does the press cover health policy
debates?
32. Does any legislation or regulation address medical
malpractice?
Accountability
(continued)
33. Is there a functioning consumer defense movement
or league, and to what extent does it focus on
health related issues?
34. What do the health laws mandate? Do they clearly
define roles and responsibilities in the health
sector?
35. Describe the government system for licensure of
health professionals; regulation of the safety,
minimum physical infrastructure, and equipment
availability for different types of health facilities;
adequate regulation to ensure the safety, efficacy,
and quality of medicines, as well as the
appropriateness and accuracy of product
information; and protection of consumer rights.
36. Do governmental regulatory agencies have the
necessary resources (human, technical, financial)
to enforce existing legislation and regulations?
37. Does a functioning system (public or private) exist
for accreditation or certification (or both) for health
professionals and for hospitals and health facilities?
38. Does the MOH or other government agency review,
evaluate, and propose revisions of laws and
regulations to assure that they reflect current
scientific knowledge and best practices for
achieving compliance?
39. To what extent does the government enforce
regulations in areas of public health concern
including (but not limited to) protection of drinking
water and clean air standards, enforcement of laws
governing the sale of alcohol and tobacco to
minors, and childhood immunizations
Component 2
(continued)
Regulation
40. Has the government attempted to form partnerships
with those in the regulated environment to support
compliance?
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Indicator Map—Health Financing Module (Chapter 7)
Component Topical Area Indicator Number and Content
1. Total expenditure on health as % of GDP
2. Per capita total health expenditure, at average
exchange rate (USD)
3. Government expenditure on health as % of total
government expenditure
4. Public (government) spending on health as % of
total health expenditure
5. Donor spending on health as % of total health
spending
Component 1 Revenue Collection:
Amount and Sources of
Financial Resources
6. Out-of-pocket spending as % of private health
spending
7. Ministry of Health budget trends
8. Process of MOH budget formulation
9. MOH budget allocation structure
10. Central and local government budget allocations
for health in decentralized systems
11. Percent of government health budget spent on
outpatient/inpatient care
12. Percent of government health budget allocation in
rural/urban areas
13. Percentage of government health budget spent on
salaries of health workers, medicines and supplies,
and other recurrent costs
Pooling and Allocation of
Financial Resources—
Government budget
formulation and allocation
14. Local level spending authority
Pooling and Allocation of
Financial Resources—
Health insurance
Not applicable
15. Policies for user fee payments in the public sector
16. Allocation of user fee revenues
17. Informal user fees in the public sector
Component 2
Purchasing and Provider
Payments
18. Contracting mechanisms between MOH and public
or private service providers
A1. Population coverage of health insurance
A2. Services covered by health insurance
A3. Funding mechanisms and sustainability of health
insurance
Indicators for
health
insurance
schemes
Health Insurance:
Coverage, Funding, and
Policy Issues
A4. Provider payment mechanisms under health
insurance
Chapter 2. Overview of the Approach
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Indicator Map—Health Service Delivery Module (Chapter 8)
Component Topical Area Indicator Number and Content
Availability of Service
Delivery
1. Number of hospital beds (per 10,000 population)
2. Percentage of births attended by skilled health
personnel per year
3. DPT3 immunization coverage: one-year-olds
immunized with three doses of diphtheria, tetanus
toxoid, and pertussis (DPT3) (%)
4. Contraceptive prevalence (% of women aged 15–
49)
Service Delivery Access,
Coverage, and Utilization
5. Pregnant women who received 1+ antenatal care
visits (%)
6. Life expectancy at birth, total (years)
7. Mortality rate, infant (per 1,000 live births)
8. Maternal mortality ratio (per 100,000 live births)
Component 1
Service Delivery Outcomes
9. Prevalence of HIV, total (% of population aged 15–
49)
10. Number of primary care facilities in health system
per 10,000 population
11. Percentage of primary care facilities that are
adequately equipped
12. Availability of updated clinical standards for MOH
priority areas, high burden diseases areas, and/or
areas responsible for high morbidity and mortality
Availability of Service
Delivery
13. The ratio of health care professionals to the
population
14. Percentage of people living within X kms of a health
facility
15. Financial access (select an indicator based on
available data)
16. User fee exemptions and waivers
17. Number of primary care or outpatient visits per
person to health facilities per year
18. Private sector service delivery
Service Delivery Access,
Coverage, and Utilization
19. Existence of corporate social responsibility (CSR)
programs that offer health services among the
country's largest employers
20. Daily availability of full range of key primary health
care services
21. Number of vertical programs
22. Level of informational continuity of care
Organization of Service
Delivery
23. Level of vertical continuity of care
Component 2
Quality Assurance of Care
24. Existence of national policies for promoting quality
of care
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Component Topical Area Indicator Number and Content
25. Existence of adaptation of clinical standards into a
practical form that can be used at local level
26. Existence of clinical supervision by district level
supervisor
27. Percentage of supervision visits to health centers
planned that were actually conducted
Quality Assurance of Care
(continued)
28. Existence of other processes assuring quality of
care besides supervision
29. Presence of official mechanisms to ensure the
active engagement of civil society and the
community in management of the health system
30. Presence of official mechanisms to ensure the
active engagement of civil society and the
community in service delivery
Component 2
(continued)
Community Participation in
Service Delivery
31. Existence of official mechanism for eliciting
population priorities, perceptions of quality, and
barriers to seeking care
Chapter 2. Overview of the Approach
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Indicator Map—Human Resources Module (Chapter 9)
Component Topical Area Indicator Number and Content
Component 1 Human Resources (HR)
Data
1. The ratio of five cadres of health care professionals
to the population
2. The distribution of health care professionals in
urban and rural areas
3. HR data—presence of human resources data
system
4. The existence of a functioning HR planning system
Planning
5. HR dedicated budget
6. Presence of job classification system
7. Compensation and benefits system that is used in a
consistent manner to determine salary upgrades
and merit awards
8. Formal process for recruitment, hiring, transfer,
promotion
9. Employee conditions of service documentation
(e.g., policy manual)
10. Presence of a formal relationship with unions (if
applicable)
11. Registration, certification, or licensing is required for
categories of staff in order to practice
Policies
12. Salary
13. Job descriptions are present
14. Supervision (especially clinical supervision)
15. Percentage of supervision visits to health centers
planned that were actually conducted
16. There is a formal mechanism for individual
performance planning and review
Performance Management
17. Incentives, monetary and non-monetary
18. There is a formal in-service training component for
all levels of staff
19. There is a management and leadership
development program
Component 2
Training and Education
20. There are links and “feedback loops” between the
organization and pre-service training institutions
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Indicator Map—Pharmaceutical Management Module (Chapter 10)
Component Topical Area Indicator Number and Content
1. Total expenditure on pharmaceuticals (% total
expenditure on health)
2. Total expenditure on pharmaceuticals (per capita
average exchange rate)
3. Government expenditure on pharmaceuticals (per
capita average exchange rate)
Component 1 Not applicable
4. Private expenditure on pharmaceuticals (per capita
average exchange rate)
5. Is there a National Essential Medicines Policy (NMP) or
other government document that sets objectives and
strategies for the pharmaceutical sector based on
priority health problems?
6. Is there a comprehensive pharmaceutical law?
7. Is there a National Drug Regulatory Authority (NDRA)
responsible for the promulgation of regulations and for
enforcement?
8. Is there a system for pharmaceutical registration?
9. Does the pharmaceutical registration system generate
revenue for the MOH?
10. Is there a system for the collection of data regarding the
efficacy, quality, and safety of marketed products
(postmarketing surveillance)?
Pharmaceutical Policy,
Laws, and Regulations
11. Do mechanisms exist for the licensing, inspection and
control of (1) pharmaceutical personnel, (2)
manufacturers, (3) distributors/importers, and (4)
pharmacies/drug retail stores?
12. Is there a national essential medicines list (NEML)?
13. Is there an active national committee responsible for
managing the process of maintaining a national
medicines list?
14. What is the total number of pharmaceuticals (in dosage
forms and strengths) on the NEML?
Selection of
Pharmaceuticals
15. Are international nonproprietary names (INN) or generic
names used for products on the list?
16. Are there standard operational procedures (SOPs) for
conducting procurement of pharmaceuticals in the
public sector?
17. Are generic or INN used for MOH procurement of
pharmaceuticals? (Generic names are to be
differentiated from generic branded products.)
18. On average, how many procurements are conducted
per year?
Component 2
Procurement
19. On average, what percentage (by value) of MOH
pharmaceuticals is procured through competitive bid?
Chapter 2. Overview of the Approach
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Component Topical Area Indicator Number and Content
20. Is there a procurement pre- or post-qualification
process for suppliers and products based on review of
objective information about product safety, efficacy,
and quality?
21. Are samples requested and tested as part of the
procurement process?
Procurement
(continued)
22. Are quantities of pharmaceuticals to be procured based
on reliable estimates?
23. Is distribution of (some or all) pharmaceuticals
managed through a push or pull system?
24. Are there independent supply systems for vertical
programs (such as tuberculosis, malaria, HIV/AIDS)?
For what programs?
25. Value of inventory loss (as % of average inventory
value) over 12 months
Storage and Distribution
26. At each level of the distribution system (central,
regional, district, facility), are there refrigeration units
(such as refrigerators or coolers) with functional
temperature control?
27. Are there any functioning mechanisms/tools in place to
improve the use of medicines in hospitals and health
facilities?
28. Are there national therapeutic guides with standardized
treatments for common health problems?
Appropriate Use
29. Are the treatment guidelines used for basic and inservice
training of health personnel?
Availability 30. What percentage of a set of unexpired tracer items is
available (at time of study and over a period of time) in
a sample of facilities?
31. What percent of the population has access to a public
or private health facility/pharmacy that dispenses
pharmaceuticals?
32. Are there any licensing provisions or incentives in place
to increase geographic access by consumers/patients
to quality products and services through private
wholesalers and retailers?
33. Population per licensed pharmacist or pharmacy
technician
34. Population per authorized prescriber
35. Population per drug retail outlet in the private sector
Access to Quality
Products and Services
36. Percent of households more than 5/10/20 km from a
health facility/pharmacy that is expected to dispense a
set of tracer items in stock
37. What proportion of the annual national expenditure on
medicines is by the government budget, donors,
charities, and private patients?
38. Is there a system to recover the cost of
pharmaceuticals dispensed in MOH facilities?
Component 2
(continued)
Financing
Pharmaceuticals
39. Is there a price control mechanism for pharmaceuticals
in the private sector?
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Indicator Map—Health Information System Module (Chapter 11)
Component Topical Area Indicator Number and Content
1. Maternal mortality ratio reported by national
authorities
Health Status Indicators—
Mortality
2. Mortality rate, under age 5 (per 1,000)
3. HIV prevalence among pregnant women aged 15–
24
Health Status Indicators—
Morbidity
4. Proportion of children under 5 years who are
underweight for age
5. Number of hospital beds (per 10,000 population)
6. Contraceptive prevalence rate (% of women aged
15–49)
Component 1
Health System Indicators
7. Percentage of disease surveillance reports received
at the national level from districts compared to the
number of reports expected
8. Availability of financial and/or physical resources to
support designated items within MOH/central
budget (or other central sources), regional, and/or
district budgets
9. Presence of international donors providing specific
assistance to support strengthening the entire HIS
or its individual and/or vertical components in more
than one region
10. Existence of policies, laws, and regulations
mandating public and private health
facilities/providers to report indicators determined
by the national HIS
11. Presence of a clear procedure for allocating
resources and planning in the health system based
on the information products of HIS (e.g., use of
mortality and morbidity indicators to assess health
status and allocate resources accordingly)
Resources, Policies, and
Regulation
12. Presence of mechanisms to review the utility of
current HIS indicators for the planning,
management, and evaluation process, and to adapt
and modify accordingly
13. Percentage of districts represented in reported
information
14. Percentage of private health facility data included in
reported data
15. Availability of clear standards and guidelines for
data collection and reporting procedures
16. Number of reports a typical health facility submits
monthly, quarterly, or annually
17. Presence of procedures to verify the quality of data
(accuracy, completeness, timeliness) reported,
such as data accuracy checklists prior to report
acceptance, internal data quality audit visits
Component 2
Data Collection and Quality
18. Availability of a national summary report which
contains HIS information, analysis, and
interpretation (most recent year)
Chapter 2. Overview of the Approach
2-19
Component Topical Area Indicator Number and Content
19. Availability at each level of a sufficient number of
qualified personnel and infrastructure to compile
and analyze information
20. Evidence of ongoing training activities related to
HIS data collection and analysis
21. Presence of written guidelines specifying the
methods and products of data analysis to be
performed
22. The data derived from different health
programs/subsectors are grouped together for
reporting purposes (or even integrated in a single
document), and these documents are widely
available
23. Availability of appropriate and accurate
denominators (such as population by age groups,
by facility catchment area, by sex, number of
pregnant women) for analysis
Data Analysis
24. Availability of timely data analysis, as defined by
stakeholders and users
25. Use of data for planning, budgeting, or fundraising
activities in the past year (e.g., a change in budget
levels in response to a new major health issue, fund
allocation/budgeting proposals utilizing HIS data for
advocacy)
Component 2
(continued)
Use of Information for
Management, Policy
Making, Governance, and
Accountability
26. Data or results of analyses are fed back to data
providers to inform them of program performance
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