health system rapid assessment july 2011
TRANSCRIPT
Health System Rapid Assessment:
a step by step guide
July 2011
Contents 1. Purpose ....................................................................................................................................... 1
The systems thinking that informs this rapid assessment .............................................................. 3
How the Rapid Assessment integrates health systems strengthening with MDGs on health ....... 4
The five steps of the Health System Rapid Assessment ................................................................. 5
2. Objectives of the Health System Rapid Assessment ................................................................... 6
General objective ............................................................................................................................ 6
Specific objectives ........................................................................................................................... 6
3. Principles of the Health System Rapid Assessment .................................................................... 6
4. The team to conduct the Health System Rapid Assessment ...................................................... 7
5. The five steps of the Health System Rapid Assessment ............................................................. 8
6. Step 1: A concise description of our health system .................................................................... 9
7. Step 2: Building blocks .............................................................................................................. 15
8. Step 3: The health system as a whole: synergies, gaps, obstacles, bottlenecks ...................... 38
9. Step 4: Deciding priorities for changes and sharing these with stakeholders .......................... 42
10 Step 5: Reports of the Rapid Health System Assessment ........................................................ 43
Annex 1: Examples of people who might make up the Rapid Health System Assessment Team or
participate in stakeholders’ meetings............................................................................................... 44
Annex 2: Glossary .............................................................................................................................. 46
Annex 3: Examples of how the leading questions can be adapted if used as background for a
specific strategy or funding submission ............................................................................................ 48
Annex 4: Examples of where data may already exist ....................................................................... 49
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1. Purpose This is a step by step guide on how to conduct a Health System Rapid Assessment in two weeks. It is
based on the WHO health system framework, which describes the six building blocks of health
systems1, and on the Flagship Report of the Alliance for Health Policy and Systems Research, which
describes “systems thinking” 2. The approach of systems thinking considers how the six building
blocks relate to each other. Such an understanding of the whole system can be used to identify
changes that will lead better health outcomes.
The Rapid Assessment can be used at a national or sub-national level, to clarify what is working and
what might be improved. It can identify ways to strengthen health systems or to determine priorities
for strengthening specific components of health systems. This can be useful to identify priorities for
improvements to the health system.
One example is that the Rapid Assessment might be used to strengthen the health system through
developing a new strategy or funding submission. The strategy or funding submission may be about
the health system as a whole, or about a specific disease or set of health concerns3. The strategy
may be a national or sub-national strategy. The funding submission may be to the national
government or to an international donor .
When used as a preliminary step for the development of new strategies for specific diseases, the
Rapid Assessment can ensure that the new strategies are based on a realistic understanding of the
whole health system, build on what already works, and do not lead to stand-alone initiatives that are
out of touch with the existing health system. It might be conducted before the development of
funding submissions to the Global Fund, GAVI or other international donors.
This Health System Rapid Assessment is conducted by a team which matches the building blocks
with specific diseases or sets of health concerns. The team then considers the synergies, gaps and
bottlenecks across the whole health system. The team works out what might be the most effective
priority strategies to improve the whole health system.
The Rapid Assessment can take place in just two weeks because it is based on secondary data that
already exists. The Rapid Assessment is conducted by a small national or sub-national team,
complemented with a small number of interviews with key informants or focus groups with
stakeholder groups. Towards the end of the Rapid Assessment, a meeting is held to report to a wider
group of stakeholders. The stakeholders can advise the team on important information that has
been missed, or new understandings of how the health system might be improved. Technical
assistance for the Rapid Assessment may be mobilized, as warranted, from the WHO Regional Office
for South East Asia and the WHO Country Office.
The Rapid Assessment is not, in itself, a new strategy or funding submission. Nor is it a
comprehensive analysis or evaluation of the health system, or a development of an entire Health
1 Everybody’s Business: Strengthening Health Systems to Improve Health Outcomes: WHO’s Framework for
Action, Geneva, WHO, 2007. http://www.who.int/healthsystems/strategy/everybodys_business.pdf 2 Systems thinking for health systems strengthening. Geneva, WHO, 2009.
http://whqlibdoc.who.int/publications/2009/9789241563895_eng.pdf 3 Specific diseases include MDG 6: HIV, TB, Malaria. Specific sets of health concerns include MDG 4: Child
health, MDG 5: Maternal health. Further specific health concerns are Neglected Tropical Diseases, Emerging Infectious Diseases, Non Communicable Diseases and Health Ageing.
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System Strategy: other guidelines are more appropriate to conduct these processes4. Although it
includes completion of tables and tentative weighting of success, it does not do this in a
comprehensive way, and it will not be used to make comparisons between countries.
The Health System Rapid Assessment was prepared by WHO South East Asia Regional Office at the
request of member countries, with input from member countries and regional experts. Some
countries had found that weak health systems undermined the success of specific health initiatives,
or that stand-alone health initiatives were not possible to implement because of system limitations.
It was field tested in Sri Lanka in 2009, discussed in the Bi-regional meeting in Manila in late 2009,
revised, then pilot tested in Indonesia in 2010. It was further developed within SEARO in 2011 and
finalized with input from member countries.
In the Health System Rapid Assessment, each national or sub-national team will choose from a range
of options. This document has been described as being like a cafeteria: a range of options is
available, but not all need to be used at any given moment.
Before conducting the Rapid Assessment, the team may have determined which disease or set of
health concerns is to be the focus, what sub-national areas might be the focus, and what funding
source may contribute to the new proposals. The latest guidelines from that funding source should
then be considered. All members of the Rapid Assessment Team should become familiar with
specific current donor requirements before conducting the Health System Rapid Assessment. A
common Health Systems Funding Platform for the GAVI Alliance, the Global Fund and the World
Bank was formed in 2009. Current guidelines are available on websites of all three of these donors.
Guidelines are often revised, so they are not summarised here.
4 For example:
Monitoring and evaluation of health systems strengthening: an operational framework (Geneva, WHO, 2010) http://www.who.int/healthinfo/HSS_MandE_framework_Oct_2010.pdf Monitoring the building blocks of health systems: A handbook of indicators and their measurement strategies (Geneva, WHO: 2010) Joint assessment of national strategies (JANS) tool http://www.internationalhealthpartnership.net/en/about/j_1253621551 Country Health intelligence Platform (CHIP) www.healthintelligenceportal.org/chip.php Choosing interventions that are cost effective: WHO Guide to cost effectiveness analysis http://www.who.int/choice/toolkit/en/ Guide to producing national health accounts http://www.who.int/nha/docs/English_PG.pdf Resource planning: Workload Indicator of Staffing Need (WISN) http://www.who.int/hrh/resources/wisn_user_manual/en/
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The systems thinking that informs this rapid assessment
The WHO approach to health systems thinking is illustrated in Figure 1, which is from the report on
Systems thinking (see footnote 2, above).
Figure 1: The way the six building blocks come together as a system.
The WHO framework includes six building blocks of health systems. These building blocks are linked,
and the state of each building block influences the state of all the others. The WHO Systems thinking
report notes that, “The building blocks alone do not constitute a system, any more than a pile of
bricks constitutes a functioning building. It is the multiple relationships and interactions among the
blocks – how one affects and influences the others, and is in turn affected by them – that convert
these blocks into a system” (see Footnote 2).
In the Health System Rapid Assessment the team will consider the whole health system, the country
context and the state of each building block. The team will then consider the interactions between
the building blocks at the national or sub-national level. Through final discussions, the team will
identify strategic priorities that take account of what works, what needs to change, and what may be
ongoing gaps that cannot be addressed in the short term. It may then decide to recommend
particular new focused strategies or funding proposals for health systems strengthening.
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How the Rapid Assessment integrates health systems strengthening with MDGs on health
The WHO conceptual framework in Figure 2 shows how strengthening some components of health
systems can maximise the potential to reach MDGs 4,5 and 6 (the MDGs for specific diseases and
health concerns, as noted in footnote 3 on page 1, above). Within the Health System Rapid
Assessment the needs and gaps identified by relevant programmes will be matched with the six
building blocks of the health system. The needs and gaps will then be considered in an
integrated manner, stepping back to view the health system as a whole. Finally, the highest priorities
for improvements will be determined.
Figure 2: Framework for health systems assessment for maximizing health outcomes related to
MDGs 4, 5 and 65
5 The order of the building blocks used here, and the titles for them, are consistent with the Systems thinking
report listed in footnote 2. Other reports use different titles and ordering for the building blocks.
Needs and gaps are
identified by relevant
programmes at national
or sub-national level:
- Immunization - HIV/AIDS - TB - Malaria - MCH
The needs and gaps are then
considered as they relate to
the six building blocks of
health system:
- Governance - Financing - Human resources - Information - Medical products,
vaccines and technologies - Service delivery
The needs and
gaps are then
addressed in an
integrated manner
which considers
the whole health
system and its
relationship to
MDGs 4,5 and 6
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The five steps of the Health System Rapid Assessment
Figure 3: The five steps of the Health System Rapid Assessment
1. SYSTEMS THINKING:
Describe the health system and the context
•DAY 1 (Section 6):
•Orientation to the process for Rapid Assessment
•Team brainstorms answers to six key questions about the health system
•Team completes summary table of overall country indicators
•Team considers the Composite Indicators Table, and gives a tentative weighting for each cell: +, ++, +++, ++++
2. BUILDING BLOCKS
one by one
•DAYS 2,3,4 (Section 7: this includes one sub-section for each building block)
•Team splits into pairs or small groups, one for each building block of the health system
•Collect and collate information already available (secondary data)
•Conduct interviews with key informants, or hold focus groups if relevant
•Conduct field visits if relevant
•Complete tables and answer questions for each building block
•Prepare to report back to the whole Rapid Assessment Team
3. SYSTEMS THINKING:
Consider the building blocks together
•DAYS 5,6 (Section 8)
•Each building block group reports to the whole team
•The team identifies synergies, gaps, obstacles across building blocks
•The team considers the Composite Indicators Table again, in light of the extra information now available about each building block. It may change the weightings given on Day One.
•The team discusses synergies, gaps and obstacles across building blocks.
4. SYSTEMS THINKING:
Decide priorities for changes
•DAYS 7,8 (Section 9)
•The team discusses what has been learnt from completeting all previous steps
•The team decides what should be the highest priorities for short term changes to the Health System (This is the most important step, and may take half a day, as there mayb be competing priorities)
•Draft report prepared
•Presentation to Stakeholders' Meeting is prepared
5. REPORTING
Stakeholders' Meeting then final reports
•DAYS 9,10 (Section 10)
•The team reports to a Stakeholders' Meeting
•The Stakeholders suggest revisions
•The team meets the next day to consider what needs to be changed
•A written report is prepared
•Depending on the reasons for conducting the Health System Rapid Assessment, the team may present the findings to another team which will develop a new strategy or funding submission
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2. Objectives of the Health System Rapid Assessment
General objective
To provide an overview of needs and gaps in the health system, in order to determine new short
term priorities at a national or sub-national level.
Specific objectives
i. To identify gaps and needs within each building block of the health system, and systematic
weaknesses across the building blocks.
ii. To consider, if appropriate, how the Health System interacts with specific situations and
responses to specific diseases (HIV/AIDS, tuberculosis, malaria) or specific sets of health
concerns (immunization, maternal and child health, neglected tropical diseases, non-
communicable diseases)6.
iii. To determine priorities for changes that will improve strategies to address specific diseases
or health concerns, or that will lead to sustainable improvements to the health system as a
whole.
3. Principles of the Health System Rapid Assessment This Health System Rapid Assessment is based on the following principles:
It is a country led process. It will build the capacity of the national or sub-national team to
conduct this Rapid Assessment and to use systems thinking in the future.
It is consistent with global guidelines for analyzing health systems, including guidelines of
WHO, GAVI and the Global Fund7.
It will be based on existing reports, indicators and recommendations. While the existing
recommendations may be reviewed during the Rapid Assessment, they will at least be
considered, rather than starting from scratch.
The team will not just collate data about each of the building blocks. It will also engage in
shared analysis of what new priorities might make most difference to the whole system, to
better support responses to specific diseases or to improve the system as a whole.
6 This will be appropriate if the Rapid Assessment is being used to inform the development of new strategies or
funding proposals that have already been given priority before the Rapid Assessment commences. For example, it may have already been decided that a funding submission will be developed. 7 The Global Fund, GAVI and WHO share commitments to cross-cutting issues. These include improving equity;
access to health services for all who need them; quality of services, medicines and vaccines; effective and
efficient systems; sustainability; human rights; gender analysis of health; and partnerships in improving health
outcomes.
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4. The team to conduct the Health System Rapid Assessment The Health System Rapid Assessment will be conducted over two weeks by a country led team. A
temporary Health System Rapid Assessment Team can be established to do this, and disbanded after
the assessment. This may be a national or sub-national team, depending on the reasons for
conducting the Rapid Assessment. If there is a Health Sector Coordinating Committee led by the
Ministry of Health Planning Department, this committee could conduct the Rapid Assessment. If the
Health System Rapid Assessment is being used as background to a funding proposal for the Global
Fund, the Country Coordinating Mechanism may decide to conduct the Rapid Assessment, or
appoint a small team to conduct it.
The Health System Rapid Assessment Team will be led by a senior leader from the Ministry of
Health. This person will be someone who already understands the whole health system and is
familiar with “systems thinking”.
The other members of the team will be a mix of people who understand each of the building blocks,
understand the specific disease or set of health concerns to be addressed, or have access to the
information that will be used to inform initial analysis of the state of each building block. Examples
of the people who may be on the Health System Rapid Assessment Team are included in Annex 2.
The Rapid Health System Assessment Team will include at least one person for each of the six
building blocks of the health system: Governance; Financing; Human Resources; Information;
Medical products, vaccines and technologies; and Service Delivery. Each of these people must
already be aware of where to find information about the building block. They will collate existing
information and recommendations, and contribute to discussions about how their building block
should be understood within the whole Health System Rapid Assessment.
If the Health System Rapid Assessment is being used as a background to developing a new strategy
of funding submission for a specific disease or set of health concerns, the team will also include
people who are familiar with the specific disease or set of health concerns. They will explain what is
needed to address the specific disease or set of health concerns, and what are the lessons learned
about how the disease or set of health concerns is affected by the whole health system. The team
will also include one person with expertise in the other specific diseases or sets of health concerns
relevant to the MDGs (so that the team as a whole covers Immunization, HIV, Tuberculosis, Malaria,
Maternal Health and Child Health).
The team may also include other people who are familiar with the linkages between the building
blocks, or the broader context in which the health system operates (e.g. there might be someone
who understands the country’s recent experiences with de-centralization, poverty reduction, gender
strategy or economic development). They will ensure that the Health System Rapid Assessment
takes account of broader national development goals and processes. This will ensure that the
proposed new strategy or funding submission is realistic and achievable, and will not undermine
strategies in other fields.
Annex 1 lists the sorts of people who may contribute to the Health System Rapid Assessment.
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5. The five steps of the Health System Rapid Assessment The Health System Rapid Assessment will take place over 10 days (usually in two weeks, separated
by a weekend). It will draw upon existing data and recommendations as well as input from a range of
stakeholders. The five steps are outlined in Figure 3, above.
The rapid assessment occurs over 10 working days. The breakdown of timing for each step and for
each day is not pre-determined. This will depend on the reasons for conducting the Rapid
Assessment. Some steps will take two or three days. Adequate time should be allowed to hold
discussions, build consensus across the whole team, decide on the next priority steps and prepare
reports.
The Rapid Assessment will be easier to conduct if efforts are made to collect available information
during the preceding weeks. Before the first step:
Appoint a Team to conduct the Rapid Assessment
Appoint a Focal Point, budget for the assessment, logistics, invitations, clarify roles of team members
All team members commence to collect available information
Have an introduction session: ensure all team members understand the process, build commitment to working together.
If the Rapid Assessment is being used as a background to preparing a new strategy or funding
submission, it will be important that it includes:
An initial briefing about the specific disease or set of health concerns to be considered
A final meeting to hand over the findings of and recommendations of the Health System
Rapid Assessment to the team that will then prepare the new strategy or funding
submission. Of course some people will be members of this team as well as the Rapid
Assessment Team.
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6. Step 1: A concise description of our health system The purpose of this concise description is to ensure that all members of the Health System Rapid
Assessment Team commence their work with a common understanding of the nature of the health
system.
6.1 Six questions about the health system
Six questions, to be answered within one page, based on a brainstorming session of the whole Rapid
Assessment Team. Qualitative responses to each question are required here. The team may choose
to also add more information to briefly explain important aspects of the health system.
1. How would you describe our health system to someone from another country?
2. What are the things that work best in our health system?
3. What are the most obvious challenges to health in our country?
(Challenges from within the health system, or broader contextual issues)
4. What are the most obvious obstacles to provision of better health services?
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5. Other sectors’ impacts on health. How do other sectors consider the potential health
impacts of their own major policy decisions and major new projects?
6. What are some other issues affecting the health of the population, or the specific health
issues of the proposed new strategy or funding submission? (e.g. there may be permanent
or temporary issues: conflicts, emergencies, food crises)
6.2 Summary tables of health system indicators
The Rapid Assessment Team should collate as much information as possible from a range of sources.
Data already exists in published reports from the Ministry of Health and from other sources within
and outside the country or province. Examples of places where data may already exist are included
in Annex 4. The Rapid Assessment Team should attempt to complete these tables on the first day.
POPULATION STATISTICS
Indicator
Latest
available
data and
source
Latest data,
and trends
over the last
3-5 years
Remarks
Total population (in thousands) Urban % Rural %
Sex ratio (Males per 100 females)
Population under 15 years (%)
Population 60 years and above (%)
Crude birth rate (per 1000 population)
Crude death rate (per 1000 population)
Annual (population) growth rate (%)
Total fertility rate (per woman)
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CORE HEALTH INDICATORS
Indicator
Latest
available
data and
source
Latest data
and trends
over 3-5
years
Remarks
Under 5 mortality rate (per 1000 population)
New born deaths per 1000 live births
Maternal mortality rate
Antenatal care coverage (for women 15-49)
Skilled attendant at birth (% of all births)
Postnatal care visit for mothers and babies
within 2 days of child birth
Exclusive breast feeding for 6 months
Antibiotic treatment for pneumonia (0-59
months)
National DTP3 coverage rate (%)
Numbers / % districts achieving ≥80%
DTP3 coverage
Probability of dying between ages 15 and
60 (Male and Female probabilities)
HIV prevalence amongst pregnant women
Antiretroviral drugs for prevention of mother
to child transmission (% of pregnant women
who are HIV+ who are on antiretroviral
drugs)
Incidence and death rates associated with
malaria
Proportion of tuberculosis cases detected
and cured (under DOTS or private services)
Met need for contraception (for females
aged 15-49)
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Prevalence of low birth weight (weight<2500
grams at birth) (%)
Prevalence of underweight (weight-for-age)
in children<5years of age (%)
Children under 5 with stunted growth
SOCIOECONOMIC INDICATORS
Indicator
Latest
available
data and
source
Latest data
and trends
over 3-5
years
Remarks
Gross national income (GNI) per capita
(PPP)
Adult literacy rate (%) >15 years
% population living on less than $1
int/cap/day
Gini index (Gini co-efficient of inequality)
Comment on inequality between provinces
(quantitative data if available, make
remarks if not: refer to UNDP Health
Development Index)
Water (quantitative data if available, make
remarks if not)
Sanitation (quantitative data if available,
make remarks if not)
Food supply (quantitative data if available,
make remarks if not)
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6.3 Composite Indicators Table: initial discussion
The Composite Indicators Table is on the next page. The whole Health System Rapid Assessment
Team will work together to complete the table and provide tentative weighting. For this weighting,
the Rapid Assessment Team will use the + symbol rather than a number, to emphasise that this table
is to stimulate discussion. It is not a quantitative assessment of the health system that will be used
for other purposes. The weightings will be +, ++, +++, or ++++. This is explained on the next page.
The purpose of providing weightings for the cells of this table is simply to enable a quick overview of
the whole health system as it interacts with the specific diseases. The reason for having this quick
overview is to provide the basis for discussions about what changes to the health system might be
the highest priorities for improvement.
In this first stage of the Rapid Assessment, the team should discuss the guiding questions and decide
what weight to put in each box of the table. The weightings are not fixed or verifiable evidence of
the state of the health system. They are simply a means to promote discussion about the whole
health system.
For example, across one line of the table, it will be possible to see the strongest and weakest
building blocks of the system as they relate to that disease. Down one column of the table, it will be
possible to see whether each building block is better at controlling one disease or another.
At this stage of the Rapid Assessment, the weightings will simply be based only on team members’
own understanding and the discussions of the whole team. There is no need at this stage to have
long discussions on exactly what weighting is appropriate for each box. That is the purpose of the
next two weeks of the Rapid Assessment. At this stage, team members may just make rough
estimates, and need not even all agree with each other. This will change at the end of the Rapid
Assessment, after more information and evidence has been considered.
For each cell of the table, provide a tentative weighting and make a summary written comment.
The guiding questions are each really a summary of many questions. Therefore, an overall tentative
weighting is required, not an insertion of data from research.
In Step 3 of the Rapid Assessment (Section 8), the team will re-consider this table. At that stage, the
team will be informed with more detailed information collated on each building block in Step 2. The
team will then re-consider this table. It may then want to change some of the weightings and
provide indicators based on data collated on each building block.
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+ The current system is hardly functioning at all
++ There are some very limited systems in place
+++ There is an adequate system in place, but it is not sustainable
++++ There is a very useful and sustainable system in place
Health system Building blocks → Specific diseases or sets of health concerns ↓
Governance Guiding question: To what extent is the necessary leadership, policy, planning and organisational support in place to adequately address the health issue?
Financing Guiding question: Is there enough money available for this health issue, given the burden of disease and the need to ensure adequate access?
Human Resources Guiding question: To what extent are there the right levels of staff, with the right levels of training and support, in posts where they are needed?
Information Guiding question: To what extent does the health information we collect, routinely and through surveys, help us plan and measure progress for this health priority?
Medical products, vaccines and technologies Guiding question: To what degree do we have the right medical products, vaccines and technologies, distributed where and when they are needed?
Service delivery Guiding question: To what extent are there good quality services being delivered and taken up by the people who need them?
Immunization
HIV/AIDS
Tuberculosis
Malaria
Maternal health
Child health
Adolescent health
Healthy Ageing
Neglected Tropical Diseases
Non Communicable Diseases
Emerging Infectious Diseases
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7. Step 2: Building blocks Each of the six building blocks will be considered by a group of two or more people appointed to
consider that building block. Some of these small groups will also have input from the members of
the Rapid Assessment Team who are providing advice on the specific disease or set of health
concerns.
The leading questions and the tables should be considered as guides: the answers need not fit on
these pages, and the small groups might have access to more important information.
7.1 Governance
The WHO publication, Systems thinking for health systems strengthening, says the role of this
building block is “ensuring strategic policy frameworks combined with effective oversight, coalition
building, accountability, regulations, incentives and attention to system design”.
7.1.1 GOVERNANCE leading questions
Q1 Are there National Health Policies, Strategies and Plans? What are the titles given to these
(they vary between countries)? Is there any provision for periodic review of the health
policies, strategies and plans? Do political authorities use these to inform their decisions
about priorities, resource allocation, performance or health impacts?
Q2 Is there a system to ensure that policy making is based on evidence?
Q3 How do community groups, non-profit organizations and other stakeholders participate in
the advocacy, development, implementation and evaluation of health policies and plans? Is
there a conscious effort to seek their involvement?
Q4 How does the government influence policies, strategies and quality of private health sector
services? How are private sector service providers involved in national or local planning?
Q5 Are there sub national (regional or local) health plans? How do they link to the national
plan? Are national and sub-national plans backed with adequate costing and funding?
Q6 Are there local health plans in the geographical areas of focus of the new proposals? If not,
should the new proposals include development of local health plans?
Q7 Is the health plan used by authorities and politicians for program priority setting, resource
allocation and performance evaluation?
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Q8 During the last election campaign (if applicable), what did political parties say about health?
Q9 Is decentralization of governance taking place effectively? If so, what is the impact on
health?
Q10 How do governance mechanisms ensure that all communities have access to health services
and equal opportunities to lead healthy lives?
Q11 Does the Government explicitly support the health related Millennium Development Goals?
Q12 Is there a Health Impact Assessment for large scale development programmes?
7.1.2 GOVERNANCE indicative statistics
Indicator
Latest
available
data
Comment on
trends over
last 3-5 years
Remarks
How many health offices are there at sub-
national levels (e.g. Departments of Health)?
How many sub-national entities have health
strategic plans based on evidence and multi-
sectoral policy formulation? (Remark on this)
How many provinces have a regulatory
framework for implementation of the health
plan?
In the provinces which will be the focus of
the proposed new program, how are
stakeholders involved in health governance
(planning, providing information, policy
making, program review)
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7.1.3 GOVERNANCE summary of Recommendations made in earlier reports
Please summarise existing Recommendations, and indicate whether these have been implemented,
rejected, or accepted in principle but not yet possible to implement.
7.1.4 GOVERNANCE associations with a proposed new strategy or funding proposal
This section is relevant if the Rapid Assessment precedes development of a new strategy or funding proposal. Please discuss these questions as a group, and prepare to report back to the whole Rapid Assessment Team. Q1 In health governance, what are the current obstacles, needs or gaps that might hinder our
ability to succeed in the specific new health initiative?
Q2 Do these obstacles, needs or gaps affect the whole health system, or just the specific new
health initiative?
Q3 What aspects of health governance work well:
a. For this specific disease or specific set of health concerns?
b. For improving health generally?
Q4 For health governance, what needs to change so that we can better address the specific
health issue? How might we measure success?
Q5 How will the proposed changes benefit or hinder the overall function of health governance?
How might we measure success?
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7.1.5 GOVERNANCE possible recommendations to include in the proposed strategy or funding
proposal
Based on all the information in this section (7.1), what does your group recommend should be
included in the proposed new strategy or funding submission about Governance?
Recommendation to include
Why this should be a priority at this stage
What it will cost (only approximate costing is required at this stage)
Ideas to spark recommendations. The WHO publication, Systems thinking for health systems strengthening suggests these “common types of interventions” for Service Delivery: - Decentralization - Civil society participation - Licensure, accreditation, registration
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7.2 Financing
The WHO publication, Systems thinking for health systems strengthening, says the role of this
building block is “raising adequate funds for health in ways that ensure people can use needed
services, and are protected from financial catastrophe or impoverishment associated with having to
pay for them”.
7.2.1 FINANCING leading questions
Q1 What priority do policy makers place on health? What is the current commitment to public
health, as compared with individual health services (e.g. immunization, skilled birth
attendants, water and sanitation, laboratory services, health promotion, mapping of
services)?
Q2 Is the National Health Accounts Assessment being conducted? How often? (Please look at
the most recent report and discuss what this suggests overall about the current adequacy of
health financing. If there is no national assessment, can you draw a diagram of health
financing?)
Q3 Are there any new initiatives to increase funds for health at national or sub-national levels?
What else could be done?
Q4 How is the government health budget developed? Can you describe other financial
contributions to population health, such as from INGOs, other ministries, donors or
insurance? Are funds from external sources incorporated into the national health budget?
What problems arise from having multiple systems for financing health?
Q5 How does central government allocate health budget to sub-national administration units?
What are the criteria for allocation?
Q6 How do sub-national governments fund health?
Q7 How do government health funds ensure that there are specific resources for the care of
poor and vulnerable communities?
Q8 When there are funds for specific diseases, what mechanisms are used to ensure that
people affected by those diseases don’t receive services out of proportion to those provided
for other health problems?
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Q9 Do patients pay user fees or other informal fees for outpatient care or inpatient care? How
much are they, and does this sometimes create a financial barrier for access to care? Are
there fees associated with specific diseases such as tuberculosis or malaria?
7.2.2 FINANCING indicative statistics
This table should be used as a guide. The group working on this building block may add other
indicators of the state of the health financing system.
Comment also on differences between national and sub-national financing statistics.
Indicator
Latest
available
data and
source
Comment on
trends over
last 3-5 years
Remarks
Total Expenditure on Health (THE) as % of
Gross Domestic Product (GDP)
General Government Expenditure (GGE) as
% of total Expenditure on Health (THE)
Percentage of national health budget
allocated for health promotion or preventive
public health programmes
Out-of-pocket Expenditure on Health
(OOPS) as % of private Expenditure on
Health (If no data, please just make a
remark)
Out of pocket expenditure as % of Total
expenditure on health (If no data, please just
make a remark)
Private expenditure on health as % of THE
General expenditure on health as % of total
Government expenditure
21
7.2.3 FINANCING summary of Recommendations made in earlier reports
Please summarise existing Recommendations, and indicate whether these have been implemented,
rejected, or accepted in principle but not yet possible to implement.
7.2.4 FINANCING associations with a proposed new strategy or funding proposal
This section is relevant if the Rapid Assessment precedes development of a new strategy or funding proposal. Please discuss these questions as a group, and prepare to report back to the whole Rapid Assessment Team. Q1 In Financing, what are the current obstacles, needs or gaps that might hinder our ability to
succeed in the specific new health initiative?
Q2 Do these obstacles, needs or gaps affect the whole health system, or just the specific new
health initiative?
Q3 What aspects of Financing are done well:
For this specific disease or specific set of health concerns?
For improving health generally?
Q4 For Financing, what needs to change so that we can better address the specific health issue?
How might we measure success?
Q5 To reduce the out of pocket expenditure of people affected by this specific disease, what
other sources of funding may be available (e.g. insurance)?
Q6 How can we measure changes in those sources of funding over time?
22
7.2.5 FINANCING possible recommendations to include in the proposed strategy or funding
submission
Based on all the information in this section (7.2), what does your group recommend should be
included in the proposed new strategy or funding submission about Financing?
Recommendation
Why this should be a priority at this stage
What it will cost (only approximate costing is required at this stage)
Ideas to spark recommendations. The WHO publication, Systems thinking for health systems strengthening suggests these “common types of interventions” for Financing: - User fees - Conditional cash transfers (demand side) - Pay-for-performance (supply side) - Health insurance - Provider financing modalities - Sector Wide Approaches (SWAPS) and basket funding
23
7.3 Human Resources
The WHO publication, Systems thinking for health systems strengthening, says the role of this
building block is to ensure that the health workforce is “responsive, fair and efficient given available
resources and circumstances, and available in sufficient numbers”.
7.3.1 HUMAN RESOURCES leading questions
Q1 Briefly describe an overview of the health workforce. Here are some issues to consider:
What categories of staff are there?
How many are in each category?
What is the geographical distribution?
What is the quality of health workforce relating to current health situations?
Beyond the Health Department, who else works on health issues relating to the
proposed new strategy or funding submission? (e.g. private sector doctors,
community volunteers, HIV peer educators, people living with HIV, water and
sanitation workers)
Which of these other workers support primary health in priority communities?
Q2 What is the distribution of the health workforce in relation to:
Population distribution (e.g. enough appropriate health staff in remote areas)?
People working in their posts (e.g. really working where assigned)?
Disease burden (e.g. health staff with relevant expertise in the districts where this is
needed for specific diseases or health concerns)?
The needs of specific population groups (e.g. ethnic groups, mobile populations, sex
workers, men who have sex with men, drug users)?
Q3 What is the national plan on health workforce?
Q4 How is the size and quality of the health workforce maintained?
Describe the country’s educational institutes for doctors, nurses and other health personnel.
Include description of in-service training and appraisal systems. Does the current number of
yearly graduates cover national and sub-national requirements? If not, what is being done?
Q5 What are the supportive mechanisms to retain the health workforce (career development,
supportive supervision, safety, mobility, welfare)? Is migration of health workers within or
beyond the country a concern?
24
7.3.2 HUMAN RESOURCES indicative statistics
Indicator
Latest
available
data and
source
Comment on
trends over
last 3-5 years
Remarks
Physician per 10,000 population
Nurses per 10,000 population
Midwife per 10,000 population
Public and environmental health workers
per 10,000 population
Community health workers per 10,000
population (include only those not already
counted in other categories above)
Lab technicians per 10,000 population
Other health workers per 10,000
population
7.3.3 HUMAN RESOURCES summary of recommendations made in earlier reports
Please summarise existing Recommendations, and indicate whether these have been implemented,
rejected, or accepted in principle but not yet possible to implement.
7.3.4 HUMAN RESOURCES associations with the proposed new strategy or funding proposal
Please discuss these questions as a group, and prepare to report back to the whole Rapid Assessment Team. Q1 In Human Resources, what are the current obstacles, needs or gaps that might hinder our
ability to succeed in the specific new health initiative?
Q2 Do these obstacles, needs or gaps affect the whole health system, or just the specific new
health initiative?
25
Q3 What factors of Human Resources work well:
a. For this specific disease or specific set of health concerns?
b. For improving health generally?
Q4 For Human Resources, what needs to change so that we can better address the specific
health issue? How might we measure success?
(To answer this question, consider: Would it be useful to have more training in the specific
disease or health issue? What would be an appropriate balance between training specialists
and training all health workforce about this specific disease or health issue?)
Q5 How will the proposed changes improve coverage, skills and quality of the Health
Workforce? How might we measure success?
7.3.5 HUMAN RESOURCES possible recommendations to include in the proposed strategy or
funding submission
Based on all the information in this section (7.3), what does your group recommend should be
included in the proposed new strategy or funding submission about the Health Workforce?
Recommendation
Why this should be a priority at this stage
What it will cost (only approximate costing is required at this stage)
Ideas to spark recommendations. The WHO publication, Systems thinking for health systems strengthening suggests these “common types of interventions” for the Health Workforce: - Integrated training - Quality improvement, performance management - Incentives for retention or remote area deployment
26
7.4 Information
The WHO publication, Systems thinking for health systems strengthening, says the role of this
building block is “ensuring the production, analysis, dissemination and use of reliable and timely
information on health determinants, health systems performance and health status”.
7.4.1 INFORMATION leading questions
Q1 Briefly describe an overview of the country health information system, in one page. The
following table might help to identify some of the most important reports and issues to
consider. Not all countries will have all this information.
Because health information is a cycle, the stages of that cycle (across the table) should be
considered for different types of reports. This is an analysis of what information systems
exist and how they complement each other. It is not a summary of health indicators.
Information sources might include the Ministry of Health, other ministries, the private
sector, NGOs, army, police, universities, other research institutes, WHO Collaborating
Centres. Please indicate what information is available from each of these.
Note that this question is about the Health Information Systems that are used. The health
information that is produced by those systems (e.g. health outcomes) is included above in
Section 6.2
Main sources of
health
information
Most important health
information included in
each of these sources.
How is data analysed? How are results
disseminated? How is this
data then used to inform
health sector policies or
actions?
Work with the three of these that are most often used by the health sector: Core HIS. Household surveys. National Health Surveys. Census. Civil registration of vital events. Living Standard Surveys. Private sector reporting.
Do these sources of data
exist? Yes/No
Source and dates of last
data collection.
What are the most
important health data that
are included?
Dot points to summarise
the main methods used.
Dot points on how information
is used (provide some
examples of how information
is used and who uses the
information: this is not a
question about the data, but
about the formal and informal
systems for using
information)
27
Q2 Describe the main Health Information System. It may help to draw a flow chart or a
schematic diagram. How does this compare with the WHO Regional Strategy to strengthen
health information systems?
Q3 Are there separate information systems for specific diseases, or for different components of
the whole health system? (e.g. surveillance, operational research) What problems arise from
this? Can you suggest ways to better integrate all information?
Q4 How does the Health Information System link with information systems in other sectors? For
example, do other ministries collect information on the health of their staff? Is this
information shared with the health sector?
Q5 Referring to the above table, comment on how data is disaggregated for each of these main
sources of data. (e.g. by districts, sex, wealth quintiles)
Q6 What information is available on health services and use of those services? (e.g. service
records, facility assessment, GIS mapping, geo-coordinates, patient held records)
Q7 What are the main systems used for Management Information? (e.g. workforce monitoring,
finance tracking, logistics management. Focus on the diseases or health issues of most
interest in this Rapid Assessment.)
Q8 Do different levels of administration (national and sub-national) apply the same standards
and guidelines for data collection, quality, verification, analysis and reporting?
28
7.4.2 INFORMATION summary of Recommendations made in earlier reports
Please summarise existing Recommendations, and indicate whether these have been implemented,
rejected, or accepted in principle but not yet possible to implement.
7.4.3 INFORMATION associations with a proposed new strategy or funding proposal
This section is relevant if the Rapid Assessment precedes development of a new strategy or funding proposal. Please discuss these questions as a group, and prepare to report back to the whole Rapid Assessment Team. Q1 In Health Information, what are the current obstacles, needs or gaps that might hinder our
ability to succeed in the specific new health initiative?
Q2 Do these obstacles, needs or gaps affect the whole health system, or just the specific new
health initiative?
Q3 What aspects of Health Information work well:
a. For understanding this specific disease or specific set of health concerns?
b. For understanding the most important health indicators?
Q4 For Information, what needs to change so that we can better address the specific health
issue? How will the proposed changes benefit or hinder the overall function of the Health
Information System? How might we measure success?
Q5 What information specific to this disease or set of health concerns should be reported
through the Health Information System? (include information about target populations,
including demand for services) What other specific information may require special
information systems separate to the national system?
29
Q6 Describe any current improvement plans for :
Vital events system for registration of births, deaths and causes of death
Combined data reporting from facilities, administrative sources and surveys
Disaggregated data for gender and other equity considerations for indicators on reproductive, maternal and child health
Use of Information and Communication Technologies in the national HIS and health infrastructure.
7.4.5 INFORMATION possible recommendations to include in the proposed strategy or
funding submission
Based on all the information in this section (7.4), what does your group recommend should be the
highest priorities for inclusion in the proposed new strategy or funding submission about
Information?
Recommendation
Why this should be a priority at this stage
What it will cost (only approximate costing is required at this stage)
Ideas to spark recommendations.
The WHO publication, Systems thinking for health systems strengthening suggests these “common types of interventions” for Information:
Shifting to electronic (versus manual) medical records Integrated data systems and enterprise architecture for Health Information
System design Coordination of national household surveys (e.g. timing of data collected)
Improving frameworks and standards: ideas from the Health Metrics Network
30
7.5 Medical products, vaccines and technologies
The WHO publication, Systems thinking for health systems strengthening, says this building block
includes “medical products, vaccines and other technologies of assured quality, safety, efficacy and
cost-effectiveness, and their scientifically sound and cost-effective use”.
7.5.1 MEDICAL PRODUCTS, VACCINES AND TECHNOLOGIES leading questions
Many of these questions can be answered with reference to the WHO Country Pharmaceutical
Profile. All countries will update this by the end of 2011.
Q1 What are the specific problems with respect to drug or vaccine availability, supply and
quality? Is there a separate unit to oversee rational use of medicines? Are there different
problems for public and private sectors?
(Issues to consider include: production, regulation, use, quality assurance, access to
medicines, vaccines and health technologies, supply to remote areas, supply of antiretroviral
second line drugs, stockouts, counterfeit drugs. Please prioritise these problems, and allow
up to one page of space to summarise the most important ones.)
Q2 Are there different systems of procurement, supply, storage and distribution for different
groups of drugs, for different diseases or for emergencies or epidemic outbreaks? Does this
cause problems and, if so, how might they be solved? Include information about essential
medicines, syringes, reagents, laboratory equipment and family planning technologies.
Q3 Is there a logistics management information system in place? Is there an electronic drug
inventory management system? Describe these, in a few paragraphs.
Q4 Is there a system for regulating the quality of medicines, vaccines and health technologies
produced within the country and for those that are imported? What are the weaknesses in
the drug regulatory system? Please prioritize these, within half a page.
Q5 Are there standard operating procedures for dispensing medicines in all service provision
units?
31
7.5.2 MEDICAL PRODUCTS, VACCINES AND TECHNOLOGIES indicative statistics
Indicator
Latest
available
data and
source
Comment on
trends over
last 3-5 years
Remarks
Expenditure on pharmaceuticals as a
percentage of total expenditure on health
Per capita expenditure on pharmaceuticals
Percentage availability of key essential drugs
Percentage of health facilities with adequate
systems for storage of medicines and
vaccines
% of priority districts with stockouts for any
vaccine or other supplies during the year
% of health facilities dispensing
antiretroviral drugs which have experienced
a stockout of at least one required drug in
the last 12 months
% of health facilities reporting any stock out
of first line TB drugs & lab consumables
% of Health facilities with stockouts for anti
malaria medicines and RDT for 1 week
within 3 months for integrated activities
% of health facilities reporting any stock out
of essential MNH drugs & lab consumables
% of health facilities reporting stock out of
IMCI essential drugs in the last 6 months
% of health facilities reporting stock out of
pediatric ART drugs
32
7.5.3 MEDICAL PRODUCTS, VACCINES AND TECHNOLOGIES summary of Recommendations
made in earlier reports
Please summarise existing recommendations from past reports on the pharmaceutical sector in the
past five years. Indicate whether these have been implemented, rejected, or accepted in principle
but not yet implemented.
For each report, please provide the following information.
Report (title and year):
Recommendations:
Implementation:
7.5.4 MEDICAL PRODUCTS, VACCINES AND TECHNOLOGIES associations with a proposed
new strategy or funding proposal
This section is relevant if the Rapid Assessment precedes development of a new strategy or funding proposal. Please discuss these questions as a group, and prepare to report back to the whole Rapid Assessment Team. Q1 For medical products, vaccines and technologies, what are the current obstacles, needs or
gaps that might hinder our ability to succeed in the specific new health initiative?
Q2 Do these obstacles, needs or gaps affect the whole health system, or just the specific new
health initiative?
Q3 What aspects of supply of Medical Products and Technologies work well:
a. For this specific disease or specific set of health concerns?
b. For improving health generally?
33
Q4 For Medical Products, Vaccines and Techhologies, what needs to change so that we can
better address the specific health issue? How might we measure success?
Q5 How will the proposed changes benefit or hinder the overall function of the Medical Supply
system? How might we measure success?
7.5.5 MEDICAL PRODUCTS, VACCINES AND TECHNOLOGIES possible recommendations to
include in the proposed strategy or funding submission
Based on all the information in this section (7.5), what does your group recommend should be
included in the proposed new strategy or funding submission about medical products, vaccines and
technologies?
Recommendation to include
Why this should be a priority at this stage
What it will cost (only approximate costing is required at this stage)
Ideas to spark recommendations. The WHO publication, Systems thinking for health systems strengthening suggests these “common types of interventions” for Service Delivery: - New approaches to pharmacovigilance - Supply chain management - Integrated delivery of products and interventions
34
7.6 Service delivery
The WHO publication, Systems thinking for health systems strengthening, says the role of this
building block is to “include effective, safe and quality personal and non-personal health
interventions that are provided to those in need, when and where needed”.
7.6.1 SERVICE DELIVERY leading questions
Q1 How is the national service delivery system organized? Describe briefly the responsibility and
existing capacity of the Primary Care Units. Is there an essential or basic health services
package for Primary Care Units? Is health promotion included?
Q2 Comment on the range of health services provided. Do they include preventative, curative,
palliative and rehabilitative services and health promotion activities?
Q3 What is the coverage and utilization of Primary Care Units? Please indicate how coverage
differs between provinces or districts. What are some barriers that affect demand for
services?
Q4 What is the existing system for quality assurance of Primary Care Units? Is supervision
provided regularly across programs, or do different programs have different systems for
supervision?
Q5 Are client satisfaction surveys conducted? If so, how are the results used?
Q6 Describe the referral systems used for referral of knowledge of new health problems,
specimens, and case referrals (include what happens in emergencies).
Q7 What are the roles of local government and local communities in the planning and
management of Primary Care?
Q8 Describe how the government ensures that quality of care is provided by the private sector
at reasonable prices.
Q9 How can the private and not-for-profit sectors be more constructively engaged to improve
the performance of the whole national health system?
35
7.6.2 SERVICE DELIVERY indicative statistics
This table should be used as a guide. The group working on this building block may add other
indicators of the state of service delivery.
Comment also on differences between national and sub-national service delivery.
Indicator
Latest
available
data and
source
Comment on
trends over the
last 3-5 years
Remarks
Health centres per 10,0000 population
Total number of Hospital beds per 10,000
population
Pregnant women who receive 1+ANC (%)
Pregnant women who receive 4+ANC (%)
Deliveries attended by skilled personnel (%)
Immunization:
DPT3 immunization coverage (% of one
year olds)
Malaria:
Quality of services for case finding and
treatment
Tuberculosis:
Case detection rate
Number of patients under private sector
Treatment success rate
HIV:
Coverage of antiretroviral treatment
Referrals: Are there Referral Guidelines or
Flow Charts to ensure there is a Continuum
of Care for various health concerns?
36
7.6.3 SERVICE DELIVERY summary of Recommendations made in earlier reports
Please summarise existing Recommendations, and indicate whether these have been implemented,
rejected, or accepted in principle but not yet possible to implement.
7.6.4 SERVICE DELIVERY associations with a proposed new strategy or funding proposal
This section is relevant if the Rapid Assessment precedes development of a new strategy or funding proposal. Please discuss these questions as a group, and prepare to report back to the whole Rapid Assessment Team. Q1 In Service Delivery, what are the current obstacles, needs or gaps that might hinder our
ability to succeed in the specific new health initiative? Do these obstacles, needs or gaps
affect the whole health system, or just the specific new health initiative?
Q2 Based on evidence, what aspects of Service Delivery are done well:
a. For this specific disease or specific set of health concerns?
b. For improving health generally?
Q3 For Service Delivery, what needs to change so that we can better address the specific health
issue, and how will these changes affect overall service delivery? How might we measure
success?
37
7.6.5 SERVICE DELIVERY possible recommendations to include in the proposed strategy or
funding submission
Based on all the information in this section (7.6), what does your group recommend should be
included in the proposed new strategy or funding submission about Service Delivery?
Recommendation
Why this should be a priority at this stage
What it will cost (only approximate costing is required at this stage)
Ideas to spark recommendations. The WHO publication, Systems thinking for health systems strengthening suggests these “common types of interventions” for Service Delivery: - Approaches to ensure continuity of care - Integration of services versus centrally managed programmes - Community outreach versus fixed clinics
38
8. Step 3: The health system as a whole: synergies, gaps, obstacles,
bottlenecks
8.1 The findings about building blocks are shared with the whole Rapid Assessment Team
The first component of Step 3 is that the conclusions and recommendations about each building
block are reported to the whole Rapid Assessment Team. This may take a whole day, but should not
take longer. Remember, the point is to use the findings about building blocks to inform a discussion
about the synergies, gaps, obstacles and bottlenecks in the whole system. There is no point just
compiling a long report focusing on the building blocks themselves. Decisions have to be made about
what the most important priorities for changes. Not all building blocks can be substantially improved
at once.
8.2 Leading questions on the health system across the building blocks
The next questions will now be considered by the whole Rapid Health System Assessment Team
working together (Q1, Q2 and Q3, below). These questions aim to prompt the whole team to adopt
“Systems thinking” and focus on the interactions between the building blocks.
The Rapid Assessment Team is encouraged to discuss what might be the highest priorities right now.
This will be particularly important if the Health System Rapid Assessment is to be used as
background for a funding proposal. Not every gap in every building block can be funded through one
submission to one donor.
In answering these questions, a range of factors will be considered. These factors are based on the
WHO health system framework:
a. Interactions between building blocks
b. Contextual issues of the health system (such as primary health care revitalization,
decentralization, health systems in remote areas, health system financing)
c. Contextual issues at national or sub-national level (such as demographics, gender, urban growth,
conflict zones, mobile populations, migration in and out)
d. Use of health services (access, one time use, continual use, predicted future use)
e. Quality and safety of health services provided: how did they make a difference to the people
who used them?
Q1 What system-wide enablers or constraints should we take into account if we are going to
make changes (e.g. if we are to proceed with the proposed strategy or funding submission)?
What should be the highest priorities if we can only make two or three changes to the whole
system?
39
Q2 What is now the HIGHEST PRIORITY to improve the health system?
For example, if we are to proceed with a new funding proposal, should we be seeking
funding for Health Systems Strengthening that is related to a specific disease or to
immunization? Or should we be aiming for strategic improvement across the Health System
as a whole?
(Write down some pro’s and con’s of each option. Make a choice. Explain the reasons for
making this choice.)
Q3 Sustainability. If our proposed changes occur (e.g. If the government adopts the new
strategy, or if our funding application succeeds):
- What will be sustainable?
- What will not be sustainable?
- What will contribute to sustainable outcomes (even if it is not itself
sustainable)?
40
8.3 Completing and using the Composite Indicators Table again
The team now considers the Composite Indicators Table again, in light of the extra information now
available about each building block and the information about synergies, gaps and obstacles across
building blocks. It may change the weightings that it developed in Step 1 (Section 6). It may choose
to include indicators for each cell. This can then become a baseline for reference in years to come.
Health system Building blocks → Specific diseases or sets of health concerns ↓
Governance Guiding question: To what extent is the necessary leadership, policy, planning and organisational support in place to adequately address the health issue?
Financing Guiding question: Is there enough money available for this health issue, given the burden of disease and the need to ensure adequate access?
Human Resources Guiding question: To what extent are there the right levels of staff, with the right levels of training and support, in posts where they are needed?
Information Guiding question: To what extent does the health information we collect, routinely and through surveys, help us plan and measure progress for this health priority?
Medical products, vaccines and technologies Guiding question: To what degree do we have the right medical products, vaccines and technologies, distributed where and when they are needed?
Service delivery Guiding question: To what extent are there good quality services being delivered and taken up by the people who need them?
Immunization
HIV/AIDS
Tuberculosis
Malaria
Maternal health
Child health
Adolescent health
Health Ageing
Neglected Tropical Diseases
Non Communicable Diseases
Emerging Infectious Diseases
41
8.4 Discussions about what is learnt from completing the Composite Indicators Table again
The whole Rapid Assessment Team will discuss what is learnt from this second completion of the
Composite Indicators Table.
Across the table, for each specific disease or set of health concerns: What does the weighting tell us
about how the Health System will enable or hinder success of the proposed new strategy or funded
program?
Down the table, for each building block: What does the weighting tell us about the way each building
block may contribute to overall success of the health system in addressing a diversity of diseases and
health concerns?
42
9. Step 4: Deciding priorities for changes and sharing these with
stakeholders
9.1 Choosing priorities for short term changes to the health system
The whole Health System Rapid Assessment Team discusses what has been learnt from completing
all previous steps.
The team decides what should be the highest priorities for short term changes to the Health System.
This will not be easy. It is very unlikely that just one new strategy or just one new tranche of funding
will result in improvements to every aspect of the Health System.
The challenge for the team will be to choose which one, two or three changes might make the
biggest difference to improve health outcomes.
For example, if the reason for conducting the Rapid Assessment was as background for a new
funding proposal for malaria, what changes to the health system might make the biggest difference
in tackling malaria?
9.2 Preparing a Draft Report
This should be no more than 20 pages long8. Not all the information collected for the building blocks
will need to appear in the report, as the information has already been considered by the whole
team. The report should focus on synergies, gaps and bottlenecks. It should clearly identify priorities
for change.
9.3 Preparing a Presentation to Stakeholder’s Meeting
The team should decide what will be presented, by whom and how.
8 Note that GAVI and the Global Fund have a “Common Health System Proposal Form”. This form asks for a
total of only eight pages to describe the National Health System Context, Key Health System Constraints and Barriers, Current HSS Efforts, Health System Strengthening Objectives prioritized in the proposal and Main Beneficiaries. If this Rapid Assessment is to be used as background to preparation of a funding submission, it will be important that it present all information and priorities in a concise way.
43
10 Step 5: Reports of the Rapid Health System Assessment The reporting of the Rapid Health System Assessment takes place in three ways.
10.1 The team reports to a Stakeholders' Meeting
First, the team presents its findings and recommendations for priorities to a Stakeholder’s Meeting.
This meeting ensures that many stakeholders now understand what has been learned through the
rapid assessment, and have contributed to it.
The Stakeholders suggest revisions, and the team meets the next day to consider what needs to be
changed.
10.2 The team prepares a written report
Second, the team will prepare a written report. The report can follow the same format as the steps
of the rapid assessment. This means it will include:
- A concise description of the health system
Five key questions about the health system
Summary table of overall health system indicators
- A description of each building block, which will include:
Building block indicative statistics
Building block leading questions
Building block associations with the specific disease or set of health
concerns
- The health system as a whole: synergies, gaps, obstacles, bottlenecks
Descriptions based on the outcomes of the discussions within the Rapid
Health Assessment Team, and discussions within the final Stakeholders’
Meeting
The Composite Indicators Table, including scoring and final comments
- Decisions on priorities for short term changes to the Health System
10.3 The team hands over the Health System Rapid Assessment to the relevant people
Depending on the reasons for conducting the Health System Rapid Assessment, the team may
present the findings to another team which will develop a new strategy or funding submission.
44
Annex 1: Examples of people who might make up the Rapid Health System
Assessment Team or participate in stakeholders’ meetings
Team Leader, Health System Rapid Assessment Team: The Health System Rapid Assessment Team will be led by a senior leader from the Ministry of Health. This person will be someone who already understands the whole health system and is familiar with “systems thinking”. Rapid Assessment Team reports to: - Secretary of Health
(who may also be the leader of the Health System Rapid Assessment Team) Leader of Rapid Health System Assessment Team: - Secretary of Health - Director General of one department of the Ministry Of Health - Director of Planning Members of the Rapid Health System Assessment Team may include these sorts of people, or people who report to them: Governance: - Chief, Policy, Planning and Health Sector Reform - Director, Primary Health Care - A well respected leader of a particular health section - Representatives of other relevant ministries - Representatives of local governance bodies (not health-specific) - End users: consumer groups or agencies - Relevant private sector bodies (e.g. the mining sector in a province with large mines) - UNDP Financing: - Director, Health Finance - Vice Director, Health Finance - Regional or Provincial Director of Health Services (or finance people) - Hospital Accountants - Heads of local level health administration - World Bank, or Asian Development Bank Human Resources: - Director, Human Resources - President of professional associations, such as Medical Society, Nursing Association - Director, Health Practitioner Regulation - ILO Information: - Director, Health Information Systems - Chief Medical Statistician - Director, Monitoring and Evaluation - ADB
45
Medical products, vaccines and technologies: - Director, Pharmaceutical Services - Director, Central Medial Store - UNICEF - UNFPA - Representatives of people who inject drugs (if the focus is to be HIV) Service delivery: - Experts in TB, HIV, Immunization, Malaria, MCH or Primary Health - Director, Clinical Services - Director, Public Health Services - Clients of services:
o Consumer groups o NGOs which focus on health issues o NGOs which include health issues in broader development work o Representatives of vulnerable groups (e.g. networks of people living with HIV,
sex worker groups, people who inject drugs, men who have sex with men) Sub-national health and other partners: - This will be important if the Rapid Assessment focuses on the situation and needs of specific
sub-national areas. System wide enablers or constraints: - A well respected health academic - Leader of a health focused NGO - Director, National Planning Department - Ministry of Finance representative
46
Annex 2: Glossary
A system
A set of inter-related and inter-dependant parts designed to achieve a set of goals.
A health system
A health system consists of all organizations, people and actions whose primary intent is to promote,
restore or maintain health. This includes efforts to influence determinants of health as well as
activities directly addressing health. A health system is more than the pyramid of publicly owned
facilities that deliver health services. It includes, for example, a mother caring for a sick child at
home; private providers; behaviour change programmes; vector-control campaigns; health
insurance organizations; occupational health and safety legislation. It also includes inter-sectoral
action by health staff: for example, encouraging the ministry of education to promote female
education, which is a recognized determinant of health.
Health System Strengthening
At its broadest, health system strengthening (HSS) can be defined as any array of initiatives and
strategies that improves one or more of the functions of the health system, and that leads to better
health through improvements in access, coverage, quality, or efficiency .
Health system goals
Health systems have multiple goals. The World Health Report 2000 defined overall health system
outcomes or goals as: “Improving health and health equity, in ways that are responsive, financially
fair, and make the best, or most efficient, use of available resources”. There are also important
intermediate goals: the route from inputs to health outcomes is through achieving greater access to
and coverage for effective health interventions, without compromising efforts to ensure provider
quality and safety.
Health system function
The World Health Report 2000 identified the four key functions of the health system: (1)
stewardship (often referred to as governance or oversight), (2) financing, (3) human and physical
resources, and (4) organization and management of service delivery.
Health systems performance
Since the publication of the World Health Report 2000, regional consultations have found that the
links between the measurement of performance and the development of policy require
strengthening. In addition, many countries have expressed interest in active collaboration with WHO
to assess the performance of their own systems and to use the evidence to formulate policies to
improve performance.
To explain the reasons behind good or poor performance, one needs to look at how well a health
system is carrying out its different tasks. Ultimate responsibility for performance of the country's
health system lies with government.
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Indicator
A variable which helps to measure changes, directly or indirectly.
A statistic of direct normative interest which facilitates concise, comprehensive, and balanced
judgments about conditions of major aspects of the society
A variable with characteristics of quality, quantity and time used to measure, directly or indirectly,
changes in a situation and to appreciate the progress made in addressing it. It also provides a basis
for developing adequate plans for improvement.
Health indicator
An indicator applicable to a health or health-related situation.
Input, process, output and outcome indicators
Input indicator: Refers to health supply or resources that are incorporated into the system.
Process: A continuous and regular action or succession of actions, taking place or being carried out
in a definite manner, and leading to the accomplishment of some results.
Output: A change to a situation resulting from an action.
Process indicator: Refers to quality of health and management activities.
Output indicators: Refers to the results achieved in terms of products services, cares or goods. They
could be divided in following three types:
(a) Functional output indicators: these measure the number of activities conducted in
each functional area.
(b) Service outputs indicators: these measure the adequacy of the service delivery
system in terms of accessibility, quality and image.
(c) Service utilization indicators: these measure the extent to which the services are
used.
Outcome indicator
Effects Indicators: relating to measure of change in knowledge, attitude and practice (e.g. behavior
change including coverage) occurring in a short or medium term (2-5 years).
Impact Indicators: focusing on change in health status due to the effects of interventions and
occurring over the long-term (over 5 years).
Health system Gaps
The difference between what is currently existing to what is planned (targeted) in terms of input,
process, output or outcome using either quantitative and or qualitative measurements.
Gap Analysis is an analysis to explain the gap in quantitative or qualitative terms, or both.
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Annex 3: Examples of how the leading questions can be adapted if used as
background for a specific strategy or funding submission
Here are some examples of how the leading questions might be adapted according to the purpose of
conducting the Rapid Health System Assessment.
How does the current state of our health information system affect our ability to prevent malaria?
We have identified a gap: there is a lack of health services in a particular remote part of the country.
If there are no health services here, does this mean that we can’t address any health issues? How
might funding for a specific disease help to change this?
How does the system for Health Financing affect our ability to improve maternal health?
For the Building Block of Health Workforce, who are the people and institutions who are best at
training health staff?
For the Building Block of Information, what needs to change so that we can scale up immunization?
If we receive funding to improve HIV counselling and testing, how will this affect our Service Delivery
for other health issues?
Issues that might be considered here will vary from country to country or from province to province.
The issues that might be considered include Poverty, Age Demographics, Gender Issues, Border
Areas, Urban Growth, Mobility, Access to services for different Ethnic Groups, etc, etc.
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Annex 4: Examples of where data may already exist
Health Information For each of the 11 member countries, the WHO SEARO website has a section on Health Information. Much information is available in the document, 11 health questions about the 11 SEAR countries, New Delhi, WHO Regional Office for South East Asia, 2006. This book is available in your country. It can also be downloaded from the website http://www.searo.who.int/EN/Section313_13467.htm Health profile of the country Health services structure, organization, resources and utilization WHO Country Pharmaceutical Profile (this will be completed by all SEARO countries in 2011, with Global Fund Support) Health Systems strengthening The GAVI-HSS proposal and Annual Performance Report The GFATM country performance report USAID country fact sheet Epidemiology Surveillance data Burden of disease study Special surveys: Country national Demographic and health surveys, AIDS/STI case reporting HIV/TB surveillance Policies, strategies, progress reports PHC revitalization progress report, decentralization reports Country health plan: Annual and mid term Further essential data can also be found on the website of WHO Regional Office for South East Asia: http://www.searo.who.int/ Further data is also available from people within the country offices of WHO, World Bank, UNICEF, USAID and others.