The Primary Health Care (PHC) Measurement for Improvement collaborative has released Measuring the Performance of Primary Health Care: A Practical Guide for Translating Data into Improvement, a toolkit for practitioners, health system managers and policymakers to support better collection and use of PHC data to improve system performance.
Developed in partnership with the Primary Health Care Performance Initiative (PHCPI), this toolkit draws on the expertise and experiences of practitioners from 15 countries – Argentina, Bangladesh, Benin, Cameroon, Chile, Ethiopia, Ghana, India, Indonesia, Kenya, Malaysia, Mexico, Nigeria, Rwanda, and Vietnam – and includes practical guidance, tools, and case studies for users in both the public and private sectors.
Achieving universal health coverage (UHC) — the delivery of high-quality essential health services that are accessible to all without the risk of financial hardship — is an important development priority for many countries. Globally, there is growing agreement that PHC, with its ability to address up to 90 percent of a population’s diverse health needs, is central to the achievement of UHC.
Strong PHC is not simply the provision of basic services. It is an integrated approach to care that addresses the health needs of most of the population – from curative care to prevention and health promotion – and forms the foundation of efficient, equitable, responsive and resilient health systems. Many countries are taking concrete action toward strengthening their PHC systems and recognize that data on PHC performance are critical for identifying areas for improvement, determining practical solutions and monitoring progress; yet challenges related to the current state of health data systems often hinder improvements.
The PHC Measurement for Improvement Toolkit was developed through a combination of in-person workshops and virtual engagement that drew on the practical experiences of the Joint Learning Network (JLN) Measurement for Improvement (M4I) collaborative member countries. Country participants worked closely with JLN technical facilitators from Results for Development (R4D), with support from PHCPI partners from Ariadne Labs and the World Bank Group, to document lessons and combine them with global expertise in PHC measurement and data analytics to produce the toolkit.
The toolkit serves as a practical guide to address common measurement challenges faced by countries to support the collection of more useful data on PHC system performance and the effective use of data for performance improvement. JLN collaborative members reflected on the critical nature of PHC on the path towards universal health coverage and their experiences applying the Measurement for Improvement Cycle (Figure 1)—the foundational framework of the toolkit—highlighting how this toolkit, and the M4I experience, will help accelerate their progress toward health for all:
- Assessing Existing Monitoring Frameworks and Identifying Measurement Gaps
Establishing an effective measurement system starts with articulating clear measurement priorities: what questions are you trying to answer and what do you need to measure? Combining the Measurement for Improvement Cycle with the PHC Conceptual Framework developed by PHCPI, this toolkit provides an effective framework for identifying measurement priorities and allowing countries to identify the appropriate strategies and tools to support their own priorities.
Kenya underwent a process to develop a single unified monitoring and evaluation framework for the health sector, conducting a mid-term review of its health sector strategic plan to consider the scope of indicators collected across the system. Through this evaluative process, Kenya was able to identify gap areas and take concrete steps to address them.
“Measurement for improvement in PHC is critical as countries move toward the global aspiration of UHC,” noted Dr. Isabel Maina, of the Kenyan Ministry of Health. Kenya’s experience, described in the toolkit, is just one example of the innovative approaches countries are taking towards improved measurement for UHC.
- Addressing Measurement Gaps
Assessing the quality of health services is an important aspect of understanding how health system inputs translate into outcomes. Collaborative members identified three difficult-to-measure gap areas faced by countries in PHC measurement – technical quality, experiential quality and community engagement. Over the life of the collaborative, participants identified ways in which their countries were working to collect data within these gaps and cataloged best practices that could be applied in all contexts.
Reviews of work currently undergoing implementation, such as the Bangladesh Community Based Health Care program, detail both the motivating factors that led to the creation of these projects and explain how data are collected, disseminated and used to drive improvement. The Bangladesh program promotes community representation in clinic management and supports community education efforts.
“Experience showed the more the community is engaged in the management of [a] Community Clinic, the better the performance of the clinic in providing the health care to the community. The case study in the toolkit will help other countries to understand the modalities of involving the communities in Community Clinic management,” explained Dr. Khaleda Islam of the Bangladesh Directorate General of Health Services.
- Managing and Linking Disparate Data Sources
Data collection is only one aspect of assembling data that can be translated into information to help decision-makers make improvements. Collaborative members reflected on the importance of high-quality data that accurately depicts reality and developed guidance on how to establish a data warehouse to link fragmented data sources and ensure that data are easily accessible to all users.
In many countries, health information systems and data sources are fragmented—owned by different organizations or stakeholders—which makes it difficult for data users to access the information they need when they need it. Often these systems develop in isolation, rely on different technologies, and store data in different ways, requiring sophisticated technical solutions to link and centralize the data.
In Ghana, tools have been developed that address the many ways data quality might be compromised. Standardized registers and reporting forms with definitions work to minimize errors and ensure uniformity while a health information management platform supports effective data storage and retrieval. Dr. John Koku Awoonor-Williams of the Ghana Health Service noted that “the guidance in this toolkit will be used to inform measurement strengthening processes to evaluate PHC improvement,” referencing the tools and checklists developed to guide practitioners in establishing their own processes to ensure data quality and the effective use of data for decision-making.
- Using Data for Decision-Making
Once the right data are collected, they must be analyzed and communicated to stakeholders to support decision-making. As Dr. Sam Obasi of the National Public Health Agency in Nigeria explained, measurement for improvement is not simply a matter of knowing “what to measure and how to measure” but requires a culture of data use that relies as much on technology and data as it does on the people who drive this process forward.
The Data to Improvement Pathway walks practitioners through the process of identifying and collecting the right data, translating those data into information, communicating the information to increase knowledge, and using it to make decisions and take action.
A thoughtful evaluation of the data culture landscape in Nigeria revealed that data producers and data users weren’t always aligned with their understandings during the data production process. An inclusive process to build a data dictionary was an important step to overcoming this challenge: defining criteria for the format and structure of data elements has allowed decision-making processes at all levels of the system to align around common understandings and priorities.
An Ongoing Community for Joint Problem-Solving
As the PHC Measurement for Improvement Collaborative completed its first product, the members of the group reflected on their experiences and the journey ahead: “The camaraderie of this group is so comforting in that we have developed a vast network of friends whom we can fall back upon if we have to find answers to tough questions,” shared Dr. Kamaliah Noh of Malaysia. She underscored the importance of ongoing collaboration and joint problem-solving, both among the collaborative and the JLN community at large. “It is nice to know that we are not alone in our journey to UHC!”
Authors: Allyson English and Chloe Lanzara, Results for Development; Samuel Chukwuemeka Obasi, National Primary Health Care Development Agency, Nigeria; Khaleda Islam, Directorate General of Health, Bangladesh; Koku Awoonor-Williams, Ghana Health Service; Isabel Maina, Ministry of Health, Kenya; Kamaliah Mohamad Noh, Cyberjaya University College of Medical Sciences, Malaysia