An open letter to WHA70 delegates from the JLN community Jun 02, 2017

An open letter to WHA70 delegates from the JLN community
As the 70th World Health Assembly (WHA) meeting comes to a close, it is important to recognize that dialogue among country actors and the global community is critical for collective progress. In this open letter to WHA delegates, members of the Joint Learning Network for Universal Health Coverage Primary Health Care Measurement for Improvement Collaborative share key insights on the need to better measure and strengthen primary health care systems.

An Open Letter to Delegates of the 70th World Health Assembly from Members of the JLN PHC Measurement for Improvement Collaborative

This week, the 70th World Health Assembly (WHA) meeting, which represents an important moment for dialogue between member states of the World Health Organization and the global health community, has come to a close. As members of the Joint Learning Network for Universal Health Coverage, we regularly have the opportunity to bring our specific country experiences to a global forum to learn from one another and co-develop new knowledge and tools. We recognize that dialogue among country actors and the global community is critical to our collective progress. Therefore, we call on the WHA delegates to join in and continue this important dialogue. To start, we offer seven insights we’ve gained regarding the need to better measure and strengthen our primary health care (PHC) systems. 

1. To effectively measure primary health care performance, we need to align on a collective vision for what strong primary health care systems look like.

Each of our countries is committed to the achievement of universal health coverage (UHC) and believes that strengthening PHC is the foundation of this work. Though we acknowledge and uphold the definition of PHC proposed by Alma Ata—the provision of basic preventive, curative, rehabilitative, and palliative care—we know that when it comes to our own systems, we operationalize that definition differently. Differences aside, we agree that PHC is not just a set of basic services or a model of care—it’s a philosophy of care delivery. It’s a complex and integrated approach to care that starts with individuals, families and communities and is the foundation of the health system. The framework for primary health care as put forth by the Primary Health Care Performance Initiative and the concept of integrated people-centered care, as developed by the WHO, are helpful ways to begin to conceptualize this model. As we continue to monitor and strengthen our systems, we need guidance on how to operationalize this philosophical consensus into actions that effectively promote people´s well-being.

2.  We need to evolve our approach to measurement to match that vision for PHC.

To support the design, implementation and continuous improvement of strong PHC systems, we need to work with the global community to re-examine the functions of our health information systems and the ways in which we’ve historically monitored PHC performance. Instead of measuring in disease-specific siloes, integrated PHC systems require integrated strategies and platforms for monitoring and evaluation. Designing and implementing these systems is challenging and context-specific, but if the goal at the country level is to enable a more cross-cutting system view, we need to mirror that approach at the global level. We are not advocating to replace detailed, disease-specific monitoring that is carried out, but we need to complement this with a system-wide approach, which can tell us our overall performance, and which can stimulate collective action from a broader range of disciplines and stakeholders. 

This has implications on what’s measured. We need cross-cutting measures that highlight whether our system is delivering comprehensive, continuous, high-quality, person-centered care. Several countries in our collaborative are already using innovative measures such as basic effective health coverage (Argentina), antenatal care and immunization dropout rates (Mexico), and surveys on patient perception of care (Chile and Malaysia) to collect information in these areas.

It also has implications on our performance measurement systems. In order to view PHC performance level, we need to build data warehouses on PHC, drawing from civil records, surveys, program data such as TB, HIV, malaria, maternal health, NCDs, mental health, immunization and administrative and health inputs data such as finance, human resource, supply chain and procurement. This need to measure performance across the system may require us to evolve our information systems to accommodate different types of data and allow for more sophisticated analytics while keeping results social and accessible to wider range of stakeholders including subnational level providers and communities. We are each using different technology solutions and agree that there is no one right answer, but we need to start a healthy dialogue on the advantages and disadvantages of each if we want to improve and enable others to leapfrog.

3.  We need to ensure that we are capturing the full PHC system in our monitoring frameworks.

We are collecting tomes of data, but we may have too much that doesn’t matter and not enough that does. We need to collectively develop guidance on how to identify the gaps in our monitoring systems from a conceptual lens. The reality is that the available budget for performance measurement may be insufficient or inefficiently used. We need to be judicious in interrogating our data collection efforts to make sure we are capturing data that will give decision-makers at different levels— global, national, regional, local and community levels – relevant information that is actionable and represents the full PHC system.

Within the PHC Measurement for Improvement Collaborative, we have realized the value of this process and have taken a first step by developing the PHC Indicator Inventory, a tool that compiles existing indicators being used within our countries as well as those included on global normative lists, then maps them to a conceptual framework for PHC. This tool allows us to map our indicators against the framework, identify gaps, then look to see what measures other countries are using that we can learn from. .

4. We need to work together to address critical measurement gaps.

At both country and global levels, however, many service delivery processes—such as technical and experiential quality, community engagement, and facility-level management—possess critical gaps. For example: 
  • Existing measurement of quality of care typically focuses on technical quality—whether care meets standard guidelines or protocols—but we know that experiential quality is equally, if not more important in determining whether an individual will follow the doctor’s advice and come back again. We need better guidance on how to capture patient satisfaction and experience if we want to evolve towards high quality PHC. .
  • Additionally, we know first-hand the importance of community engagement in disease prevention and health promotion, but we don’t have robust ways to measure whether or not it’s happening effectively, or happening at all. There are examples to learn from though, including efforts in Chile, Indonesia, Cameroon and Ghana. .

We need guidance not only on the right indicators to use, but on how to determine the best measurement approach to fit our context and measurement goals. .

5. We need to make sure that information is fed back, especially to individuals and communities.

Individuals and communities make billions of health decisions daily. Those decisions such as where to deliver, how to feed the baby, where to buy good drugs, and where to get immunization are key determinants of the ultimate performance outcome of our system. However, communities are often not equipped with appropriate and reliable health information. Our collaborative has begun to draw attention to this critical gap and is committed to developing appropriate tools to improve this neglected function of health information systems. 

6. We can’t wait for the “ideal”—we need guidance on what to do tomorrow.

We need to have an ideal vision as our North Star, but we also need to make decisions about how to take action tomorrow. Our countries are at different stages of development with respect to our epidemiological profile, information system maturity and primary health care systems. The reality is that the next step will look different for each of us.

We need recommendations for feasible next steps we can each take to strengthen the measurement of PHC performance and help us point to actionable areas for improvement. As members of the Joint Learning Network, we hope we can meaningfully contribute to this goal. 

7. Most importantly, we need to find ways to create a culture of improvement.

We need to move beyond what to measure, and how to measure, to understanding how to create a culture that will embrace experimentation, learning and improvement. We regularly look to the global community to highlight best practices, but we also need to embrace examples where we tried and failed, as we know there is often even more to learn from those experiences. We want to become a community that has the institutional support to share these experiences—both positive and negative—and can champion each other to constantly strive to improve.

We, the undersigned, look forward to continuing this dialogue together. 

JLN PHC Measurement for Improvement Collaborative Members and Facilitation Team  

Mr. Samuel Nkeng Akwe
Sub-Director for Primary Health Care
Ministry of Health, Cameroon
Dr. Atikah Adyas
Senior Lecturer, Health Human Resource Institution
Ministry of Health, Indonesia
Dr. Koku Awoonor-Williams
Director, Policy Planning Monitoring and Evaluation
Ghana Health Service, Ghana
Mr. Jean-Paul Dossou
Research Coordinator
Research Centre in Human Reproduction and Demography, Benin
Dr. Fauziah Ehsan
Head of PHC Informatics Sector
Family Health Development Division
Ministry of Health, Malaysia
Ms. Meredith Kimball
Program Director
Results for Development, USA
Dr. Rachel Koshy
Public Health Physician
& Senior Principal Assistant Director
Division of Family Health Development
Ministry of Health, Malaysia
Mr. Luis Martínez Liévano
Director of New Models
Directorate General of Health Planning and Development
Federal Ministry of Health, Mexico
Ms. Chloe Lanzara
Senior Program Associate
Results for Development, USA
Dr. Isabel Maina
Head of Health Sector Monitoring & Evaluation Unit
Ministry of Health, Kenya
Dr. Jacqueline Matsezou
Permanent Secretary of the Steering and Follow up Committee 
of Health Sector Strategy, 
Ministry of Public Health, Cameroon
Mrs. Epote Nkiondalle
Management Accountant
National Health Management Information System Bureau
Southwest Region, Cameroon
Dr. Kamaliah Noh
Associate Professor (Public Health),
Cyberjaya University College of Medical Sciences, Malaysia 
Head of PHC Section
Family Health Development Division, Ministry of Health, Malaysia
Dr. Samuel Obasi
Assistant Director: Planning, Research, and Statistics; and,
Monitoring/ Evaluation Focal Person,
National Primary Health Care Development Agency, Nigeria
Ms. Hannah Ratcliffe
Primary Health Care Research Specialist
Ariadne Labs, USA
Mr. Alexis Ahumada Salinas
Professional of the Department of Primary Health Care
Under-Secretariat of Health Care Networks, Ministry of Health, Chile
Mr. Humberto Silva
Independent Consultant
Former Strategic Planning Coordinator
Programa Sumar, Argentina
Dr. Adolfo Martinez Valle
Director General
Performance Evaluation Ministry of Health, Mexico