Primary Health Care Improvement Global Stakeholder Meeting Report

This report provides background on the challenges and opportunities in the field of measurement for improvement in primary health care (PHC). It describes current, relevant multi-stakeholder efforts to address these challenges and opportunities, followed by key questions for consideration and potential deliverables for the global stakeholder community. The report also discusses the Primary Health Care Performance Initiative (PHCPI) and the Health Data Collaborative (HDC) and their role in improving PHC in low- and middle-income countries.

Primary Health Care Improveme
Global Stakeholder Meetin
6-8 April 2016

| P a g e 2

| P a g e 3
Table of Contents
Table of Contents ........................................................................................................................ 3
Key Messages ............................................................................................................................. 4
Acronym Index ............................................................................................................................ 5
Purpose ...................................................................................................................................... 7
Background ................................................................................................................................. 7
Measurement ............................................................................................................................. 9
Monitoring and Evaluation Framework ................................................................................................. 9
Establishing priorities for PHC measurement ....................................................................................... 10
Health Data Collaborative ................................................................................................................... 13
From Measurement to Improvement ........................................................................................ 15
Accelerating the process of using measurement to drive improvement ............................................... 15
Knowledge Management .................................................................................................................... 16
Action for Improvement ............................................................................................................ 18
Common causes of poor PHC performance .......................................................................................... 18
Strategies for PHC improvement ......................................................................................................... 19
PHC improvement activities (current and future) ................................................................................ 20
Global Challenge for Primary Health Care Improvement ...................................................................... 21
Annex 1: Situation Analysis Measurement ................................................................................ 23
Annex 2: PHCPI Vital Signs ........................................................................................................ 24
This report contains the collective views of an international group of experts, and does not necessarily
represent the decisions or the stated policy of the World Health Organization.

| P a g e 4
Key Messages
1. Health systems based on high-performing primary health care (PHC) are able to achieve better health
outcomes, more equitably, and at lower relative cost than health systems that over emphasize disease-
specific and/or hospital-based care.
2. Little is known about the performance of PHC, particularly in domains of service delivery: access,
comprehensiveness, continuity, coordination, people-centeredness and quality. Challenges exist across
the measurement spectrum from data collection, analysis, visualization and use for improvement.
3. Recent efforts by international agencies, including the Primary Health Care Performance Initiative
(PHCPI) and the Health Data Collaborative (HDC), offer an opportunity for stakeholders to collaborate
and complement country investments in the area of PHC measurement for improvement.
4. The Primary Health Care Performance Initiative (PHCPI) seeks to catalyze improvements in PHC in low-
and middle-income countries by developing better measurement of PHC-relevant domains, increasing
data availability and sharing knowledge.
5. The Health Data Collaborative (HDC) aims to address disparate funding and fragmented sources of
health data that lead to the current inadequacy of data for reliable, timely decision-making. The output
of HDC is more collaborative and efficient investment in country information systems and monitoring
and evaluation plans.
6. This meeting seeks to inform these stakeholder efforts and provide a common work plan for (1)
improved PHC performance measurement including research and development of less measured
domains of quality PHC and incorporation of these measures into existing measurement platforms and
(2) PHC improvement efforts including relevant guidance and tools and the WHO Global Challenge on
Primary Health Care Improvement.

| P a g e 5
Acronym Index
AeHIN Asia eHealth Information Network
ASSD Africa Symposium on Statistical Development
BMGF
CoP
CQI
The Bill and Melinda Gates Foundation
Community of practice
Continuous quality improvement
CRVS Civil registration and vital statistics
DHIS District Health Information System
GAVI Global Alliance for Vaccines and Immunization
GFATM The Global Fund to Fight AIDS, Tuberculosis and Malaria
GFF Global Financing Facility in Support of Every Woman Every Child
GIZ German Corporation for International Cooperation
HDC Health data collaborative
HMIS Health management information system
IHP+ The international health partnership
IPCHS Integrated, people-centred health services
JICA Japan International Cooperation Agency
LMIC Low and Middle Income Countries
M&E Monitoring and evaluation
NHA National health accounts
NORAD Norwegian Agency for Development Cooperation
OECD Organisation for Economic Co-operation and Development
PEPFAR The United States President's Emergency Plan for AIDS Relief
PHC Primary health care
PHCPI Primary health care performance initiative
RBF Results based financing
SARA Service Availability and Readiness Assessment
SDG Sustainable development goal
SDI Service Delivery Indicators
SPA Service Provision Assessment
UHC Universal health coverage
UNFPA United Nations Population Fund
UNICEF United Nations Children's Fund
UNSD United Nations Statistical Division
USAID United States Agency for International Development
WBG World Bank Group
WHO World Health Organization

| P a g e 6

| P a g e 7
Purpose
This document provides background on situation, challenges, and opportunities in the field of
measurement for improvement in primary health care (PHC). It then describes current, relevant multi-
stakeholder efforts to address these challenges and opportunities, followed by key questions for
consideration and potential deliverables for the global stakeholder community. These deliverables (some
underway, some proposed) are offered as a draft roadmap toward a collaborative process for supporting
country PHC measurement and improvement efforts. This document will undergo significant revision with
inputs from the PHC Improvement Global Stakeholder Meeting on 6-8 April to develop a work plan for (1)
improved PHC performance measurement including research and development of less measured domains of
quality PHC and incorporation of these measures into existing measurement platforms and (2) PHC
improvement efforts including the development of relevant guidance and tools and the WHO Global
Challenge on Primary Health Care Improvement.
Background
The highest attainable standard of health, including access to timely, acceptable, affordable, and high-
quality health care is a fundamental right of every human being. Primary health care (PHC), as a regular site
of first-access and on-going care with the capacity to address the majority of health problems, has long been
recognized as critical to attaining health for all.1 Numerous international reviews have bolstered this claim,
demonstrating that health systems based on high-performing PHC are able to achieve better health
outcomes, more equitably (even equilibrating the negative impact of social determinants of health), and at
lower relative cost than health systems that over emphasize selective disease-specific and/or hospital-based
care. 2,3,4,5
It is undeniable that strong PHC is foundational to achieving health for all, particularly the most
marginalized and vulnerable. In addition, strong PHC is essential to attaining today’s leading global health
objectives including Universal Health Coverage (UHC), Integrated People-centred Health Services (IPCHS)6,
and health related Sustainable Development Goals (SDGs). Yet, too often the potential of PHC for dramatic
improvements in the health of populations and function of health systems is undermined by lack of
1 Recognizing that primary care has variable definitions, this paper is grounded in the historical approach of primary health care established at
Alma Ata while emphasising health system and service delivery reforms relevant to primary care. We adopt a definition from the World Health
Report 2008: Primary health care – now more than ever: care that exhibits features of person-centeredness, comprehensiveness, integration,
continuity of care, participation of patients, families and communities. This requires health services that are organized with close-to-client
multidisciplinary teams responsible for a defined population, collaborate with social services and other sectors, and coordinate the contributions of
specialists and community organizations.
2 Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457-502
3 Kruk, Margaret Elizabeth, et al. "The Contribution of Primary Care to Health and Health Systems in Low-and Middle-Income Countries: a critical
review of major primary care initiatives." Social science & medicine 70.6 (2010): 904-911.
4 Starfield B. Policy relevant determinants of health: an international perspective. Health Policy, 2002, 60:201-218.
5 Rohde J, et al 30 years after Alma-Ata: has primary health care worked in countries?, The Lancet, Volume 372, Issue 9642, 13–19 September
2008, 950-961
6 WHO Framework on integrated people-centred health services was recently adopted by the 138th Session of the Executive Board, and will be
discussed at this year’s World Health Assembly. The framework proposes five interdependent strategies (including reorienting the model of care
around primary-care based systems) for health services to become more integrated and people-centred. The proposed resolution includes a request
for research and development on indicators to trace global progress on integrated people-centered health services; as well as technical support and
guidance to Member States for the implementation, national adaptation and operationalization of the framework.
http://apps.who.int/gb/ebwha/pdf_files/EB138/B138_37-en.pdf

| P a g e 8
emphasis and underinvestment. As a result, PHC implementation has lagged far behind its aspirational
objectives: continuing to focus on the delivery of a basic package of health interventions for selected priority
diseases rather than comprehensive care, ineffective decentralization that impedes PHC from responding to
local conditions, failing to focus on improved coordination between providers and levels of care, missing out
on the benefits of multidisciplinary care, limiting access hours of PHC facilities, and under-emphasising
health work force development and retention resulting in overworked and under-supported staff.
In most countries, little is known about the performance of PHC, particularly in service delivery domains
that are critical to its effectiveness but often not well measured: access7, comprehensiveness8, continuity9,
coordination10, people-centeredness11 (family and community orientation), and quality (both technical and
interpersonal). These domains characterize high-quality primary care (as first contact care) and help explain
performance variation across country contexts, in all settings from low- to high-income countries. While
there are numerous typologies of primary care, not all of them lead to desirable outcomes and impact.
Measuring these domains of high quality PHC acknowledges their importance in explaining performance
variation and can lead to critical reforms. Increased and improved measurement of PHC performance, with
measures relevant to community, facility, district and national processes, is needed to promote
accountability and guide improvement efforts at each level of the health system. There is tremendous
opportunity to have a major impact on health through targeted measurement of what drives strong primary
health care systems and better utilization of these data for improvement by stakeholders at all levels of the
health system.
Several recent collaborative efforts by international development agencies have drawn further attention
to this area including the Health Data Collaborative (HDC)12 and the Primary Health Care Performance
Initiative (PHCPI). 13 HDC seeks to facilitate and accelerate progress in strengthening country systems for
monitoring progress and performance for accountability and transparency within the context of the health
related SDGs. PHCPI brings together partners to improve PHC in low- and middle-income countries through
better measurement to inform and accelerate national and sub-national PHC progress and knowledge-
sharing.
As a key next step, this meeting serves to engage leadership of Member States, partner organizations,
international development associations, academic partners and WHO to move toward a common roadmap
for strengthened PHC measurement and improvement. Stakeholder input obtained through this meeting will
be used to shape the concrete steps needed to advance the measurement and improvement agenda,
including: (1) improved performance measurement (2) research and development for under-measured
domains (3) improved transparency and accountability (4) and evidence-informed decision making all
leading to (5) performance improvement.
7 Access: Available, affordable services in close proximity to people. Primary care serves as the entry point into the health care system and the
first and regular source of care for most health needs.
8 Comprehensiveness: Delivers a broad spectrum of preventive, promotive, curative and palliative care across the life-course
9 Continuity: Individuals have a relationship with same provider and team over time, health information is available over time, and health
management plans are continuous.
10 Coordination: Primary care offers a hub from which people are guided through the health system, managing care across levels, referring to
specialists as needed and effectively following-up to monitor health progress.
11People-centeredness: an approach to care that consciously adopts individuals’, carers’, families’ and communities’ perspectives as
participants in, and beneficiaries of, trusted health systems that are organized around the comprehensive needs of people rather than individual
diseases, and respects their preferences. People-centred care also requires that patients have the education and support they need to make
decisions and participate in their own care and that carers are able to attain maximal function within a supportive working environment. People-
centred care is broader than patient and person-centred care, encompassing not only clinical encounters, but also including attention to the health of
people in their communities and their crucial role in shaping health policy and health services.
12 Health Data Collaborative www.healthdatacollaborative.org
13 Primary Health Care Performance Initiative www.phcperformanceinitiative.org

| P a g e 9
Measurement
In order to improve primary health care performance, countries, districts, and facilities first need
information about how their systems are performing and what barriers are preventing them from delivering
high-quality, patient-centered primary care services. The last decade saw progress in many low- and middle-
income countries toward producing, using, and sharing health data; yet, most country health information
systems still do not meet current data demands.
In many countries data collection is not harmonized around the needs of planners and managers, but
rather numerous reporting tools to meet the stated objectives of multiple implementers and stakeholders.
This lack of coordination requires an enormous data collection effort from already overburdened human
resources. At times country HMIS efforts are siloed or lack interoperability, missing out on opportunities for
analysis of complex, crosscutting problems. Far too often, there are limited resources for HMIS reforms.
Even where coordinated, high-functioning systems exist, data quality assurance can remain challenging.
Traditionally, measures of PHC performance have focused on quantifying the inputs—human resources,
facilities, and financing, for example—and describing service delivery volume and outcomes, including
disease-specific morbidity and mortality. Measurement of quality service delivery has been largely
neglected, as has the experience of patients, health workers, and communities in seeking, accessing and
delivering health services. Most countries, districts, and facilities lack data on many of the core functions of
quality PHC (first contact accessibility, continuity, coordination, and comprehensiveness), patient-
centeredness and responsiveness, and primary care organization and management. This lack of data and
knowledge about which components of service delivery and organization need strengthening impedes the
ability of actors at all levels of the health system to take action for improvement.
Ideally, measurement of PHC functions and service delivery should be occurring in a coordinated way at
the community and facility, subnational and national levels. In such a system, actors at each level of the
system - national planners and policy makers, sub-national managers, and providers and communities -
would be able to access and use standardized and interoperable data collection platforms to track key
performance indicators to continually assess the quality and effectiveness of care delivered and proactively
plan for future service delivery needs as well as identify areas where change in existing systems and policies
are needed.
Data needs for these activities range from measurement of the local burden of disease to drug and
supply availability and from health worker performance and motivation to experiential quality and results of
care delivery. Subnational-level decision makers need access to this information from facilities in their
catchment area in order to track trends in performance and outcomes over time, quickly detect and act
upon emerging issues and gaps, and identify positive outliers to extract and spread promising practices. The
same is true at the national level, where timely information from districts is converted to knowledge to drive
action for improvement and used to inform future practices, policies and strategic planning. At the global
level, measurement informs global surveillance efforts, donor investment priorities, and international
policies. At all levels, measurement is a tool for enabling comparability, identifying promising practices for
sharing, and creating accountable and transparent systems that are responsive to the needs of their
constituents.
Monitoring and Evaluation Framework
Given the expansive field of health systems measurement, an organizing framework for understanding
monitoring and evaluation (M&E) is critical. The IHP+ common M&E Framework (Figure 1) provides a results-

| P a g e 10
chain representation of the key components of a national M&E strategy. It identifies four major indicator
domains: system inputs and processes, outputs, outcomes, and impact. The framework demonstrates how
inputs to the system and processes result in outputs, outcomes and impact. The framework facilitates the
identification of core indicators along the results chain, while also identifying key data collection methods.
The framework also highlights the need for analysis and synthesis of data from multiple sources, including
data quality assessment; and demonstrates how the data need to be communicated and used to inform
decision-making at different levels.
Figure 1. IHP+ common M&E framework14
Establishing priorities for PHC measurement
The above framework addresses the key components of a monitoring and evaluation strategy; however,
current monitoring and evaluation efforts have overemphasized inputs, outcomes and impact without
sufficiently focusing on crosscutting processes at various levels of service delivery – including information on
clinical quality and safety. Several efforts at PHC performance assessment frameworks have been
undertaken historically; however, due to difficult/costly methodologies, lack of integration into routine data
collection efforts, and under emphasis of crosscutting issues, few have had sufficient uptake and integration
into national monitoring and evaluation strategies to have sustainable impact.
Despite the vast array of surveys and facility assessment conducted in LMICs, many core PHC service
delivery concepts are not routinely measured effectively. For example, existing data collection
methodologies in use in LMICs do not adequately capture indicators of the four functions of PHC—first
contact accessibility, continuity, comprehensiveness, and coordination. Although the centrality of these
functions to primary care is consistent across high, middle, and low-income settings, most existing measures
14 WHO. Monitoring, evaluation and review of national health strategies: a country-led platform for information and accountability. 2011.
http://www.internationalhealthpartnership.net/fileadmin/uploads/ihp/Documents/Tools/M_E_Framework/M%26E.framework.2011.pdf

| P a g e 11
are currently validated and used in only high-income countries. Expert consensus is that these measures are
not applicable to most LMICs, particularly fragile states. This leads to the paradoxical situation of many low
and middle-income countries in which countries are overwhelmed by data and reporting requirements, but
lack critical data for decision-making and improvement efforts.
The Primary Health Care Performance Initiative (PHCPI) 15 framework (Figure 2) attempts to address
these challenges by more explicitly articulating the key inputs, functionalities, and desired goals of an
effective PHC system. This framework draws from other measurement frameworks while offering a novel
focus on the intersection between service delivery and the core functions of PHC as key drivers of
performance variation. The PHCPI Conceptual Framework highlights people- and community-centered care,
supply and demand functions, and integrated service delivery through effective organization and
management.
Figure 2. Primary Health Care Performance Initiative Framework
Based on an extensive review of the scientific literature and consultations with international experts and
health systems practitioners across the globe, PHCPI also identified and selected indicators to assess the
performance of country primary health care systems, understand the root causes of primary health care
performance and give countries more clarity on what and how to improve.
Using a rigorous process, a core set of internationally comparable indicators and an expanded set of
indicators were selected to help countries assess overall primary health care system performance (Core set:
Vital Signs indicators – See Annex 3) and identify performance determinants (Expanded set: Diagnostic
indicators), while recognizing that each country will collect a unique set of indicators based upon country
priorities in each domain. The chosen Vital Signs indicators align and complement the Global Reference List
of 100 Core Health Indicators16 by focusing on important service delivery processes that are crucial for
15 The Primary Health Care Performance Initiative (PHCPI) is a new partnership that brings together country policymakers, health system
managers, practitioners, advocates and other development partners to catalyze improvements in primary health care (PHC) in low- and middle-
income countries through better measurement and knowledge sharing. PHCPI was officially launched by the Bill & Melinda Gates Foundation, World
Bank Group, and World Health Organization on the sidelines of the UN General Assembly in September 2015. www.phcperformanceinitiative.org
16 Developed through technical consultation of the Interagency Working Group on Indicators and Reporting Burden in 2013 and updated in
2015, the Global Reference List of 100 Core Health Indicators is a standard set of 100 core indicators prioritized by the global community to provide
concise information on the health situation and trends including responses at national and global levels.
http://www.who.int/healthinfo/indicators/2015/en/

| P a g e 12
achieving universal health coverage and other global priorities. Diagnostic indicators, which provide more
detailed information to identify performance gaps are, by nature, less internationally comparable, and will
need to be tailored to country context and health management information system (HMIS) capacities.
Currently available information on LMIC performance related to the Vital Signs can be found on the PHCPI
website at www.phcperformanceintiative.org.
Through the process of developing the Conceptual Framework and identifying and selecting indicator
sets, two major gaps in available PHC measures were identified: 1) the need for better ways of measuring
PHC service delivery; and 2) the need for expanded data availability of existing measures.
Within the arena of measure development, more work is also needed to create indices of PHC system
performance such as composite metrics. Such measures would serve to provide quick, easily comparable
snapshots of facility, district, or national PHC systems performance and could focus on inputs, effective
service coverage, equity, or preventable morbidity or mortality. While the PHCPI partnership is actively
engaged in improving measurement in these areas in partnership with the HDC, there is need for global
consensus on priority areas and measures as well as a need for increased research on reliability and validity
of these measures in differing contexts.
In addition to developing improved measures of PHC service delivery, there is a pressing global need to
expand PHC performance data availability and comparability to help countries assess their own performance
and to assist the global community to identify positive outliers where effective PHC delivery has been
achieved. For example, harmonization of global surveys, including the Service Availability and Readiness
Assessment (SARA) and the Service Provision Assessment (SPA), and Service Delivery Indicators (SDI) are
one means of ensuring that valid and comparable data are available at the sub-national, national and global
levels.
Finally, work also remains to ensure that country-owned HMIS data platforms are able to regularly
collect indicators of PHC performance and rapidly feed this information to local and national decision makers
for use in informing action and improvement. Incorporation of parallel data platforms into HMIS, such as
those available for results based financing (RBF), might offer an additional way to expand data available at
the national and subnational level relevant to domains of PHC function.
Areas of focus for improved PHC measurement:
•Core functions of PHC - accessibility, comprehensiveness, coordination, continuity and
people-centeredness (including participation)
•PHC Quality - safety, effectiveness, timeliness, efficiency and equity
•PHC organization and management - facility management and leadership capabilities, team-
based care organization, supportive supervision, population health management,
information system use, and continuous quality improvement (CQI) processes.
•Provider performance - motivation, competence, and workload.
•Patient and community experience of care and the health system - trust, respect,
communication, and responsiveness
•PHC resource prioritization and investment
•Intersectoral action

| P a g e 13
Key Questions:
 What data is needed at different levels of decision
making to improve performance?
 Which of these data about PHC performance already
exists?
 What data gaps for PHC performance assessment exist
and how can they best be filled using current or, if
necessary, novel data collection methodologies?
 What can be done to support decision makers to
access the data they need in a timely manner to inform
their upcoming decisions, so they can meet the primary
health care needs of the population they serve?
Potential Deliverables:
 New indicators (definition and methodology)
developed for prioritized under-measured domains of
PHC for use at facility/community, sub-national,
national, and international levels
 Primary health care relevant composite indicators
 Plan to incorporate key PHC indicators into
subnational measurement efforts
o Health facility assessments
o Routine HMIS
o Community data sources (household surveys, CHWs)
 Further refinement of list of PHC “vital signs” and
“diagnostics” indicators to reflect ongoing efforts in
improved measurement and stakeholder input
 PHC indicators relevant across country income/health
system development levels
 Research consortium with prioritized research agenda
for measurement and learning
 Cross-walk of regional PHC assessment frameworks
and indicators
 PHC self-assessment guide for use at sub-national level
 Global PHC performance report
 Communities of practice: IPCHS, Joint Learning
Network Primary Health Care Performance
Measurement & Improvement Collaborative; linkages
to other active CoPs
 Systems to increase transparency of performance such
that countries are aware the performance of their PHC
systems and accountable to their citizens, civil society
organizations and the global community.
Numerous stakeholders have been engaged in activities relevant to each of the above identified
measurement gaps (indicator development, health
facility assessment harmonization efforts, composite
development) as well as efforts to strengthen country
HMIS. A scoping of stakeholder activities and
investments in health data activities can be found in
Annex 1. However, to date little of this effort has
been specifically focused on improving primary health
care. In addition, efforts to develop further quantify
quality of care have been fragmented, lacking global
consensus on priority measures, indicator definitions
and best practices for data collection methodologies.
Quality of care measures have also been focused on
disease-specific measures, which while relevant to
PHC, miss out on the cross-cutting benefits of
measuring whole system function. The text box to
the right demonstrates key questions relevant to
improved measurement of PHC and lists potential
PHC measurement deliverables for the global
stakeholder community.
Recently, global stakeholders interested in
collaborating on health data investments joined
together to form the Health Data Collaborative (HDC).
17 The primary strategies of the HDC are to enhance
country statistical capacity and stewardship and for
partners to align their technical and financial
commitments around strong nationally owned health
information systems and a common monitoring and
evaluation plan. Work at global level to establish
common standards, indicators and databases will be
geared to contribute to countries health information
systems.
Health Data Collaborative
Launched in March 2016, the Health Data
Collaborative (HDC) is an inclusive partnership of
international agencies, governments, philanthropies,
donors and academics, with the common aim of
addressing disparate funding and fragmented sources
of health data which, in part, leads to the current
inadequacy of data for reliable and timely decision
making.
The output of the HDC is a more efficient
investment in information systems. The timely,
accurate and comparable data arising from the national information system can be used to understand the
17 The Health Data Collaborative aims to facilitate and accelerate progress in strengthening country systems for monitoring progress and
performance for accountability within the context of the health related SDGs and health sector strategic plans. www.healthdatacollaborative.org

| P a g e 14
health challenges, to design and monitor effective interventions and to demonstrate outcomes and impact
at national and global level. Further efficiencies will be achieved by sharing experience and learning from
countries and other data initiatives.
Figure 3. Health Data Collaborative Objectives18
Numerous multi-stakeholder working groups, focused on key areas of monitoring for accountability,
manage the programmatic and technical work of the Health Data Collaborative. These groups work with and
strengthen existing global initiatives and communities of practice working to improve health data systems in
country, in an effort to respond to specific data needs and reduce duplication. While the work of numerous
working groups intersects the efforts to measure and improve PHC performance, particularly relevant are
the working groups on facility and community systems (HMIS/DHIS/Facility Surveys), quality of care and
performance improvement measurement (Co-led by PHCPI and GFATM), digital health systems and
interoperability and analytics and use. Within the quality working group, the research and development of
new indicators and measurement methodologies are critical for service delivery improvement. The majority
of the listed potential deliverables above could be delivered through existing working groups of the HDC, but
will require extensive stakeholder collaboration to succeed.
18 The Health Data Collaborative. Measurement, Performance and Learning for Accountability: Operational Work-plan 2016–2020. 19 January
2016.

| P a g e 15
Table 1. Health data collaborative working groups
From Measurement to Improvement
Accelerating the process of using measurement to drive improvement
Measurement alone is insufficient to drive improvement. In order to move from measurement to
improvement, measured data and information must be transformed into knowledge of what is and is not
RESULTS WORKING GROUPS LEADS +
STAKEHOLDERS
DELIVERABLES 2016
Repository of global
standards
Core Group + working groups Lead: WHO + D4Health Repository established –
2016
Monitoring of the state
and performance of
country systems
Core group Report published Q1 2017
Country & regional
engagement
WG on Country action & regional
engagement
Lead: Core team + IHP+,
global, regional, country
partners, civil society
Engagement in 5 +
countries and joint actions
in 5+ countries on specific
requests
Global and country
databases
WG on Global data Leads: WHO, UNICEF, PEPFAR
+UNAIDS, UNDESA
Global health observatory
updated with SDGs ,
linkages with global &
national databases
Facility and community
systems
WG on facility data (HMIS/DHIS)
WG on facility data (surveys)
Leads: University of
Oslo/WHO
+ TGF, GAVI, PEPFAR, BMGF,
USAID, Measure Evaluation,
PHCPI
Leads: WHO, WB, USAID,
UNICEF, UNFPA
Package of data standards
& tools (Q4 2016)
Facility survey instruments
– Q3 2016; country action
(10+)
Quality of care and
performance improvement
measurement
WG on quality of care &
performance
Leads: PHCPI; WBG, BMGF,
WHO +USAID, UNICEF
Joint work in 5+ countries
Digital health systems and
interoperability
WG on digital health systems &
interoperability
Leads: USAID, WHO,
+BMGF, Open HIE
HIS Interoperability
Framework and guidelines
Joint work in pathfinder
countries
Analytics and use WG on analytics and use Leads: WHO
+ UNSD, Measure Evaluation
WG, TGF, PEPFAR, UNICEF,
Countdown
Set of tools to facilitate
data quality assessment &
analysis (mid 2016);
regional strategy in place
Household surveys Link with International
Household Survey Network; +
UNICEF, USAID, WB collaboration
WB- UNICEF, USAID
WHO, Measure, UNSD
Set of harmonized survey
modules in IHSN Question
Bank (Q3 2016)
CRVS Link with existing coordination
mechanism
IAWG on CRVS (UNSD)
Regional bodies (e.g. UNECA,
UNESCAP, ASSD), WBG, D4H
Electronic training tool kit
(WB lead) (Q4 2016)
Better health systems
monitoring
Link with existing mechanisms on
HRD data, financial measurement
Health workforce information
reference group (WHO &
USAID);
Health expenditure data work

| P a g e 16
working to inform improvement efforts, and decision makers must be empowered to make effective
changes to address the identified gaps. Performance assessment represents a key first step to
understanding problems and promising practices. This must be complemented with formal research and
evaluation to better understand root causes. In addition performance assessment and data utilization
should be routinely linked to policy formulation cycles and CQI efforts to facilitate the translation of
knowledge into action. Knowledge from past experiences or the experience of others can facilitate the
process of improvement by inform what changes best address identified gaps.
Figure 4 further describes the processes necessary to convert data into information, information into
knowledge, knowledge into action, and how to assure that the actions taken resulted in improvement. Each
of these steps is complex and requires existing expertise to assure the correct transition to the next step in
the process.
Figure 4. Transforming data into improvement
While many of the challenges to using data for improvement are technical in nature, the importance of
an enabling environment to support change cannot be underestimated. Health service reform can be
challenging at many levels. Addressing these challenges requires sustained political commitment,
transformational leadership, change management approaches, and mobilizing and engaging health
professionals and communities. Effective collaboration will be needed between all stakeholders in countries,
with the support of national and international partners, including development organizations, citizens
groups, health provider associations, and academics and researchers.
Knowledge Management
Knowledge management is the “systematic process of collecting and curating knowledge and connecting
people to it so they can act effectively.” Knowledge management enables the generation, collection, sharing,
and use of explicit and tacit knowledge for action and improvement. The processes that make up knowledge
management include:19, 20
19 Sullivan TM, Limaye RJ, Mitchell V, D’Adamo, Baquet Z. Leveraging the Power of Knowledge Management to Transform Global Health and
Development. Global Health Science and Practice. 2015:3;150-162

| P a g e 17
1. Knowledge Generation: The formulation of new information and knowledge through research,
collaboration, and innovation. This work includes transforming data into information into
knowledge.
2. Knowledge Capture: The identification and extraction and documentation of existing data,
information or knowledge (tacit or explicit) 21
3. Knowledge Synthesis: The organization and interpretation of explicit and/or tacit knowledge from
various sources into generalized frameworks, evidence-informed guidance, tools or approaches,
reports and manuscripts.
4. Knowledge Organization and Prioritization: Evaluating and sorting knowledge and presenting it in
meaningful and organized manner around specific themes or areas of focus. Including the
identification of knowledge gaps to stimulate further knowledge generation.
5. Knowledge Sharing: The transfer of knowledge within and among groups of people with common
interests and goals through online platforms, organized collaborations, meetings, print and online
publications, etc.
Together, these processes lead to the creation of methods and tools that are designed to drive
knowledge uptake and use. These tools include: (1) Products and resources, ex. websites, toolkits,
assessment guides (2) Publications, ex. peer-viewed literature, white papers, reports (3) Training and events,
ex. conferences, meetings, and consultations (4) Partnerships and communities of practice that can be used
to inform learning and action for systems improvement, ex. JLN, Integrated People-Centered Health Systems
communities of practice.
When considering knowledge management, it is important to recognize that there are two different
types of knowledge, both of which are valuable to improvement efforts22:
 Explicit knowledge is already articulated and could be found in reports, publications or other
modalities. This can include lessons learned on improvement, how and what was done and the
impact.
 Tacit knowledge is intuitive knowledge that is rooted in context, experience, and practice. This
knowledge has not been extracted and might reside in front line implementers, country leaders or
the community being served. Capturing this knowledge might need methods such as qualitative
interviews and focus groups, case studies and direct observations.
Each of these types of knowledge can either already exist or be emerging through new activities. There are
numerous current activities by partners taking place within each knowledge management process. Examples
of relevant activities can be found in Table 2. Of note, this list is not intended to be exhaustive.
Knowledge management is an inherently participatory process and requires inputs from actors at all
levels of the health system. Knowledge management activities at the community, facility, district, national,
and global levels all inform and draw on each other. For example, knowledge generated through
improvement efforts in a facility and community can be captured, synthesized, and shared at the district
level to inform similar improvement efforts at another facility within the district. Similarly, this knowledge
that is synthesized at the district level may be curated, synthesized, and shared at the national level, leading
to the creation of toolkits, reports, and collaborative communities of practice so that lessons learned in the
first district can accelerate improvements nation-wide. Globally, knowledge of facility, district, and national
policies, practices, and reforms can inform publications, be presented at conferences, used to generate
toolkits and implementation guides, and inform activities and trainings in other countries.
20 Ohkubo, S., Sullivan, T. M., Harlan, S. V., Timmons, B. T., & Strachan, M.(2013). Guide to monitoring and evaluating knowledge management
in global health programs. Baltimore, MD: Center for Communication Programs, Johns Hopkins Bloomberg School of Public Health.
21 Tacit would typically require qualitative methods such as KI interviews, observation etc. Explicit sources could include reports or published
literature, existing data such as GHO)
22 http://www.knowledge-management-tools.net/different-types-of-knowledge.html

| P a g e 18
Table 2. Sample knowledge management efforts relevant to PHC improvement
Examples Generation Capture Synthesis Org/Prioritization Sharing
PRIMASYS PRIMASYS
captures tacit
and explicit
knowledge
about PHC
systems
Using this
knowledge,
develop case
studies
Case studies
shared
through
WHO and
PHCPI
websites
Joint Learning Network Generate new
knowledge
through learning
sessions.
Harvesting
implicit and
explicit
knowledge
during peer-
to-peer
sharing.
Development of
new tools
drawing from
generation and
capture of
knowledge.
During peer-
to-peer
learning and
through
PHCPI and
JLN websites
PHCPI Website Quantitative
analysis of PHCPI
Vital Signs data to
identify low or
high performing
countries on
critical PHC
functions
Generate mini-
case studies
profiling high-
performing
primary care
systems
Prioritized
literature made
available through
the Health
Systems Evidence
platform in
partnership with
McMaster
University
Sharing of all
PHCPI
products
IntegratedCare4People
web platform
Practices
database
Academic
digests/policy
briefs
Curated
resources
Communities
of practice
Action for Improvement
Moving from data to information to knowledge to action and ensuring that the chosen action leads to
improvement are critical steps to link measurement efforts to desired impact. The HDC provides a
mechanism by which best practices for measurement can be established, coordinated, and scaled within the
setting of support to country planning processes. Combined efforts of global stakeholders toward improve
measurement of currently under measured domains through the HDC will result in improved data availability
for service delivery decision-making at numerous levels. Equally collaborative efforts are needed to support
and achieve service delivery improvements. PHCPI offers a partnership model whereby stakeholders, in
partnership with countries, agree upon methodologies for country-specific assessment exercises that result
in tailored improvement plans, containing relevant actions for facility, subnational and national levels. These
plans should be supported in a coordinated manner by global stakeholders and be imbedded in national
health policies, strategies, and plans. Technical assistance and financing must be better aligned to provide
collaborative support and maximize efficiencies.
Common causes of poor PHC performance
When measures demonstrate that effective, affordable health care is not reaching the populations
in need, the PHC system has failed. This can occur for many reasons, some of which are highlighted in the
PHCPI framework (Figure 2, page 6). For example, providers may have inadequate skills or an inappropriate
skill mix, the consequence of failure or lack of training, investment or incentives; essential drugs and
equipment may be unavailable due to poor supply chain management or purchasing. A lack of universal
financial protection can deter populations from seeking care, or impede the ability of facilities to finance
care delivery. Health information systems may be inadequate to provide necessary information for
decision-making. Relevant to primary health care, potential areas for improvement exist in all health system

| P a g e 19
building blocks23 as well as the processes relevant to ensuring that health services are integrated (rather
than fragmented) and people-centred (meeting health needs across the care continuum and life course in a
way that responds to situation and preferences). However, even when adequately resourced and prioritized,
in the presence of necessary inputs financial support, service delivery is often inadequate due to
dysfunctional organization and management of the health system.24
Strategies for PHC improvement
Strategies to improve PHC are as numerous as the possible issues confronted and should be tailored to
each context according to the gaps identified through performance assessment and further investigation.
Several key functions have been identified, with each level of the health system playing a unique role to
support PHC performance improvement. At the community and facility levels, improvement efforts often
focus on improved community empowerment and increased engagement as well as CQI processes to
improve service delivery and performance. Within sub-national systems, PHC can be supported through
improved organization and management (including supportive supervision), ensuring necessary autonomy
and resources. At a national level, policies, financing, governance and leadership arrangements must create
an enabling environment that includes financial arrangements and incentives that are supportive of PHC and
its central role within the health system, a reorientation of the workforce including improved working
conditions, compensation mechanisms, and multi-professional teams, and policies that enable and reinforce
the critical functions of PHC.
In addition, there must be clear guidelines for how services should be coordinated both across levels of
the health sector (PHC and secondary or hospital care), and clear arrangements for interactions with the
private sector, including regulatory functions. The answers for how to achieve these changes should be
based upon the best available evidence with tailoring to country context. Civil society has a role to play at all
levels, particularly as it relates to accountability to improve areas of poor PHC performance.
Much of the necessary improvement requires political will to reorient health systems toward clear
objectives of high-quality PHC: effectiveness, equity, and health for all. This requires a revaluing of health
promotion, prevention and public health and facilitating intersectoral action, as well as moving away from
overinvestment in disease oriented efforts which do not take into account the overall disease burden and
reorienting resources away from specialized outpatient care and hospital inpatient care (so that each fills its
essential role in the most efficient way possible). In addition, it involves ensuring adequate funding,
appropriate training and important connections to other services and sectors. Progress requires increased
capacities to collect, organize, analyze, use and act on data – for policy making, managerial and
organizational decisions, and CQI processes.
Political, system, and resource constraints influence the ability to make necessary reforms to
prioritize PHC. As a result, stakeholders must come together to create an enabling environment for
transformational change. Necessary features include a favorable configuration of political forces around
health care reform, inclusive national health policy conversation; shared vision for health care and health
system development; health policy capacity in government, the health sector and the community; the level
and relevance of health policy research and the engagement research networks; and standards of integrity,
accountability and transparency. These features combined can bring about necessary changes in legislative
frameworks, financial arrangements and incentives, and the reorientation of the workforce and public
policy-making.25
23 As described in Strengthening Health Systems to improve health outcomes: WHO’s framework for action, the building blocks of a
health system include: service delivery; health workforce; information; medical products, vaccines and technologies; financing; and
leadership and governance (stewardship).
24 WHO. The World health report 2000: health systems: improving performance. http://www.who.int/whr/2000/en/whr00_en.pdf?ua=1
25 WHO. WHO Global strategy on people-centred and integrated health services: interim report. Geneva, Switzerland. 2015.
http://apps.who.int/iris/bitstream/10665/155002/1/WHO_HIS_SDS_2015.6_eng.pdf?ua=1

| P a g e 20
PHC improvement activities (current and future)
Numerous tools and mechanisms are in place
to facilitate improvement efforts. The process of
developing national health sector strategic plans and
reviews enables multi-stakeholder involvement and
investment to support a single country-led national
health strategy – in line with IHP+. In addition, through
PHCPI there is opportunity for the development of
ethical and evidence-based policy options as well as
normative standards and guidance documents for
common gaps in PHC system functioning. There are
current plans for the development of open access
tools, including a self-assessment guide for PHC
performance. This guide will be informed by scoping
reviews and strengths, challenges, and gaps in previous
PHC assessment efforts. Finally, the WHO is currently
developing an assessment guide for Integrated,
people-centred health services for use at the sub-
national level.
International partners may provide direct
technical support to build sustainable in-country
capacity. As discussed above, the development of a
research agenda, including operational research for
best practices for data analysis and use for decision-
making, is a key output in order to stimulate the
generation, translation, and dissemination of
important crosscutting themes for improving PHC
performance. 26 There is an opportunity for sharing
and application of best practices with innovation to
address local context. In addition, existing
communities of practice (Joint Learning Network,
Health Harmonization in Africa, and
IntegratedCare4People) offer an opportunity to share
experiences and creating new knowledge to advance
the field of data use for improvement in PHC.
The text box above demonstrates key questions relevant to PHC improvement and lists potential
deliverables for the global stakeholder community. A current situation analysis on improvement efforts is
being developed through analysis of pre-meeting surveys.
26 WHO Twelfth General Programme of Work: Not merely the absence of disease 2014-2019.
http://www.who.int/about/resources_planning/twelfth-gpw/en/
Key Questions:
 How can data producers and users work
together to identify key programmatic
questions, link these questions to available
data, and analyze the data to develop
improvement solutions?
 What other factors affect the process of using
data to guide the political process of allocating
health resources at the district and national
levels?
Potential Improvement Deliverables:
 Systematic review of improvement strategies in
primary health care
 PHC assessment tool linked to best practices
for improvement
 Set of tools to facilitate data quality
assessment & analysis through HDC working
groups
 Practices database relevant to: integrating
vertical programmes and measurement for
improvement (IntegratedCare4People)
 Implementation pathways
 Webinar on PHC improvement
 PHC Case studies (PRIMASYS, etc.) and analysis
for cross-cutting themes
 Prioritized literature made available through
the Health Systems Evidence platform in
partnership with McMaster University
 Communities of practice actively working on
improvement of data analysis and use for
decision making in PHC (JLN, HHA, IPCHS)
 Operational research on strategies to increase
data use at national, sub-national, facility and
community level
 Global Challenge for PHC Improvement

| P a g e 21
Advocacy
•Raise awareness of potential
of high performing PHC
systems to improve health
outcomes
•Draw attention to current
situation in PHC service
delivery
•Identify focal points and
champions
•Engage stakeholders
•Platform for sharing for
practices supporting PHC
reform (CoP)
Momentum
•3-5 Member States as early
signatories
•Evaluate PHC performance
•Identify areas for
improvement (some global,
some tailored)
•Co-development of pledge
•Global launch event
•Country level event with
cascading stakeholder
pledges
Support
•PHC performance
assessment tool linked to
improvement strategies
•Best practices
•Implementation pathways
•Technical assistance
•Resource allocation
•Follow-up
assessment/evaluation
Global Challenge for Primary Health Care Improvement
One such effort focused on performance improvement is a Global Challenge. Building upon processes
and lessons learned from previous patient safety campaigns (“Clean care is safer care”27 and “Safe
Surgery”28) WHO Service Delivery and Safety Department is proposing a Global Challenge for PHC
improvement as part of the PHCPI. Such an international and multistakeholder effort will increase
awareness of the potential of high-quality PHC, heighten participation and buy-in for PHC measurement and
improvement among Member States, and facilitate action on country-specific PHC priorities while offering a
platform for sharing best practices among countries that have prioritized similar areas for improvement.
This short-term advocacy and support strategy should reinforce the medium and long-term improvement
plans prioritized through NHPSP. Importantly, this challenge will provide resources and technical assistance
to countries seeking to prioritize PHC improvement within their national health strategy, aligned to national
planning cycles.
Figure 5. Theory of action - Global Challenge
Primary health care improvement requires multiple actions by actors across levels of the health system,
and, therefore, represents a larger technical challenge than previous campaigns, which targeted relatively
focused interventions such as hand washing and the safe surgery checklist. Therefore, a successful Global
Challenge for PHC Improvement will require additional assessment activities and efforts to adjust to country
heath system context. These assessment activities will build upon tools and guides being developed through
IPCHS, PHCPI, HDC and other relevant efforts.
As part of a global challenge, Member States co-develop a pledge with technical support from partners
that highlights the areas of that are targeted for improvement. This pledge is then signed as a
demonstration of commitment to improve. Given the context-specific nature of PHC reforms, decisions will
need to be made regarding the proportion of the Global Challenge pledge that will be standardized (i.e. all
countries could commit to improved monitoring and data use relevant to their PHC systems, or to increased
financial allocation toward PHC) and what proportion will be tailored to respond to an evaluation of current
PHC performance (I.e. pledges would address areas of performance below benchmarks).
Typically, such global challenges include a global launch event followed by regional or country level
launches. Given the decentralized, first-access nature of PHC, there is great potential to involve various
country level stakeholders in a country-level event, highlighting role-specific cascading pledges from all
27 WHO Service Delivery and Safety. Clean Care is Safer Care. http://www.who.int/gpsc/en/
28 WHO Service Delivery and Safety. Safe Surgery. http://www.who.int/patientsafety/safesurgery/en/

| P a g e 22
involved levels of the health sector (WHO representatives, ministries of health, monitoring and evaluation
experts, health system managers, providers – PHC and potentially specialty representatives, donor
governments and organizations, CSOs). Cascading pledges would highlight how various stakeholders intend
to contribute to national goals and objectives (i.e. If a country has pledged to increase provider competency,
ministries could discuss planning relevant to incentives, accreditation and continuing professional
development, while training institutions and professional organizations could highlight their respective
efforts to improve professional opportunities.)
Participants in the global challenge could also participate in relevant communities of practice or
partnerships for shared learning among countries that have identified similar objectives in order to facilitate:
networking and communication, research and development, education and training, technical support, and
evaluation and feedback.

| P a g e 23
Annex 1: Situation Analysis Measurement29
Technical area Existing platforms and initiatives Global investors
Country planning and investment
framework
 IHP+, country compacts, multi partner
coordination groups at country level, Civil Society
WHO, WB, GFATM, GAVI, USG, GFF, EC,
GIZ
CRVS  Regional strategies led by UN commissions
 CRVS Centre of Excellence (Canada)
 INDEPTH
 Data4Health
 Addressing Development Data Gaps including
CRVS (WBG)
Bilaterals (Canada ++)
World Bank and regional development
banks, GFF
UNICEF; WHO, UNSD, and other UN,
Bloomberg Philanthropies, GFATM,
BMGF
Population surveys, census &
population estimates
 International household survey network
 DHS-MICS- collaboration
 LSMS working group
 UN statistical commission expert group
 Addressing Development Data Gaps including
household surveys (WBG) UN Interagency working
groups (child mortality, maternal mortality,
WASH, immunization)
 IHME data work
USAID, UNICEF, World Bank, UNSD,
WHO, GAVI, GFATM, BMGF
Disease surveillance  Global Health Security Agenda
 Global Outbreak Alert and Response Network
WHO, USG, CDC, WBG
Health facility assessments  Interagency harmonization group (WHO, USAID,
World Bank, UNICEF)
 PHC Performance Initiative
 Specific quality of care initiatives
USAID, PEPFAR, GFATM, GAVI, WBG,
UNFPA, BMGF, PHCPI, UNICEF
Open approaches to facility and
community reporting
 DHIS academies
 Open HIE communities,
 RHINO, AeHIN, African Open data initiative,
 IHR, IDSR, GPHIN
 Health workforce
UNAIDS, PEFPAR
TGF, USAID
UNICEF, RBM HWG
NORAD, Measure Evaluation
Administrative data / Health
workforce / National health
accounts
 Health workforce information reference group USG, EU, bilateral donors, UNICEF, WHO,
other UN, BMGF, World Bank
National health accounts /
expenditure tracking
 WHO NHA
 WB PETS
WHO, World Bank, GIZ
Improving national HIS
institutional capacities
 Ministry of Health, national statistical offices,
National Institutes of Public Health
WHO, Paris21
Analytics, data use & open access  International Association Public health institutes
 USAID/Measure & WHO curriculum working group
PEPFAR, USAID; Measure Evaluation,
UNAIDS
Scorecards & profiles  Countdowns (MNCH, NCD; UHC), UNICEF/RMNCH,
Life-saving Commodities
 PHCPI
 Alma 2030, IHP+
Civil Society, ALMA, African Union,
AMDD, BMGF, World bank, USAID,
PEPFAR, UNICEF, GFF
29 The Health Data Collaborative Measurement, Performance and Learning for Accountability: Operational Work Plan 2016-2020. Version 1.2
18 December 2015

Anne
Domain Sub-Domain Indicators Data Sources
E. Outcomes E1. Health Status Maternal mortality ratio (per 100,000 live births) GHO
Adult mortality from non-communicable diseases GHO
Under-five mortality rate (per 1,000 live births) GHO
E3. Equity Equity: Under-five mortality wealth differential GHO
E4. Efficiency Efficiency: under five mortality rate relative to PHC spending per capita GHO, WHO SHA
D. Outputs D1. Effective Service
Coverage
Coverage Index UNICEF, WHO,
World Bank – W
Indicators
Antenatal care coverage (4+ visits) UNICEF
Contraceptive prevalence rate DHS
Children with diarrhea receiving appropriate treatment World Bank - W
Indicators
Diphtheria-tetanus-pertussis (DTP3) coverage UNICEF/WHO
Facility-based deliveries UNICEF
C. Service Delivery C1. Access Access barriers due to treatment cost DHS
C2. Availability of
Effective PHC
Services
Provider absence rate SDI
Diagnostic accuracy SDI
C3. People-Centered
Care
Continuity of care: Antenatal care dropout rate UNICEF
Continuity of care: Diphtheria-tetanus-pertussis (DTP3) dropout rate WHO/UNICEF
Continuity of care: Tuberculosis treatment success rate GHO
C4. Organization &
Management
Caseload per provider (daily) SDI
B. Inputs B1. Drugs & Supplies Minimum equipment availability SDI, SARA
Essential drug availability SARA, SPA
Vaccine availability SDI
B2. Facility
Infrastructure
Health center and health post density (per 100,000 population) GHO
B4. Workforce Community health worker, nurse, and midwife density (per 1,000
population)
GHO
A. System A2. Health Financing Percent of government health spending dedicated to PHC WHO SHA2011
Per capita primary health care expenditure (PPP) WHO SHA2011