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. 4. 5. 6. 7. 8. 9. 10 Principles of the Health System Rapid Assessment .................................................................... 6 The team to conduct the Health System Rapid Assessment ...................................................... 7 The five steps of the Health System Rapid Assessment ............................................................. 8 Step 1: A concise description of our health system .................................................................... 9 Step 2: Building blocks .............................................................................................................. 15 Step 3: The health system as a whole: synergies, gaps, obstacles, bottlenecks ...................... 38 Step 4: Deciding priorities for changes and sharing these with stakeholders .......................... 42 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

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

Everybodys Business: Strengthening Health Systems to Improve Health Outcomes: WHOs 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.

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.

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/

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.

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.

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

Figure 2: Framework for health systems assessment for maximizing health outcomes related to MDGs 4, 5 and 65

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.

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

Figure 3: The five steps of the Health System Rapid Assessment 5

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, noncommunicable 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.

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.

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 countrys 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.

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.

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?

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 Latest available data and source Latest data, and trends over the last 3-5 years

Indicator

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

Latest available data and source Latest data and trends over 3-5 years

Indicator

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 Latest available data and source Latest data and trends over 3-5 years

Indicator

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

Governance

Financing

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

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

Specific diseases or sets of health concerns Immunization

Guiding question: To what extent is the necessary leadership, policy, planning and organisational support in place to adequately address the health issue?

Guiding question: Is there enough money available for this health issue, given the burden of disease and the need to ensure adequate access?

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?

Guiding question: To what extent are there good quality services being delivered and taken up by the people who need them?

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 Q1 GOVERNANCE leading questions 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? 15

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

Latest available data Comment on trends over last 3-5 years

Indicator

Remarks

How many health offices are there at subnational levels (e.g. Departments of Health)? How many sub-national entities have health strategic plans based on evidence and multisectoral 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 Q1 FINANCING leading questions 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 dont 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.
Latest available data and source Comment on trends over last 3-5 years

Indicator

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

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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?

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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

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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 Q1 HUMAN RESOURCES leading questions 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 countrys 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?

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7.3.2

HUMAN RESOURCES indicative statistics

Latest available data and source Comment on trends over last 3-5 years

Indicator

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?

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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

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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 Q1 INFORMATION leading questions 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. 26 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)

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?

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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?

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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

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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?

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7.5.2

MEDICAL PRODUCTS, VACCINES AND TECHNOLOGIES indicative statistics

Latest available data and source Comment on trends over last 3-5 years

Indicator

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

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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? 32

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

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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 Q1 SERVICE DELIVERY leading questions 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?

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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.
Latest available data and source Comment on trends over the last 3-5 years

Indicator

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?

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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?

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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

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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?

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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 pros and cons 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)?

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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

Governance

Financing

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

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

Specific diseases or sets of health concerns Immunization

Guiding question: To what extent is the necessary leadership, policy, planning and organisational support in place to adequately address the health issue?

Guiding question: Is there enough money available for this health issue, given the burden of disease and the need to ensure adequate access?

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?

Guiding question: To what extent are there good quality services being delivered and taken up by the people who need them?

HIV/AIDS

Tuberculosis

Malaria

Maternal health

Child health

Adolescent health Health Ageing Neglected Tropical Diseases Non Communicable Diseases Emerging Infectious Diseases

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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?

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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 Stakeholders Meeting The team should decide what will be presented, by whom and how.

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.

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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 Stakeholders 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.

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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

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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

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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. Service outputs indicators: these measure the adequacy of the service delivery system in terms of accessibility, quality and image. Service utilization indicators: these measure the extent to which the services are used.

(b)

(c)

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 cant 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.

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