Web Annex. Technical specifications Primary health care measurement framework and indicators: monitoring health systems through a primary health care lens
Web Annex. Technical specifications Primary health care measurement framework and indicators: monitoring health systems through a primary health care lens Primary health care measurement framework and indicators: monitoring health systems through a primary health care lens. Web Annex. Technical specifications ISBN (WHO) 978-92-4-004423-4 (electronic version) © World Health Organization and the United Nations Children’s Fund (UNICEF), 2022 This joint report reflects the activities of the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. 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The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO or UNICEF be liable for damages arising from its use. This publication forms part of the document entitled Primary health care measurement framework and indicators: monitoring health systems through a primary health care lens. It is being made publicly available for transparency purposes and information. Contents Acknowledgments ...............................................................................................................................iv Abbreviations .......................................................................................................................................vi Introduction ...........................................................................................................................................1 1. Overview of indicators for monitoring primary health care .....................................................4 2. Indicators for monitoring primary health care with metadata ...............................................18 2.1 Governance indicators ...........................................................................................................19 2.2 Indicators of adjustment to population needs ........................................................................30 2.3 Financing indicators ...............................................................................................................34 2.4 Physical infrastructure indicators ............................................................................................47 2.5 Health workforce indicators ...................................................................................................52 2.6 Medicines and other health products indicators .....................................................................57 2.7 Health information indicators .................................................................................................66 2.8 Digital technologies for health indicators ...............................................................................75 2.9 Models of care indicators .......................................................................................................79 2.10 Systems for improving quality of care indicators ...................................................................104 2.11 Resilient health facilities and services indicators ....................................................................105 2.12 Access and availability indicators ..........................................................................................107 2.13 Quality care indicators .........................................................................................................121 2.14 Additional hospital-oriented indicators .................................................................................136 3. Cross-cutting indicators for monitoring quality, equity and resilience ................................146 3.1 Quality indicators ...................................................................................................................147 3.2 Equity indicators ....................................................................................................................149 3.3 Resilience indicators ..............................................................................................................151 Acknowledgements WHO Primary Health Care Monitoring and Evaluation Technical Steering Group This framework and guidance was produced under the overall joint leadership of the WHO Primary Health Care Monitoring and Evaluation Technical Steering Group under the direction of Dr Ed Kelley (Integrated Health Services) and Dr Suraya Dalil (WHO Primary Health Care Special Programme). Technical coordination and development of this guidance was led by Kathryn O’Neill, Shannon Barkley, Chelsea Taylor and Briana Rivas-Morello. Significant contributions were provided by the following technical steering group members: WHO headquarters: Mathieu Boniol, Khassoum Diallo, John Fogarty, Ann-Lise Guisset, Dirk Horemans, Jee-Ae Kim, Inke Mathauer, Hernan Montenegro, Denis Porignon,Teri Reynolds, Sohel Saikat, Gerard Schmets, Shamsuzzoha Syed, Kavitha Viswanathan (consultant) and Ke Xu; WHO Regional Office for Africa: Humphrey Karamagi, Hyppolite Kalambay Ntembwa and Benson Droti; WHO Regional Office for the Americas/Pan American Health Organization: Amalia del Riego and James Fitzgerald; WHO Regional Office for Europe: Melitta Jakab and Tomas Zapata; WHO Regional Office for South-East Asia: Manoj Jhalani and Mark Landry; WHO Regional Office for the Eastern Mediterranean: Awad Mataria, Arash Rashidian and Hassan Salah; and WHO Regional Office for the Western Pacific: Jun Gao and Martin Taylor. Primary Health Care Performance Initiative Partners of the Primary Health Care Performance Initiative (PHCPI) provided substantial technical contributions to the development of the conceptual framework and indicators and merit particular acknowledgement: Ben Chan, Federica Secci and Manuela Villar Uribe (World Bank), Balaji Lakshmi Narasimhan (UNICEF), Laurel Hatt and Emma Stewart (Results for Development), Jeff Markuns and Beth Tritter (PHCPI secretariat), Hannah Ratcliffe and Dan Schwarz (Ariadne Labs), and Ethan Wong (Bill and Melinda Gates Foundation). UNICEF WHO expresses its gratitude to UNICEF colleagues for the joint coordination of this publication and important contributions: Julianne Birungi, Anne Detjen, Hannah Sarah Dini, Rania Elessawi, David Hipgrave, Maureen Kerubo Momanyi, Elevanie Nyankesha, Anu Puri, Jennifer Requejo, Rie Takesue and Claudia Vivas. Organisation for Economic Co-operation and Development The following Organisation for Economic Co-operation and Development (OECD) colleagues reviewed and provided valuable feedback to the framework and indicators: Eliana Barrenho, Caroline Berchet, Katherine Debienassis and Niek Klazinga. Additional technical contributors WHO wishes to thank the following WHO technical staff and consultants who reviewed and provided inputs into development of this framework and guidance: WHO headquarters: Faten Ben Abdelaziz, Jonathan Abrahams, Anna Aceves Capri, Benedetta Allegranzi, Luke Allen, Jotheeswaran Amuthavalli Thiyagarajan, Laura Anderson, John Aponte Varon, Melanie Bertram, Michel Beusenberg, Nelly Biondi, Gautam Biswas, Elaine Borghi, Marie-Charlotte Bouesseau, Francesco Branca, Abril Campos Rivera, Diana Chang Blanc, Neerja Chowdhary, Alarcos Cieza, David Clarke, Carolina Danovaro, Wouter De Groote, Neelam Dhingra-Kumar, Theresa Diaz, Marie Donaldson, Tarun Dua, Tessa Edejer, Farshad Farzadfar, Gabriela Flores, Katherine Floyd, Gilles Forte, Dongbo Fu, Marta Gacic-Dobo, Philippe Glaziou, Bruce Gordon, Fern Greenwell, Richard Gregory, Jan Grevendonk, Nikhil Gupta, Regina Guthold, Elizabeth Gwyther, Naofumi Hashimoto, Sara Hollis, Khondkar Rifat Hossain, Ahmadreza Hosseinpoor, Qudsia Huda, Young Jeong, Richard Johnston, Matthew Jowett, Vijay Kannan, Kanokporn Kaojaroen, Elizabeth Katwan, Rania Kawar, Ghazanfar Khan, Pauline Kleinitz, Kira Koch, Theadora iv Koller, Joseph Kutzin, Benjamin Lane, Daniel Low-Beer, Alpana Mair, Robert Marten, Bruno Meessen, Nana Mensah Abrampah, Ann-Beth Moller, Margaret Montgomery, Allisyn Moran, Francis Moussy, Hani Mowafi, Saqif Mustafa, Moise Muzigaba, Matthew Neilson, Maria Neira, Abdisalan Noor, Asiya Odugleh-Kolev, Irina Papieva, Annette Prüss-Ustün, Arlene Quiambao, Dheepa Rajan, Ankur Rakesh, Anna Ray, Pryanka Relan, Francesco Ribolzi, Leanne Riley, Alastair Robb, Lisa Rogers, Benjamin Rouffy- Ly, Aurora Saares, Giovanni Sala, Julia Sallaku, Lale Say, Redda Seifeldin, Charalampos Sismanidis, Slim Slama, Samir Sodha, Agnes Soucat, Rajesh Sreedharan, Karin Stenberg, Julie Storr, Kathleen Strong, Ayda Taha, Jia Tan, Florian Tille, Jørgen Torgerstuen Johnsen, Nuria Toro Polanco, Anthony Twyman, Temo Waqanivalu, Nicole Valentine, Mark Van Ommeren, Cherian Varghese, Adriana Velazquez Berumen, Wendy Venter, Diana Zandi and Zandile Zibwowa; WHO Regional Office for Africa: Gertrude Avortri, Nonso Ejiofor, Lokombe Elongo, Hillary Kipruto, Aminata Seydi, Regina Titi-Ofei and Prosper Tumusiime; WHO Regional Office for the Americas/Pan American Health Organization: Ernesto Bascolo, Jonas Gonseth-Garcia, Natalia Houghton and Hernan Luque; WHO Regional Office for Europe: Liesbeth Borgermans, Stefania Davia, Ayesha De Lorenzo, Antoni Dedeu, Anne Johansen, Arnoldas Jurgutis, David Novillo Ortiz, and Robert West; WHO Regional Office for South-East Asia: Anjana Bhushan, Ibadat Dhillon, Sangeeta Jasmine, Alaka Singh, Hui Wang and Masahiro Zakoji; WHO Regional Office for the Eastern Mediterranean: Ali Ardalan, Hagar Azab, Henry Doctor, Faraz Khalid, Mondher Letaief and Yara Saleh; WHO Regional Office for the Western Pacific: Peter Cowley, Ogochukwu Chukwujekwu and Mengjuan Duan; and WHO country offices: Tasmia Islam, Sultan Murad, Md. Nuruzzaman and Sangay Wangmo (Bangladesh); Hilde De Graeve and Dilip Mairembam Singh (India); Rajesh Sambhajirao Pandav (Nepal); Thomas Valdez (Mozambique); Kabinda Maotela Jeff (Senegal); Sudirikku De Silva, Shreenika Desilva, Olivia Nieveras, Roshan Sampath, Rajani Ved (Sri Lanka); Vinay Bothra (Timor-Leste). In addition, WHO thanks the following experts who participated in the Delphi process and contributed to the selection of the indicators: Samy Alsirafy, Kasr Al-Ainy School of Medicine, Cairo University; Ties Boerma, University of Manitoba/WHO Collaborating Centre; Gianluca Cafagna, World Bank; Stephen Connor, Worldwide Hospice Palliative Care Alliance; Jan De Maeseneer, WHO Collaborating Centre on Family Medicine and Primary Health Care, Ghent University, Department of Public Health and Primary Care; Eric de Roodenbeke, International Hospital Federation; Denizhan Duran, World Bank; Yutaka Endo, UNICEF; Erin Ferenchick, Global Fund to Fight AIDS, Tuberculosis and Malaria; Cynthia Goh, National Cancer Centre Singapore/Singhealth Duke-NUS Global Health Institute; Nicholas Goodwin, University of Newcastle, Australia; Lisa Hirschhorn, Northwestern University Feinberg School of Medicine; Amanda Howe, World Organization of Family Doctors; Otmar Kloiber, World Medical Association; Eric L. Krakauer, Harvard Medical School/Massachusetts General Hospital; Margaret Kruk, Harvard T.H. Chan School of Public Health; Guilhem Labadie, UNICEF; Peter Lachman, ISQua; Andrew Likaka, Ministry of Health, Malawi; James Macinko, University of California, Los Angeles; Don Matheson, Ministry of Health, New Zealand; Alberto Meléndez, Osakidetza; Sergio Minué-Lorenzo, Escuela Andaluza de Salud Pública; Kamaliah Binti Mohamad Noh, University of Cyberjaya; Shabir Moosa, World Organization of Family Doctors Africa; Ahmad Jan Naeem, Management Sciences for Health; Anthony Ofosu, Ghana Health Service; Hibah Osman, Dana Farber Cancer Institute; Luisa Pettigrew, London School of Hygiene and Tropical Medicine; Robert Phillips, American Board of Family Medicine Center for Professionalism and Value in Health Care; Lukas Radbruch, International Association for Hospice and Palliative Care; Jon Eliot Rohde, retired from Management Sciences for Health; Alexander Rowe, Global Fund to Fight AIDS, Tuberculosis and Malaria; Kelly Saldana, USAID; Miguel Antonio Sánchez-Cárdenas, University of Navarra; Kawaldip Sehmi, International Alliance of Patients Organizations; Leiyu Shi, Johns Hopkins University; and Jose M. Valderas, University of Exeter. WHO would like to thank the following partners for financial contributions towards the development of this guidance: the Bill & Melinda Gates Foundation, the government of the Republic of Korea, and the UHC Partnership (funded by the European Union, Luxembourg, France, Ireland, Japan, DFID and Belgium). v Abbreviations CHW community health worker CPD continuing professional development CRS creditor reporting system CRVS civil registration and vital statistics DAC Development Assistance Cooperation EPHF essential public health functions GDP gross domestic product GIS geographical information system GPW13 Thirteenth General Programme of Work 2019–2023 HBP health benefits package HHFA harmonized health facility assessments HiAP health in all policies HMIS health management information systems ICT information and communication technologies IHR International Health Regulations IPC infection prevention and control IPCAF Infection Prevention and Control Assessment Framework IVD in vitro diagnostic M&E monitoring and evaluation MCH maternal and child health NCD noncommunicable disease NHA national health account NHPS national health policy and strategy NHRIS national human resource information system NHWA national health workforce accounts NPHI national public health institute ODA official development assistance PHC primary health care POC point of care RDT rapid diagnostic test RHIS routine health information systems SARA service availability and readiness assessments SCORE survey population health risks; count births, deaths and causes of death; optimize health service data; review progress and performance; enable data use for policy and action SDG Sustainable Development Goal SPA service provision assessment SPAR state party annual report TB tuberculosis UHC universal health coverage WASH water, sanitation and hygiene vi Introduction This document provides technical specicfications for each indicator included in the the menu of indicators proposed for primary health care (PHC) measurement framework and indicators. In the first section below, Tables 1.1 and 1.2 provide a summary overview of the menu of indicators, including brief definitions, possible disaggregations, level of data, and preferred data source. This is then followed by detailed metadata for each indicator. Metadata tables include additional information such as definitons (including details on key criteria and or attributes), numerator and denominator, rationale for the indicator, references, and available data collection tools as and where relevant. Indicators that are of significant value for monitoring dimensions of quality, equity, and resilience across the entire framework are marked with superscripted text. As quality, equity and resilience have been highlighted as key cross-cutting monitoring dimensions in the PHC measurement framework, the second section of this document includes tables 3.1, 3.2, 3.3 that list specific indicators to help monitor these dimensions. Figure 1 presents the PHC performance measurement framework and indicators, demonstrating how measuring PHC contributes to monitoring UHC, health-related SDGs, and overall impact on health and well-being. Many of the indicators (particularly those that assess outcomes and impact) draw from globally agreed standards, including the Global indicator framework for the Sustainable Development Goals and the WHO Thirteenth General Programme of Work 2019–2023 (GPW 13) Impact Framework. Other indicators are more novel and have been included to address critical areas of PHC measurement. These indicators will require further testing and development. As such, these technical specifications will be reviewed and refined regularly to take account of lessons learned from experiences applying the framework as well as new approaches to measuring PHC that emerge over time. 1 UHC - Service coverage UHC service coverage (index) [SDG 3.8.1] Service intervention coverage - Family planning demand satisfied with modern methods [SDG 3.7.1] - ANC4 - Child immunization coverage (DTP3) [SDG 3.b.1] - Care-seeking for suspected pneumonia - TB treatment - HIV ART - Use of insecticide-treated nets (ITN) - Children receiving ACT among those with fever - Population with basic sanitation (WASH) - Hypertension treatment coverage - Diabetes treatment coverage - Cervical cancer screening - Availability of essential medicines - Skilled birth attendance [SDG 3.1.2] - Number of people requiring interventions against NTDs [SDG 3.3.5] - Coverage of interventions for substance-abuse disorders [SDG 3.5.1] - AMR blood stream infections - Patterns of antibiotic consumption UHC - Financial protection Proportion of population with large/impoverishing household expenditure on health as share of total household expenditure of income [SDG 3.8.2] Health security IHR/SPAR capacity [SDG 3.d.1] Routine/emergency vaccine coverage [SDG 3.b.1] Timeliness of emergency detection and reporting Proportion of vulnerable people in fragile settings provided with EHS Number of cases of poliomyelitis caused by wild poliovirus Figure 1 PHC measurement framework and menu of indicators (including outcomes and impact indicators) Health systems determinants Structures Physical infrastructure* Health facility density and distribution (including primary care) Availability of basic WASH amenities Availability of power and communications - Bed density (inpatient only)** Access to emergency transport for inter-facility transfer Health workforce* Health worker density and distribution [SDG 3.c.1] Accreditation mechanisms for education and training institutions National systems for continuing professional development Medicines & other health products* Regulatory mechanisms for medicines Availability of essential medicines [SDG 3.b.3] Availability of essential in vitro diagnostics Availability of priority medical equipment and other medical devices Health information Information systems Completeness of reporting by facilities Percentage of facilities using comprehensive patient records Regular system of facility and patient surveys Functional national human resource information system Completeness of birth registration Completeness of death registration Regular system of population-based health surveys Surveillance Existence of effective surveillance system Digital technologies for health* National e-health strategy Telemedicine access Percentage of facilities using electronic health records Models of care* Selection and planning of services Service package meeting criteria Roles and functions of service delivery platforms and settings defined Service design Existence of an empanelment system System to promote first contact accessibility Protocols for patient referral, counter-referral and emergency transfer Existence of care pathways for tracer conditions Organization and facility management Professionalization of management Management capability and leadership Multidisciplinary team-based service delivery Existence of supportive supervision system Existence of facility budgets and expenditures meeting criteria Community linkages and engagement Collaboration between facility- based and community-based service providers Community engagement in service planning and organization Proactive population outreach Services for self-care and health literacy in primary care Systems for improving quality* Percentage of facilities with systems to support quality improvement Resilient health facilities and services Percentage of facilities meeting criteria for resilient health facilities and services Governance Political commitment & leadership* Health in all policies with multisectoral coordination Existence of right to health legislation Governance & policy frameworks* Existence of national health policy oriented to PHC and UHC Existence of policy, strategy or plan for improvement of quality and safety Existence of health emergency and disaster risk management strategies Institutional capacity to meet essential public health functions and operations Engagement with communities and other stakeholders* Coordination mechanisms with multistakeholder participation and community engagement National, sub-national and local strategies for community participation Engagement with private sector providers* Evidence of effective stewardship of mixed health systems Adjustment to population needs Monitoring and evaluation* Priority setting is informed by data & evidence Existence of an M&E framework for national health plan meeting criteria PHC oriented research Total net ODA to medical research & basic health sector Percentage of public research funding for primary care research Financing Funding and allocation of resources* Current expenditure on health (total and PHC specific) as a percentage of gross domestic product (GDP) Per capita health expenditure on health (& PHC- specific) Government PHC spending Sources of expenditure on health (& PHC-specific) Contingency funds available for emergencies Purchasing & payment systems* Services included in health benefits package (including primary care) Purchasing and provider payment methods are in place (including primary care) Health financing follows established guidelines Processes Health system objectives Access and availability Accessibility, affordability, acceptability Geographical access to services Perceived barriers to access due to (distance, cost, sociocultural) Access to emergency surgery Existence of a system of post-crash care Service availability and readiness Percentage of facilities offering services according to national defined service package Provider availability (absence rate) Percentage of facilities meeting minimum standards to deliver tracer services Percentage of facilities compliant with infection prevention and control (IPC) measures Utilization of services Outpatient visits Emergency unit visits Hospital discharges Leading diagnoses (primary care/outpatient visits, inpatient diagnoses at discharge) Quality care Core primary care functions (first-contact accessibility, continuity, comprehensiveness, coordination, people-centredness) Patient-reported experiences People’s perceptions of health system and services Effectiveness Diagnostic accuracy (provider knowledge) Adherence to clinical standards for tracer conditions 30-day hospital case fatality rate (for acute myocardial infarction or stroke) Avoidable complications (lower limb amputation in diabetes) Hospital readmission rate for tracer conditions Admissions for ambulatory care sensitive conditions - Institutional mortality Safety Prescribing practices for antibiotics Proportion of people 65 years and over prescribed antipsychotics - Caesarean section rate - Postoperative sepsis - Postoperative pulmonary embolism - Postoperative deep vein thrombosis - Perioperative mortality rate - Hospital-acquired infections Efficiency Provider caseload Bed occupancy Timely access Cancer stage at diagnosis (by cancer) - Coverage of timely emergency resuscitation at first-level hospitals Waiting time to elective surgery Improved health status Healthy life expectancy Life expectancy Avoidable mortality Probability of premature death from NCDs [SDG 3.4.1] Maternal mortality rate [SDG 3.1.1] Neonatal mortality rate [SDG 3.2.2] Under-five mortality rate [SDG 3.2.1] Mortality rate due to air pollution [SDG 3.9.1] Mortality rate due to unsafe WASH [SDG 3.9.2] Mortality rate from unintentional poisoning [SDG 3.9.3] Suicide mortality [SDG 3.4.2] Road deaths [SDG 3.6.1] New HIV infections [SDG 3.3.1] TB incidence [SDG 3.3.2] Malaria incidence [SDG 3.3.3] Hepatitis B [SDG 3.3.4] Cancer incidence Responsiveness Equity Within-country inequalities reduced Outcomes ImpactOutputs Monitoring Quality, Equity, Resilience Monitoring capacity of PHC Monitoring performance of PHC Monitoring impact Determinants of health and risk factors Focus of the PHC monitoring conceptual framework Tier 1 indicators (n=39) Tier 2 indicators (n=48) - Grey text: additional hospital-oriented indicators * PHC strategic & operational levers In te g ra te d h ea lt h s er vi ce s M u lt is ec to ra l p o lic y an d a ct io n Em p o w er ed p eo p le & c o m m u n it ie s Service delivery [promotion, prevention, diagnosis, treatment, rehabilitation, palliation] PHCcomponents Tobacco use [SDG 3.a.1] Prevalence of hypertension Prevalence of diabetes Child stunting/wasting/overweight [SDG 2.2.1/2.2.2] Child development [SDG 4.2.1] Alcohol consumption [SDG 3.5.2] Clean household fuels [SDG 7.1.2] Air pollution level in cities [SDG 11.6.2] No. of people affected by disasters [SDG 1.5.1/11.5.1/13.1.1] Obesity (adults and children) [WHA 66.10] Trans fats policy [WHA 66.10] Intimate partner violence [SDG 5.2.1] Informed sexual choice Female genital mutilation /cutting [SDG 5.3.2] Adolescent birth rate [SDG 3.7.2] Non-partner sexual violence [SDG 5.2.2] Violence against children [SDG 16.2.1] Safely managed water and sanitation [SDG 6.1.1/6.2.1a/6.2.1b] towards achievement of UHC and the SDGs From PHC-oriented health systems 1. Overview of indicators for monitoring primary health care 4 Table 1. Summary overview of indicators: primary health care monitoring N Indicator Definition Disaggregations (Details in document) Level Preferred data source Tier Governance Political commitment and leadership 1 Health in all Policies (HiAP) with multisectoral coordination The country has implemented an HiAP approach that includes key elements (see technical specifications) Not applicable National Subnational Qualitative assessment Tier 1 + Global 2 Existence of right to health legislation The country has an enabling legal environment for universal health coverage (UHC) that includes key elements (see technical specifications) Not applicable National Subnational Qualitative assessment Tier 2 Governance and policy frameworks 3 Existence of national health policy oriented to PHC and UHC The country has a national health sector policy, strategy oriented to PHC and UHC based on minimum standards (see technical specifications) Not applicable National Subnational Qualitative assessment Tier 1 + Global 4 Existence of policy, strategy, or plan for improvement of quality and safety There is a validated national strategic direction on quality and safety, measured against key criteria (see technical specifications) Not applicable National Subnational Qualitative assessment Tier 1 + Global 5 Existence of health emergency and disaster risk management strategies There is a health emergency and disaster risk management strategy that is measured against key criteria (see technical specifications) Not applicable National Subnational Qualitative assessment Tier 1 6 Institutional capacity to meet essential public health functions and operations There is a public health institution or entity that carries out key public health functions (see technical specifications. Not applicable National Subnational Qualitative assessment Tier 2 Engagement with communities and other multisectoral stakeholders 7 Coordination mechanisms with multistakeholder participation and community engagement A national coordination mechanism for PHC toward UHC exists and meets key criteria (see technical specifications) Not applicable National Subnational Qualitative assessment Tier 1 + Global 8 Existence of national, subnational and local strategies for community participation Strategies exist to promote and support community engagement in defining and monitoring objectives of the national health plans/strategies and follow minimum standards (see technical specifications) Not applicable National Subnational Qualitative assessment Tier 2 Engagement with private sector providers 9 Evidence of effective stewardship of mixed health systems There is a national policy, strategy or plan guiding the engagement of private sector providers in health service delivery sector that follow WHO recommended behaviours (see technical specifications) Not applicable National Subnational Qualitative assessment Tier 2 5 N Indicator Definition Disaggregations (Details in document) Level Preferred data source Tier Adjustment to population health needs Monitoring & evaluation 10 Priority setting is informed by data and evidence Priority setting in the national health strategic plan/policy is based on data and evidence, and is measured against key criteria (see technical specifications) Not applicable National Subnational Facility Qualitative assessment Tier 1 11 Existence of an M&E framework for national health plan meeting criteria The country’s national health plan and policies include an M&E plan with a focus on PHC for UHC Not applicable National Subnational Qualitative assessment Tier 1 PHC-oriented research 12 Total net official development assistance (ODA) to medical research and basic health sector Total net ODA to the medical research and basic health sectors is currently measured by the gross disbursements of total ODA from all donors to medical research and basic health sectors Not applicable National Subnational Global database Tier 1 13 Percentage of public research funding for primary care research Percentage of public research funding devoted to primary care research Not applicable National Subnational Qualitative assessment Tier 2 Financing Funding and allocation of resources 14 Current expenditure on health (total and PHC- specific) as percentage of gross domestic product (GDP) Total (and PHC-specific) current expenditure on health as a percentage of GDP Current and total PHC-specific expenditure Source of funding (e.g., GGHE-D, private, external) National Subnational National health accounts Tier 1 15 Per capita health total health expenditure (and PHC-specific) Per capita health expenditure (total and PHC-specific) Current and total PHC-specific expenditure Source of funding (e.g., GGHE-D, private, external) National Subnational National health accounts Tier 1 + Global 16 Government PHC spending as percentage of government health expenditure Domestic general government expenditure on PHC as a share of domestic general government health expenditure Not applicable National Subnational National health accounts Tier 1 + Global 17 Sources of expenditure on health (and PHC- specific) Distribution of expenditure on health by source (private (including out of pocket), domestic government, external) Current and total PHC-specific expenditure Source: out of pocket, domestic government, external National Subnational National health accounts Tier 2 18 Contingency funds available for emergencies Contingency funds available for emergencies measured against key criteria National Subnational National Subnational Qualitative assessment Tier 2 6 N Indicator Definition Disaggregations (Details in document) Level Preferred data source Tier Purchasing and payment systems 19 Services included in health benefits package (HBP) (including primary care) HBP defines a set of services to be financed from public sources that have been assessed for inclusion in the benefit package as part of a systematic, transparent process, including criteria on economic evidence and budget impact/cost- effectiveness Type of service Disease area/life- course need Delivery platform National Subnational Qualitative assessment Tier 1 20 Purchasing and provider payment methods are in place (including primary care) Purchasing and provider payment methods are in place as measured against key criteria Not applicable National Subnational Qualitative assessment Tier 2 21 Health financing follows established guidelines Health financing (or access to HBP or insurance scheme) follows WHO-recommended guidelines, including key criteria (see technical specifications) Not applicable National Subnational Qualitative assessment Tier 2 Physical infrastructure 22 Health facility density/ distribution (including primary care) Total number of health facilities (and primary care facilities) per 10 000 population, disaggregated by managing authority Facility type Managing authority Subnational Urban/rural National Subnational Facility Facility census Tier 1 + Global 23 Availability of basic water, sanitation and hygiene (WASH) amenities Percentage of facilities that have basic WASH amenities (see technical specifications) Facility type Managing authority Urban/rural National Subnational Facility Facility survey Tier 1 + Global 24 Availability of power Percentage of facilities that use, at least some of the time, any source of electrical power, excluding standalone medical devices Facility type Managing authority Subnational Urban/rural National Subnational Facility Facility survey Tier 1 25 Availability of communications Percentage of facilities that have access to communication systems including key attributes (see technical specifications) Facility type Managing authority Subnational Urban/rural National Subnational Facility Facility survey Tier 1 26 Access to emergency transport for interfacility transfer Percentage of facilities that have access to emergency transport, measured by having key components (see technical specifications) Facility type Managing authority Urban/rural National Subnational Facility Facility survey Tier 2 Health workforce 27 Health worker density and distribution Number of health workers per 10 000 population, by occupation Activity level Occupation Facility type Gender, Age Managing authority Location National Subnational NHWA Tier 1 + Global 7 N Indicator Definition Disaggregations (Details in document) Level Preferred data source Tier 28 Accreditation mechanisms for education and training institutions There are national and/or subnational mechanisms for accreditation of education and training institutions, health care organizations, and their programmes, measured against key criteria (see technical specifications) Occupation National Subnational NHWA Tier 2 29 National systems for continuing professional development There is a national system for continuing professional development, measured against key criteria (see technical specifications) Occupation National NHWA Tier 2 Medicines and other health products 30 Regulatory mechanisms for medicines There are regulatory mechanisms for medicines, measured against key criteria (see technical specifications) Not applicable National Subnational Qualitative assessment Tier 2 31 Availability of essential medicines Percentage of health facilities that have a core set of relevant essential medicines available and affordable on a sustainable basis (Sustainable Development Goal (SDG) indicator) Facility type Managing authority Subnational Urban/rural National Subnational Facility Facility survey Tier 1 + Global 32 Availability of essential in vitro diagnostics Percentage of health facilities that have an appropriate set of diagnostics for their health care facility level, based on the WHO’s model list of essential in vitro diagnostics (EDL 3) Facility type Managing authority Subnational Urban/rural National Subnational Facility Facility survey Tier 2 33 Availability of priority medical equipment and other medical devices Percentage of health facilities with availability of essential equipment and other health products Facility type Managing authority Subnational Urban/rural National Subnational Facility Facility survey Tier 2 Medicines and other health products Information systems 34 Completeness of reporting by facility Percentage of facilities that uses information systems for capturing and reporting comprehensive patient and facility data and report according to district and/or national requirements within the required deadline Facility type Managing authority Subnational Urban/rural Service area (immunization, MCH, etc.) National Subnational RHIS Tier 2 35 Percentage of facilities using comprehensive patient records Percentage of facilities using single, comprehensive patient records that provide a longitudinal health history of patients across time and for all health conditions and which includes key components (see technical specifications) Facility type Managing authority Subnational Urban/rural National Subnational Facility Facility survey Tier 2 36 Regular system of facility and patient surveys Country has a regular system of facility and patient surveys to independently monitor health services and patient perspectives. Not applicable National Subnational Qualitative assessment Tier 2 N Indicator Definition Disaggregations Level Preferred data source Tier 8 N Indicator Definition Disaggregations (Details in document) Level Preferred data source Tier 37 Functional national human resource information system NHRIS and national health workforce NHWA NHRIS is in place and functional and can generate key required HR information (see technical specifications) Not applicable National Subnational NHRIS NHWA Tier 1 38 Completeness of birth registration 1. Percentage of births that are registered 2. Proportion of children under 5 years of age whose births have been registered with a civil authority. (both definitions are used) Subnational National Subnational CRVS Population- based survey Tier 1 39 Completeness of death registration Percentage of deaths that are registered (with age and sex) and include valid cause-of-death Subnational National Subnational CRVS Tier 1 40 Regular system of population-based health surveys Country can generate regular, comprehensive, high-quality, nationally representative statistics with equity dimensions on population health status, health-related behaviours and risk factors, access to health interventions and out-of-pocket spending on health Not applicable National Qualitative assessment Tier 2 Surveillance 41 Existence of effective surveillance system Country has an effective surveillance system based on the average of two SPAR indicators on early warning function (C6.1) and mechanisms for event management (C6.2) (see technical specifications) Not applicable National SPAR Tier 1 Digital technologies for health 42 National eHealth strategy There is a national digital/eHealth strategy that includes key criteria (see technical specifications) Not applicable National Subnational Qualitative assessment Tier 2 43 Telemedicine access Percentage of patients that have had at least one virtual health consultation in the past 12 months Facility type National Subnational Qualitative assessment Tier 2 44 Percentage of facilities using electronic health records Percentage of facilities with a system of electronic capture of patient-level health data (patient records system) with following attributes (see technical specifications) Facility type Managing authority Subnational Urban/rural National Subnational Facility Facility survey Tier 1 N Indicator Definition Disaggregations Level Preferred data source Tier 9 N Indicator Definition Disaggregations (Details in document) Level Preferred data source Tier Models of care Selection and planning of services 45 Service package meeting criteria Service package of essential health services (including primary care services) and public health functions is developed and meets set criteria (see technical specifications) Not applicable National Subnational Qualitative assessment Tier 1 + Global 46 Roles and functions of service delivery platforms and settings defined The roles and functions of service delivery platforms, including scope of services, are defined within the context of integrated health service delivery networks (see technical specifications) Not applicable National Subnational Qualitative assessment Tier 1 Service design 47 Existence of an empanelment system An empanelment system exists and is measured by key criteria (see technical specifications) Subnational Urban/rural Gender Wealth quintiles National Subnational Population- based survey Tier 2 48 System to promote first contact accessibility There is a system to promote first contact through primary care provider which meets key criteria (see technical specifications) Not applicable National Subnational Qualitative assessment Tier 1 49 Protocols for patient referral, counter- referral and emergency transfer Explicit protocols and structured communication mechanisms are in place to promote reporting and feedback between primary care practitioners and other levels of care (referral and counter- referral) to promote coordination and information continuity that include key data elements (see technical specifications) Not applicable National Subnational Qualitative assessment Tier 2 50 Existence of care pathways for tracer conditions A multidisciplinary management plan exists that maps care pathways through the health system for individuals and includes key attributes (see technical specifications) Subnational National Subnational Qualitative assessment Tier 2 Organization and facility management 51 Professionalisation of management The conditions are in place nationally (and subnationally) to ensure professionalised management and leadership in health care organization, including key criteria (see technical specifications) Not applicable National Subnational Qualitative assessment Tier 2 52 Management capability and leadership Percentage of facilities with a manager/management team that has decision-making responsibilities in key areas Facility type Managing authority Subnational Urban/rural National Subnational Facility Facility survey Tier 1 53 Multidisciplinary team- based service delivery Percentage of facilities where providers work as part of a multidisciplinary team that is characterized by key criteria (see technical specifications) Facility type Managing authority Subnational Urban/rural National Subnational Facility Facility survey Tier 2 10 N Indicator Definition Disaggregations (Details in document) Level Preferred data source Tier 54 Existence of supportive supervision system Percentage of facilities that implement or receive supportive supervision including key attributes (see technical specifications) Facility type Managing authority Subnational Urban/rural National Subnational Facility Facility survey Tier 1 55 Existence of facility budgets and expenditures meeting criteria Percentage of facilities that have budgets and expenditures that meet key criteria (see technical specifications) Not applicable National Subnational Facility survey Tier 2 Community linkages and engagement 56 Collaboration between facility and community- based service providers Percentage of primary care facilities and first-referral hospitals that have established formal linkages with community-based service providers (including community health workers) Facility type Managing authority Subnational Urban/rural National Subnational Facility Facility survey Tier 2 57 Community engagement in service planning and organization There is a system to ensure local service planning is informed by community voices including vulnerable groups, including key activities (see technical specification) Not applicable National Subnational Qualitative assessment Tier 2 58 Proactive population outreach Percentage of facilities that actively provide services to communities according to local health needs and priorities Facility type Managing authority Subnational Urban/rural National Subnational Facility Facility survey Tier 2 59 Services for self-care and health literacy in primary care Percentage of facilities promoting self-management and health literacy based on key criteria (see technical specifications) Facility type Managing authority Subnational Urban/rural National Subnational Facility Facility survey Systems for improving quality of care 60 Percentage of facilities with systems to support quality improvement Percentage of health facilities with systems to support and implement quality improvement, measured against key criteria (see technical specifications) Facility type Managing authority Subnational Urban/rural Facility survey Qualitative assessment Tier 1 Resilient health facilities and services 61 Percentage of facilities meeting criteria for resilient health facilities and services Percentage of health facilities that are meeting criteria for resilient health services measured against key attributes (see technical specifications) Facility type Managing authority Subnational Urban/rural National Subnational Facility Facility survey Tier 2 Access and availability Accessibility, affordability, acceptability 62 Geographical access to services Percentage of population living within 5 km (or 1 hour) of a comprehensive primary care facility/provider and 2 hours of an emergency care unit/provider Urban/rural Subnational National Subnational Facility database Geographical information system (GIS) Tier 2 11 N Indicator Definition Disaggregations (Details in document) Level Preferred data source Tier 63 Perceived barriers to access (geographical, financial, sociocultural) Percentage of target population reporting problems in accessing care when they have a health care need, by problem. Population-based survey only: Wealth quintile Education Both: Urban/rural Age Gender Subnational Facility survey only: Facility type Managing authority National, subnational Population- based survey Facility survey (exit interviews) Tier 1 64 Access to emergency surgery Percentage of the population that can access, within 2 hours, a facility that can perform emergency caesarean section, laparotomy and open fracture fixation Urban/rural Subnational National Subnational RHIS GIS Tier 2 65 Proactive population outreach Existence of a system for post-crash care that includes key attributes (see technical specifications) Urban/rural Subnational Qualitative assessment RHIS (for prehospital emergency care) Tier 2 Service availability and readiness 66 Percentage of facilities offering services according to national defined service package Percentage of primary care facilities/units offering services according to national defined service package Facility type Managing authority Subnational Urban/rural National Subnational Facility Facility survey or RHIS Tier 1 67 Provider availability (absence rate) Percentage of clinical staff who are expected to be at facility but are not present at a facility during an unannounced visit compared to the expected number of staff at a given time. Facility type Managing authority Subnational Urban/rural National Subnational Facility Facility survey Tier 2 68 Percentage of facilities meeting minimum standards to deliver tracer services Percentage of facilities offering services that meet minimum standards including availability of Staff and guidelines Equipment Diagnostics Medicines and commodities Facility type Managing authority Subnational Urban/rural National Subnational Facility Facility survey Tier 1 69 Percentage of facilities compliant with infection prevention and control (IPC) measures Facility meets standards (inadequate, basic, intermediate, advanced) based on the eight core components of the Infection Prevention and Control Assessment Framework (IPCAF): Facility type Managing authority Subnational Urban/rural National Subnational Facility Facility survey Tier 1 Utilization of services 70 Outpatient visits Number of outpatient visits (e.g., to facilities or doctors) per person per year Subnational Age Gender National Subnational Facility RHIS Population based surveys Tier 1 + Global N Indicator Definition Disaggregations Level Preferred data source Tier 12 N Indicator Definition Disaggregations (Details in document) Level Preferred data source Tier 71 Emergency unit visits Number of emergency department visits per 1 000 population Subnational Age Gender National, Subnational Facility RHIS Tier 2 72 Hospital discharges** Number of patients who are admitted to or leave a hospital after staying at least one night per 1 000 population (includes death following inpatient care but excludes same-day discharges) Subnational Age Gender National Subnational Facility RHIS Tier 1 73 Leading diagnoses (primary care/ outpatient visits, inpatient diagnoses at discharge**) Number, Rate per 1 000 population and percentage distribution of the main diagnostic categories Subnational Age Gender Service type National Subnational Facility RHIS Tier 1 Quality of care Core primary care functions first-contact accessibility, continuity, comprehensiveness, coordination, people-centredness) 74 Patient-reported experiences Percentage of key attributes for patient experience, satisfaction and health systems responsiveness being met (see technical specifications) Population-based survey and facility survey: Age Gender Subnational Urban/rural Only facility survey: Facility type Managing authority if measured through facility survey National Subnational Facility Patient survey Facility survey (exit interviews) Tier 1 75 People’s perceptions of health system and services Percentage of people that have positive perception of health system and services that include key domains (see technical specifications) Provider type Wealth quintile Education Gender Age National Subnational Population- based survey Tier 2 Effectiveness 76 Diagnostic accuracy (provider knowledge) Percentage of cases correctly diagnosed out of the number of patients examined, as observed through clinical vignettes on multiple common conditions, including patients with multimorbidity Facility type Managing authority (public/private) Subnational Urban/rural Cadre Tracer condition National Subnational Facility Facility survey (patient-provider observation or record review) Tier 2 N Indicator Definition Disaggregations Level Preferred data source Tier 13 N Indicator Definition Disaggregations (Details in document) Level Preferred data source Tier 77 Adherence to clinical standards for tracer conditions Adherence to clinical guidelines measures the number of relevant history and physical examination questions asked by a provider during a clinical encounter compared to the total number of relevant history and examination questions that should have been asked, examined through clinical vignettes. Alternatively, could be examined through exit interviews or household surveys. Facility type Managing authority (public/private) Subnational Urban/rural Cadre National Subnational Facility Facility survey (patient-provider observation or record review) Tier 2 78 30-day hospital case fatality rate (for acute myocardial infarction or stroke)** Percentage of hospital inpatients with primary diagnosis of acute myocardial infarction or stroke who died within 30 days of admission Cause Facility type Managing authority Subnational Urban/rural Gender Age Education National Subnational Facility RHIS Facility survey (record review) Tier 2 79 Avoidable complications (lower limb amputation in diabetes) Admissions who had a major lower extremity amputation as a percentage of population age 15 and older with diabetes Age Gender Subnational National Subnational Facility RHIS Facility survey (record review) Tier 2 80 Hospital readmission rate for tracer conditions** Percentage of unplanned and unexpected hospital readmissions for tracer conditions (acute myocardial infarction, pneumonia, asthma, diabetes, surgical site infections) Tracer condition Facility type Managing authority (public/private) Subnational Urban/rural Age Gender Education National Subnational Facility RHIS Facility survey (record review) Tier 2 81 Admissions for ambulatory care sensitive conditions Rate of admission with ambulatory care-sensitive conditions, including asthma or chronic obstructive pulmonary diseases, congestive heart failure, hypertension, and diabetes per 100 000 population in a specified year and as percentage of all hospitalizations Tracer condition Subnational Gender Age National Subnational Facility RHIS Tier 1 + Global Safety 82 Prescribing practices for antibiotics Overall volume of antibiotics for systemic use prescribed Subnational National Subnational Facility Prescription database Tier 1 83 Proportion of people 65 years and over prescribed antipsychotics Proportion of people 65 years and over prescribed antipsychotics during the reference year Subnational National Subnational Facility Prescription database Tier 2 Indicator efinition isaggregations Level Preferred data source Tier 14 N Indicator Definition Disaggregations (Details in document) Level Preferred data source Tier Efficiency 84 Provider caseload Average number of outpatient services provided by a given health worker in a specified period (e.g., working day, year) Facility type Managing authority Subnational Urban/rural Cadre National Subnational Facility Facility survey Tier 2 85 Bed occupancy** Percentage of available beds that have been occupied over a given period Facility type Managing authority Subnational Urban/rural National Subnational Facility RHIS Tier 2 Timely access 86 Cancer stage at diagnosis (by cancer) Percentage of all stageable cancers diagnosed that are recorded as presenting as a Stage 1 or 2 Gender Cancer types National Subnational Cancer registry Tier 2 87 Waiting time to elective surgery** Average number of days that patients have been waiting for elective procedure (i.e., non- urgent) surgeries – cataract, coronary angioplasty, hip replacement, knee replacement, skin biopsies Type of procedure Facility type Sub-national Urban/rural Gender National, Subnational Facility RHIS (waiting time management systems) Tier 2 ** Hospital-oriented indicators considered important for broader PHC monitoring and relevant in terms of inter-relations with primary care. N Indicator Definition Disaggregations Level Preferred data source Tier 15 N Indicator Definition Disaggregations (Details in document) Level Preferred data source Physical infrastructure A Bed density (inpatient only) Total number of hospitals beds per 10 000 population Facility type Managing authority Subnational Urban/rural Type of bed National Subnational Facility RHIS - facility census Quality care Effectiveness B Institutional mortality Number of institutional deaths as a percentage of total admissions Cause -of- death Age Facility type Managing authority Subnational Urban/rural National Subnational Facility RHIS Death surveillance and response systems Safety C Caesarean section rate Number of caesarean deliveries performed per 100 live births From facility surveys: Facility type Managing authority Subnational Urban/rural Population-based surveys: Age Education National Subnational Facility RHIS Population- based survey Facility survey (record review) D Postoperative sepsis Percentage of discharges with postoperative sepsis among abdominopelvic discharges only Facility type Managing authority Subnational National Subnational Facility RHIS Population- based survey Facility survey (record review) E Postoperative pulmonary embolism Percentage of discharges with pulmonary embolism among all hip and knee replacement discharges Facility type Managing authority Subnational National Subnational Facility RHIS F Postoperative deep vein thrombosis Percentage of discharges with pulmonary embolism among all hip and knee replacement discharges Facility type Managing authority Subnational National Subnational Facility RHIS Facility survey (record review) G Perioperative mortality rate All-cause death rate prior to discharge among patients having one or more procedures in an operating theatre during the relevant admission Emergency versus elective surgery Tracer condition Facility type Managing authority Subnational National Subnational Facility RHIS Facility survey (record review) Table 2. Summary overview of indicators: additional hospital-oriented indicators 16 N Indicator Definition Disaggregations (Details in document) Level Preferred data source H Hospital-acquired infections Percentage of hospitalised patients with at least one health care-associated infection (which is relevant to country context) Tracer condition Facility type Managing authority Subnational National Subnational RHIS Facility survey (record review) Timely access I Coverage of timely emergency resuscitation at first- level hospitals Proportion of adults and children [at first- level hospitals] admitted or transferred with pneumonia or shock from any cause, who received oxygen and/or intravenous volume in the emergency unit prior to admission or transfer Managing authority (public/private) Subnational Urban/rural National Subnational RHIS Facility survey (record review) 17 18 2. Indicators for monitoring primary health care with metadata Indicator1 Health in All Policies with multisectoral coordination Indicator short name Health in All Policies with multisectoral coordination Indicator long name Adoption of a Health-in-all-Policies approach with multisectoral coordination Domain Governance Subdomain Political commitment and leadership M&E domain Structures Definition The country has implemented an HiAP approach that includes the following elements: • Existence of a national HiAP strategy and plan of action involving multiple sectors • Existence of recognized functional mechanisms to manage and monitor HiAP development and implementation • Mechanism for monitoring and oversight to examine the impact on health and equity of outcomes of HiAP • Evidence of collaborations across sectors to address health issues or determinants of health including: Existence of operational policy/strategy/action plan to reduce physical inactivity Age limits alcohol service/sales Alcohol taxation Drunk driving laws Alcohol advertising restrictions Alcohol licensing requirements Existence of a national seat-belt law Existence of national speed limit MPOWER measures fully implemented (tobacco) Existence of any policies to reduce population salt consumption Existence of policies on marketing of foods to children Existence of tax on sugar-sweetened beverages • Training opportunities and knowledge change for health workforce and institutions • Opportunities for community engagement through consultations and level of community participation. Disaggregation(s) Not applicable Numerator Not applicable Denominator Not applicable Preferred data source Qualitative assessment based on interview with key informant and/or desk review of country documents. Rationale Multisectoral policies and action are a core component of PHC. In order to bring about policy changes in other sectors, the health community needs to advocate for change and to generate evidence on the health impacts of multisectoral determinants. This is particularly important because a number of the policy changes that are most important for improving health and well-being involve vested commercial interests, which often have significant influence over policymakers. HiAP is a whole-of-government approach to multisectoral policy and action at the national, subnational and regional levels: “an approach to public policies across sectors that systematically takes into account the health implications of decisions, seeks synergies, and avoids harmful health impacts in order to improve population health and health equity” (WHA67.12). HiAP underscores the alignment of interests across policies to serve all people’s basic right to a healthy, productive life. It provides a framework for addressing determinants by developing the needed leadership and governance and providing an umbrella for multiple sets of actions across sectors. In an HiAP approach, the health sector is seen as the champion for health, keeping health on the agenda but aware of the need for policy action with mutual benefit with other sectors, seeking overall societal gains. National health assemblies can bring together key stakeholders, including those from other sectors, to shape policymaking. Reference(s) Health in all Policies (HiAP). Framework for Country Action. Geneva: World Health Organization; 2014 (https:// www.who.int/healthpromotion/hiapframework.pdf, accessed 16 August 2021). Health in All Policies as part of the primary health care agenda on multisectoral action. Geneva: World Health Organization; 2018 (https://apps.who.int/iris/handle/10665/326463, accessed 30 August 2021). Existing data collection tool To note, a qualitative assessment tool with recommended scoring methodology is currently under development by WHO and will be forthcoming by end 2022. Governance 2.1 Governance indicators 19 Indicator 2 Existence of right-to-health legislation Indicator short name Existence of right to health legislation Indicator long name Existence of right to health legislation Domain Governance Subdomain Political commitment and leadership M&E domain Structures Definition The country has an enabling legal environment for UHC that includes: • Legal recognition to all people of access rights to essential health services, essential medicines and vaccines • Protection of individuals from discrimination when accessing quality essential health services, essential medicines and vaccines • Right to access to a limited set of essential health services, essential medicines and vaccines accessible to all people independent of their right to health care including groups without health coverage Disaggregation(s) Not applicable Numerator Not applicable Denominator Not applicable Preferred data source Qualitative assessment based on key informant interview and/or desk review of country documents Rationale The law plays a key role in a country’s progressive realisation of UHC. The quality of a country’s health laws and legal practices significantly contributes to the efficient, effective and equitable use of the available health resources and, consequently, the attainment of a country’s health system goals. Therefore, creating an enabling legal environment for UHC is a critical investment to ensure implementation of UHC policies and programmes. Reference(s) UHC law in practice: legal access rights to health care: introduction. Geneva: World Health Organization; 2019 (https://www.who.int/publications/i/item/uhc-law-in-practice-legal-access-rights-to-health-care-introduction, accessed 16 August 2021). Existing data collection tool To note: a qualitative assessment tool with recommended scoring methodology is currently under development by WHO and will be forthcoming by end 2022. Governance 20 Indicator 3 Existence of national health policy oriented to PHC and UHC Indicator short name Existence of national health policy oriented to PHC and UHC Indicator long name Existence of a comprehensive national health sector policy, strategy, oriented to PHC and UHC based on key attributes Domain Governance Subdomain Governance and policy frameworks M&E domain Structures Definition The country has a national health sector policy, strategy oriented to PHC and UHC based on the following standards: • Has been developed/revised within the past five years • Sets out clear priorities, goals, policies, objectives, interventions that are oriented towards PHC and the achievement of UHC and the health SDGs • Based on sound evidence-based analysis of the health situation • Promotes the delivery of integrated health services with an emphasis on primary care and essential public health functions at both facility and community level • Includes a section on addressing the broader determinants of health, with links to other sectors • Includes strategic actions to promote and empower individuals and communities as co-developers of health and social services and as self-carers • Specifies plans to improve health equity and specifies interventions for the most marginalised and vulnerable populations • Describes how resources will be deployed to achieve outcomes and improve equity, including how resources will be allocated to subnational level and non-state actors • Is developed and reviewed through a regular and transparent system of review of the strategy/plan with broad involvement of key stakeholders • There is an effective country led mechanism for governance, coordination and accountability for implementation of the national health strategy /plan Disaggregation(s) Not applicable Numerator Not applicable Denominator Not applicable Preferred data source Qualitative assessment based on key informant(s) and/or desk review of country documents, including national health strategic plans, PHC-specific plans, national health annual operational plans and budgets, national development plans and policy and legal frameworks. Rationale The development of sound national and subnational health policies and strategies (NHPS) through intersectoral (whole-of-government) and intersectoral inclusive policy dialogue with all health stakeholders (whole-of-society) are necessary to address common challenges to health agendas, including: the under-prioritization of health, funding inconsistency and the lack of predictability of both domestic and external resources for health; budget underspending; and misallocation of resources. They must be well prioritized and reflect the needs and the demand for health services, with resource allocation orientated toward PHC and UHC objectives. They need to clearly specify health sector goals and be anchored in strong political agreements to improve consistency and predictability. NHPSPs must be well translated into operational plans and budgets that will allow for full implementation. They also need to be well monitored and transparently evaluated for increased accountability and transparency. Reference(s) Strategizing national health in the 21st century: a handbook. Geneva: World Health Organization; 2016 (https:// apps.who.int/iris/handle/10665/250221, accessed 23 August 2021). Joint Assessment of National Health Strategies and Plans (JANS): Joint Assessment Tool, Frequently Asked Questions, Quality Assurance Checklist, 2014. Geneva: World Health Organization; 2015 (https://www.uhc2030. org/fileadmin/uploads/ihp/Documents/Tools/JANS/JANS_2014_English_WEB__1_.pdf, accessed 16 August 2021). Existing data collection tool To note: a qualitative assessment tool with recommended scoring methodology is currently under development by WHO and will be forthcoming by end 2022. Governance 21 Indicator 4 Indicator short name Existence of policy, strategy or plan for improvement of quality and safety Indicator long name Existence of national policy or strategy on quality of care and patient safety aligned with the national health strategic plan. The policy, strategy or plan addresses multiple domains of quality (effectiveness, safety, people- centredness, timeliness, equity, efficiency and integration). Domain Governance Subdomain Governance and policy frameworks M&E domain Structures Definition There is a validated national strategic direction on quality and safety, measured against the following criteria: • A national policy, strategy or plan exists (either separately or as part of the national health sector plan) that has been developed or revised /finalised within the last five years • Developed through a consultative stakeholder process, inclusive of communities and/or civil society • Defines a set of quality planning, improvement and control/assurance interventions that include: Interventions for enabling system, e.g., registration and licensing, external evaluation and accreditation, clinical governance, training and supervision of workforce An intervention on reducing harm, e.g., safety standards, protocols and checklists, adverse event reporting An intervention on improving clinical care, e.g., clinical decision support tools, clinical standards, pathways and protocols, morbidity & mortality reviews An intervention on patient, family and community engagement and empowerment, e.g., health literacy, shared decision-making, patient self-management tools • Includes specific mention defining the use of facility and provider regulatory mechanisms such as licensing, certification, external evaluations or accreditation • Includes specific mention of mechanisms to be enacted across service delivery platforms including primary care, community and outreach care, referral care and in-patient hospital care • Dedicated funding allocated in the government budget to implement the policy, strategy or plan for improvement of quality and safety There is a recognized structure such as a quality directorate/department/unit to take forward the development and operationalization of the national direction on quality Disaggregation(s) Not applicable Numerator Not applicable Denominator Not applicable Preferred data source Qualitative assessment based on interview with key informant and/or desk review of country documents Rationale National strategic direction setting on quality essential health services is important in order to systematically address local quality priorities and align all efforts in an integrated manner. In the 2018 joint WHO-World Bank- OECD global report, Delivering Quality Health Services: A Global Imperative, WHO, the World Bank and the OECD call on all countries to develop national quality policy and strategy. This is reiterated in the high-level UN Political Declaration on UHC and in the PHC operational framework lever on systems to improve quality of care (page 58). Reference(s) Handbook for National Quality Policy and Strategy. A practical approach for developing policy and strategy to improve quality of care. Geneva: World Health Organization; 2018. https://www.who.int/publications/i/ item/9789241565561, accessed 16 August 2021). Quality Health Services. A Planning Guide. Geneva: World Health Organization; 2020 (https://www.who.int/ publications/i/item/9789240011632, accessed 16 August 2021) UN Political Declaration on UHC; 2019 (https://undocs.org/en/A/RES/74/2, accessed 16 August 2021). Delivering quality health services: a global imperative for universal health coverage. Geneva: World Health Organization; 2018 (https://apps.who.int/iris/bitstream/handle/10665/272465/9789241513906-eng.pdf?ua=1, accessed 4 October 2021). Quality in primary health care. Geneva: World Health Organization; 2018 (https://apps.who.int/iris/ handle/10665/326461, accessed 30 August 2021). Existing data collection tool To note: a qualitative assessment tool with recommended scoring methodology is currently under development by WHO and will be forthcoming by end 2022. Governance Existence of policy, strategy or plan for improvement of quality and safety 22 Indicator 5 Indicator short name Existence of health emergency and disaster risk management strategies Indicator long name Existence of health emergency and disaster risk management strategies (all-hazards emergency plans for preparedness and response). (It will be important to consider documents with other possible titles, such as health emergency and disaster risk management strategies, health disaster risk reduction plans, national action plans for health security, health emergency preparedness and response plans, and risk reduction strategy/policy, etc.) Domain Governance Subdomain Governance and policy frameworks M&E domain Structures Definition There is a health emergency and disaster risk management strategy that is measured against the following criteria: • A health emergency and disaster risk management strategy has been developed/revised within the past five years • The strategy addresses the risk profiles of countries based on risk assessment • The strategy specifies the role of primary care providers regarding health emergency and disaster risk management • It is comprehensive in terms of health emergency management cycle, i.e., addresses prevention, preparedness, response and recovery measures • The strategy includes protocols for continuity and the maintenance of quality essential health services during response and safe restoration of services and strategies to address the backlog of health care needs in the recovery phase • The strategy adopts a whole-of-health system and whole of society approach (describes the roles and responsibilities of the health system, health sector and other allied sectors) • The strategy includes multilevel measures (i.e., it describes roles and responsibilities at all administrative levels of the country, e.g., national, subnational, local) • The strategy adopts inclusive, people- and community-centred approach based on PHC approach (i.e., it addresses vulnerabilities and capacities of communities including populations with higher levels) • The strategy incorporates an equity lens (i.e., it ensures financial barriers do not impede access to health care before, during and after emergencies including within primary care); it identifies vulnerable populations and addresses the needs of the vulnerable • The strategy adopts ethical and rights-based approaches (i.e., it upholds health as a human right and applies ethical standards driven by principles such as respect for persons, justice, solidarity and cultural sensitivity). Disaggregation(s) Not applicable Numerator Not applicable Denominator Not applicable Preferred data source Qualitative assessment based on desk review of country documents Rationale Reducing the health risks and consequences of emergencies is vital to local, national and global health security and to build the resilience of communities, countries and health systems. Sound risk management is essential to safeguard development and implementation of the SDGs, including the pathway to UHC, the Sendai Framework for Disaster Risk Reduction 2015–2030 (Sendai Framework), International Health Regulations (IHR) (2005), Paris Agreement on Climate Change (Paris Agreement) and other related global, regional and national frameworks. Reference(s) Health emergency and disaster risk management framework. Geneva: World Health Organization; 2019 (https:// apps.who.int/iris/handle/10665/326106, accessed 16 August 2021). State Party Annual Report for IHR (e-SPAR) (https://extranet.who.int/e-spar, accessed 16 August 2021). Primary health care and health emergencies. Geneva: World Health Organization; 2018 (https://apps.who.int/iris/ handle/10665/328105, accessed 25 August 2021). Existing data collection tool World Health Organization. IHR (2005) State Party Self-Assessment Annual Reporting Tool (SPAR). Geneva: World Health Organization; 2018 (https://www.who.int/publications/i/item/WHO-WHE-CPI-2018-16, accessed 16 August 2021). Governance Existence of health emergency and disaster risk management strategies 23 Indicator 6 Indicator short name Institutional capacity to meet essential public health functions and operations Indicator long name Existence of national public health entity that is responsible for carrying out essential public health functions. Domain Governance Subdomain Governance and policy frameworks M&E domain Structures Definition There is national public health institute (NPHI) or entity that is responsible for leadership, expertise and coordination of a country’s public health activities. This entity can have multiple forms, such as a standalone NPHI, a semi-autonomous institution under another national health authority, department(s) within the Ministry of Health, and several agencies with the responsibilities to carry out public health functions for population-based services collectively with the following characteristics: • The NPHI develops policies and interventions that address the country’s public health problems • The NPHI is a public institution operating as part of the government or with the concurrence of the government • The NPHI is the main source of technical and scientific information of the Ministry of Health, lawmakers and other parts of government • The NPHI has adequate human and financial resources to carry out its core functions • The NPHI has adequate infrastructure support (computer, communications, access to laboratories) • The NPHI coordinates activities with other national organizations at national and subnational level • The NPHI has a defined workplan with a responsibility to carry out the following public health functions: Monitoring and evaluation of health status, service utilisation, and surveillance of risk factors and threats to health Public health emergency management Assuring quality and access to health services, health protection, including environmental occupational, food safety and other hazards Health promotion and action to address social determinants and health inequity, including through community engagement Disease prevention, including early detection of illness Community engagement for advocacy and social mobilization for health Advancing public health research to inform policy and practice Assuring effective health governance, regulation and public health legislation Supporting efficient and effective health systems planning, financing, and management for population health Ensuring adequate quality and quantity of public health workforce Ensuring equitable access to and rational use of essential medicines and other health technologies Disaggregation(s) Not applicable Numerator Not applicable Denominator Not applicable Preferred data source Qualitative assessment based on interview with key informant and/or desk review of country documents, e.g., public health policies, national public health act, etc. Rationale Providing and maintaining essential public health functions (EPHFs) is a cornerstone for public health and resilient systems. The COVID-19 pandemic has exposed weaknesses in the public health capacities necessary for resilient health systems. It is important to have institutions such as NPHIs that are responsible for and able to carry out the core components of EPHFs reflective of the national context. Without dedicated responsible entity(ies) these functions will not be carried out, to the detriment of public health. Reference(s) International Association of National Public Health Institutes (IANPHI) Framework for the Creation and Development of National Public Health Institutes, IANPHI 2007 ( https://ianphi.org/_includes/documents/sections/ tools-resources/all-frameworks/frameworkfornphi.pdf , accessed 4 October 2021). Essential public health functions, health systems and health security: developing conceptual clarity and a WHO roadmap for action. Geneva: World Health Organization; 2018 (https://apps.who.int/iris/handle/10665/272597, accessed 17 August 2021). Primary health care: closing the gap between public health and primary care through integration. Geneva; World Health Organization; 2018 (https://apps.who.int/iris/handle/10665/326458, accessed 30 August 2021). Institutional capacity to meet essential public health functions and operations Governance 24 Existing data collection tool Self-assessment tool for the evaluation of essential public health operations in the WHO European Region. Copenhagen: World Health Organization Regional Office for Europe; 2015 (https://www.euro.who.int/en/ publications/abstracts/self-assessment-tool-for-the-evaluation-of-essential-public-health-operations-in-the-who- european-region-2015, accessed 17 August 2021). Assessment of essential public health functions in countries of the Eastern Mediterranean Region. Assessment tool. Cairo: World Health Organization Regional Office for the Easter Mediterranean; 2017 (http://www.emro.who.int/ about-who/public-health-functions/assessment-public-health-functions.html, accessed 17 August 2021). Pan American Health Organization/World Health Organization/Centers for Disease Control and Prevention/ Centro Latino Americano de Investigación en Sistemas de Salud. Public health in the Americas: Instrument for Performance Measurement of Essential Public Health Functions (https://www.paho.org/hq/dmdocuments/2010/ EPHF_Instrument_Performance_Measurement.pdf, accessed 17 August 2021). To note: a revised and consolidated qualitative assessment tool with recommended scoring methodology is currently under development by WHO and will be forthcoming by end 2022. 25 Indicator 7 Indicator short name Coordination mechanisms with multistakeholder participation and community engagement Indicator long name Coordination mechanisms with multistakeholder participation and community engagement Domain Governance Subdomain Engagement with communities and other stakeholders M&E domain Structures Definition A national coordination mechanism exists meeting the following criteria: • Responsible for coordinating, monitoring and implementing health- PHC and/or UHC-related strategies and policies within the national health sector policy, strategies and plans • Participation includes broad range of stakeholders, including: Community groups, including vulnerable, marginalised and excluded populations Members of parliamentary health committee Health worker associations, patient groups Civil society organizations and advocacy groups, Health insurance bodies Provider organizations/associations Private sector • The coordination mechanism has accountability for the range of health activities defined by national health policies and plans • The coordination mechanism/authority has adequate budget and sufficient staff • The mandate includes the public sector as well as oversight and regulation of the private sector where feasible Disaggregation(s) Not applicable Numerator Not applicable Denominator Not applicable Preferred data source Qualitative assessment based on interview with key informant and /or desk review of country documents. Rationale A key role of the Ministry of Health is to plan, initiate, coordinate and oversee the priority-setting process, where relevant, through health sector coordination mechanisms. Policymakers must thus lead the process, ensure broad and meaningful stakeholder participation, ensure that the priorities that are set reflect stakeholder input in a balanced way, and be held accountable for the results. The process must be transparent, with clear roles and responsibilities, especially when it comes to evaluating and discussing evidence from different angles and viewpoints. Reference(s) Adapted from the PHCPI PHC Progression Model Assessment tool. Primary Health Care Performance Initiative (PHCPI). Primary health care progression model (https://improvingphc. org/primary-health-care-progression-model, accessed 16 August 2021). Operational framework for primary health care: transforming vision into action. Geneva: World Health Organization and the United Nations Children’s Fund (UNICEF), 2020 (https://www.who.int/publications/i/ item/9789240017832, accessed 17 August 2021). Existing data collection tool To note: a qualitative assessment tool with recommended scoring methodology is currently under development by WHO and will be forthcoming by end 2022. Governance Coordination mechanisms with multistakeholder participation and community engagement 26 Indicator 8 Indicator short name Existence of national, subnational and local strategies for community engagement Indicator long name Existence of national, subnational and local strategies for community engagement and social accountability in defining and priority setting processes Domain Governance Subdomain Engagement with communities and other stakeholders M&E domain Structures Definition Strategies exist to promote and support community engagement and social accountability in defining and monitoring objectives of the national health plans/strategies and based on the following minimum standards: • Participation: Communities assess their own health needs and participate in the analysis, planning, design, implementation, monitoring and evaluation of governance, development and humanitarian initiatives • Ownership: Communities have opportunities to own and feel empowered by community engagement processes • Inclusion: Community members and groups (populations) that are under-served, underrepresented, disadvantaged, vulnerable and marginalized are identified, supported and ensured a role and a voice in all aspects of community engagement (Power dynamics need to be critically considered for this standard in implementation.) • Two-way communication: Communities give and receive clear, appropriate and accurate information through two-way communication pathways, on a regular and predictable basis • Adaptability: Community engagement approaches are developed based on local contexts and responsive to local population needs, conditions, and concerns • Building on local capacity. Community engagement builds on the existing skills and resources of community and the local groups that serve them • Budget addressing community concerns and priorities Disaggregation(s) Not applicable Numerator Not applicable Denominator Not applicable Preferred data source Qualitative assessment based on interview with key informant and/or desk review of country documents Rationale National governments have the primary responsibility to respect, fulfil and protect the rights of the population. Governments can facilitate processes through which community engagement efforts are coordinated and integrated with relevant government agencies, and work in a manner that is consistent with national policies and strategies. Government should develop policy and advance mechanisms for coordinating community engagement activities. Reference(s) Minimum Quality Standards and Indicators for Community Engagement. UNICEF; 2020. https://www.unicef.org/ mena/media/8401/file/19218_MinimumQuality-Report_v07_RC_002.pdf.pdf, accessed 16 August 2021). Operational framework for primary health care: transforming vision into action. Geneva: World Health Organization and the United Nations Children’s Fund (UNICEF), 2020 (https://www.who.int/publications/i/ item/9789240017832, accessed 17 August 2021). WHO community engagement framework for quality, people-centred and resilient health services. Geneva: World Health Organization; 2017 (https://apps.who.int/iris/handle/10665/259280, accessed 30 August 2021). Existing data collection tool The reference document above includes a checklist tool in the Annex: https://www.unicef.org/mena/media/8401/ file/19218_MinimumQuality-Report_v07_RC_002.pdf.pdf Existence of national, subnational and local strategies for community engagement Governance 27 Indicator 9 Indicator short name Evidence of effective stewardship of mixed health systems Indicator long name Evidence of effective stewardship of mixed (public/private sector) health systems Domain Governance Subdomain Engagement with private sector providers M&E domain Structures Definition There is a national policy, strategy or plan guiding the engagement of the private sector in health service delivery that includes the following WHO-recommended behaviours: • Builds understanding There are structures/platforms for data sharing Data are collected and analysed to align priorities for action Private sector data are used in relevant processes at national and subnational level for decision- making/prioritization • Fosters relations (Policy reflects shared objectives of all relevant stakeholders) Regulations and standards are in place for public/private actors that are evenly applied/enforced across public and private sectors and within different segments of the sectors The private sector is involved in decision-making (e.g., members of organization committees and/or task forces) Private health care players/providers are part of a larger federation led by a representative body/ committee Private sector is included in crisis management plans • Nurtures trust (System engenders mutual trust amongst all actors as reliable participants) There are checklists/guidelines to monitor accountability processes and diagnose symptoms of poor accountability Monitoring results are made public and there is a mechanism to ensure that the results are used for policy and planning There are transparent mechanisms in place to address challenges • Enables stakeholders (Institutional framework empowers actors) There are contracting models in place with the private sector Private sector is noted in economic and tax regulations Private sector is included within national health insurance or other results-based financing mechanisms • Delivers strategy (Policy incudes an articulation of roles and responsibilities to achieve a shared direction) There is a vision for the representative roles and responsibilities of public and private sectors Country has implemented policies for private sector engagement There are monitoring and engagement processes in place for the strategy Disaggregation(s) Not applicable Numerator Not applicable Denominator Not applicable Preferred data source Qualitative assessment based on interview with key informant and/or desk review of country documents Rationale Both public and private sectors share responsibility for provision of services, but governments must oversee and guide the whole health system in order to protect the public interest. To do this, the role of health ministries as stewards for health must be reinforced. Private sector engagement is the inclusion of private providers for service delivery in mixed health systems. Private sector engagement requires that governments focus on governance of the whole health system – both private and public – to ensure quality of care and financial protection for patients, irrespective of where they seek care. It requires that the private sector aligns with public sector health goals and commits to working to support the government agenda. Evidence of effective stewardship of mixed health systems Governance 28 Reference(s) Engaging the private health service delivery sector through governance in mixed health systems: strategy report of the WHO Advisory Group on the Governance of the Private Sector for Universal Health Coverage Strategy. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/strategy-report-engaging-the- private-health-service-delivery-sector-through-governance-in-mixed-health-systems, accessed 16 August 2021). Operational framework for primary health care: transforming vision into action. Geneva: World Health Organization and the United Nations Children’s Fund (UNICEF), 2020 (https://www.who.int/publications/i/ item/9789240017832, accessed 17 August 2021). The private sector, universal health coverage and primary health care. Geneva: World Health Organization; 2018 (https://apps.who.int/iris/handle/10665/312248, accessed 30 August 2021). Existing data collection tool To note: a qualitative assessment tool with recommended scoring methodology is currently under development by WHO and will be forthcoming by end 2022. 29 Indicator10 Priority setting is informed by data and evidence Adjustment to population needs Indicator short name Priority setting is informed by data and evidence Indicator long name Policy priority setting is informed by data and evidence on health priorities, burden of diseases, population risk, and equity analysis Domain Adjustment to population health needs Sub-domain Monitoring and evaluation M/E domain Structures Definition Priority setting in the national health strategic plan/policy is based on data and evidence, measured against the following criteria: • Includes a review of past performance (trends) over past five years • Includes a burden of disease analysis identifying populations most at risk • Includes data and analysis of performance at the subnational level • Data are disaggregated data to highlight gender responsiveness • Data are disaggregated to highlight populations experiencing vulnerabilities • Data are disaggregated to highlight spatial inequities • Stakeholder engagement is systematically used in all in priority setting exercises • A central unit or function in Ministry of Health exists to translate data and evidence into policy actions • Allocation of resources is based on results of the priority setting Disaggregation(s) Not applicable Numerator Not applicable Denominator Not applicable Preferred data source Qualitative assessment based on interview with key informant and /or desk review of country documents. Rationale Priority-setting is necessary everywhere, as resources are never unlimited. Choices must be made that reflect a society’s values and vision for the health system and integrate reflections on explicitly chosen criteria. Priority- setting exercise is where the principal decisions are made after the situation analysis discussions and . is based on criteria set by health sector stakeholders. Evidence on the different criteria is then examined jointly. The results of the evidence analysis feed into the formulation of the national health policy, strategy or plan (NHPSP). Reference(s) Score for health data technical package: assessment methodology, 2020. Geneva: World Health Organization; 2021 ( https://cdn.who.int/media/docs/default-source/medicines/regulatory-updates/gbt/2021- fair-pricing-forum/who_2021-04-16_methodology-score_web.pdf?sfvrsn=2a91f846_1, accessed 16 August 2021). Operational framework for primary health care: transforming vision into action. Geneva: World Health Organization and the United Nations Children’s Fund (UNICEF), 2020 (https://www.who.int/publications/i/ item/9789240017832, accessed 17 August 2021). Existing data collection tool World Health Organization. SCORE assessment instrument (https://www.who.int/data/data-collection-tools/ score/documents, accessed 16 August 2016). 30 2.2 Indicators of adjustment to population needs Indicator11 Existence of an M&E framework for national and local health plan meeting criteria Adjustment to population needs Indicator short name Existence of an M&E framework or plan for national health plan meeting criteria Indicator long name Existence of an M&E framework for national health plan meeting criteria Domain Adjustment to population health needs Sub-domain Monitoring and evaluation M/E domain Structures Definition • The country’s national health plan and policies include an M&E plan with a focus on PHC for UHC and includes PHC-related indicators with baselines and targets • Includes a well-balanced set of core indicators for PHC covering all three components of PHC (community engagement, multisectoral action and integrated health services) • All indicators including PHC indicators have well-defined baseline and targets • specifies disaggregations including by age, sex, gender, and by other inequity dimensions • includes specifications on data collection methods, digital architecture required for reporting of key indicators • includes data quality assurance mechanisms • includes analysis and review process specifications including roles and responsibilities • specifies use of data for policy and planning • specifies dissemination of data, including by level of care • specifies resource requirements to implement the strategic plan/policy Disaggregation(s) Not applicable Numerator Not applicable Denominator Not applicable Preferred data source Qualitative assessment based on interview with key informant and/or desk review of country documents Rationale Health data are the bedrock of sound NHSPs and decisions to accelerate improvements in health systems and health outcomes. An enabling environment is therefore critical for ensuring their effective use. Accessible, credible data from multiple sources must be available to those who are best placed to use it to improve health system performance, including decision-makers at all levels, health service funders and implementers, academic institutions, the media and the public. It must also be accessible to those who aim to hold the government accountable. Mechanisms to promote data access and dissemination include annual statistical reports, national health observatories or portals and an open data policy in the government. Policy-relevant data analyses, evidence synthesis and structured expert review processes are needed to translate this knowledge to inform policy-making and legislative proposals. The use of regular independent reviews can promote transparency, strengthen accountability and drive remedial action. To ensure data and evidence are effectively applied to improve health systems and health outcomes, it is important to recognize the political complexities around data release and use and to engage proactively with decision-makers. Reference(s) Chapter 9 Monitoring, evaluation and review of national health policies, strategies and plans. Strategizing national health in the 21st century: a handbook. Geneva: World Health Organization; 2016 (https://apps.who. int/iris/bitstream/handle/10665/250221/9789241549745-chapter9-eng.pdf, accessed 16 August 2021). Score for health data technical package: assessment methodology, 2020. Geneva: World Health Organization; 2021 ( https://cdn.who.int/media/docs/default-source/medicines/regulatory-updates/gbt/2021-fair-pricing- forum/who_2021-04-16_methodology-score_web.pdf?sfvrsn=2a91f846_1, accessed 16 August 2021). Operational framework for primary health care: transforming vision into action. Geneva: World Health Organization and the United Nations Children’s Fund (UNICEF), 2020 (https://www.who.int/publications/i/ item/9789240017832, accessed 17 August 2021). Existing data collection tool World Health Organization. SCORE assessment instrument (https://www.who.int/data/data-collection-tools/ score/documents, accessed 16 August 2016). 31 Indicator12 Total net official development assistance to medical research and basic health sector Adjustment to population needs Indicator short name Total net ODA to medical research and basic health sector Indicator long name Total net ODA to medical research and basic health sector (SDG 3.b.2) Domain Adjustment to population health needs Sub-domain Primary health care-oriented research M/E domain Structures Definition Total net ODA to the medical research and basic health sectors is currently measured by the gross disbursements of total ODA from all donors to medical research and basic health sectors. Disaggregation(s) Not applicable Numerator The sum of ODA flows from all donors to developing countries for medical research and basic health. Denominator Not applicable Preferred data source WHO, OECD, or other international database Rationale Total ODA quantifies development assistance to governments in developing countries that focuses on economic development and welfare. ODA is the main source of development aid. This indicator quantifies the public effort that donors provide to developing countries for medical research and basic health. Medical research and basic health sectors as defined by the Development Assistance Cooperation (DAC) includes all funding for activities included under Creditor Reporting System (CRS) codes 12182 (for medical research) and basic health (all codes in the 122 series). Some of the items covered under basic health include financial support to basic and primary health care programmes, paramedical and nursing care programmes, supply of drugs, medicines and vaccines related to basic health care, and activities targeted for achieving UHC, all linked to strengthening PHC. Reference(s) 2018 Global reference list of 100 core health indicators (plus health-related SDGs). Geneva: World Health Organization; 2018 (https://apps.who.int/iris/bitstream/handle/10665/259951/WHO-HIS-IER-GPM-2018.1-eng. pdf?sequence=1&isAllowed=y, accessed 16 August 2021). United Nations Department of Economic and Social Affairs Statistics Division. Indicator 3.b.2: Total net official development assistance to the medical research and basic health sectors https://unstats.un.org/sdgs/metadata/ files/Metadata-03-0b-02.pdf, accessed 18 August 2021). Existing data collection tool Data is compiled/collected by OECD/DAC. 32 Indicator13 Percentage of public research funding for primary care research Adjustment to population needs Indicator short name Percentage of public research funding for primary care research Indicator long name Percentage of public research funding for primary care research Domain Adjustment to population health needs Sub-domain Primary health care-oriented research M/E domain Structures Definition Percentage of public research funding for primary care research Disaggregation(s) Not applicable Numerator Amount of public research funding devoted to primary care research Denominator Total amount of public research funding Preferred data source Metadata under development by the World Health Organization. Rationale The comprehensive nature of primary care that focuses on the whole individual, how the individual navigates the health system and how the health system responds to the needs of individuals is a complex setting that requires research to understand and improve health service delivery. As most health care visits are managed in primary care, it is critical to strengthen this system to deliver quality health services. This effort requires evidence which is generated through primary care research. As primary care research requires funding, this measure examines the level of public funds allocated to primary care research. While overall public research funding varies between countries, and low-income countries have lower levels of research funding, the amount of public research funding devoted to primary care research reflects the level of prioritization of primary care by the government. Reference(s) Operational framework for primary health care: transforming vision into action. Geneva: World Health Organization and the United Nations Children’s Fund (UNICEF), 2020 (https://www.who.int/publications/i/ item/9789240017832, accessed 17 August 2021). Existing data collection tool Metadata under development by the World Health Organization. A data collection instrument and scoring methodology will be developed once finalized. 33 Indicator14 Current expenditure on health (total and PHC specific) as a percentage of gross domestic product (GDP) Financing Indicator short name Current expenditure on health (total and PHC-specific) as a percentage of GDP Indicator long name Current expenditure on health (total and PHC-specific) as a percentage of GDP Domain Financing Sub-domain Funding and allocation of resources M/E domain Structures Definition Total (and PHC-specific) current expenditure on health as a percentage of GDP Notes on calculation of PHC expenditure based on SHA20114 methodology include: • General outpatient curative care (HC.1.3.1) - such as visits to a general practitioner or nurse • Dental outpatient curative care (HC.1.3.2) - such as visits for regular control and other oral treatment • Curative outpatient care not elsewhere classified. (HC.1.3.nec), excluding specialized outpatient care • Home-based curative care (HC.1.4), such as home visits by a general practitioner or nurse • Outpatient (HC.3.3) and home-based (HC.3.4) long-term health care • Preventive care (HC.6), such as immunization, health check-ups, health education, disease detection, monitoring and emergency response programmes • Part of medical goods provided outside health care services (80% of HC.5) • Part of health system administration and governance costs (80% of HC.7) The medical goods category under the HC classification includes medicines purchased outside the inpatient and outpatient setting (in pharmacies and markets) or paid for separately from the consultation fee. The PHC com- ponent of medical goods includes only those for general outpatient use and self-prescribed medicine. It does not include medical goods for specialized outpatient and inpatient services. Following these criteria and assum- ing most spending recorded for medical goods is for PHC, 80% of medical goods spending was attributed to PHC spending under this global definition. Governance functions are mainly related to the administration, development and implementation of policies, and the administration of health financing. Policy development, implementation and coordination are popu- lation-based interventions in the broader public health scope and so are considered as PHC. According to this criterion, 80% of spending in the governance category is counted as PHC spending. This includes all current expenditure, regardless of the source (domestic and donor funding). Disaggregation(s) PHC-specific expenditure Source of funding (e.g., GGHE-D, private, external) Numerator Sum of all current expenditure on health (12-month period). Denominator GDP Preferred data source National health account (NHA) Rationale Health expenditure as a share of GDP provides an indication on the level of resources channelled to health relative to other uses. It shows the importance of the health sector in the whole economy and indicates the societal priority which health is given, measured in monetary terms. 34 2.3 Financing indicators Reference(s) 2018 Global reference list of 100 core health indicators (plus health-related SDGs). Geneva: World Health Organization; 2018 (https://apps.who.int/iris/bitstream/handle/10665/259951/WHO-HIS-IER-GPM-2018.1-eng. pdf?sequence=1&isAllowed=y, accessed 16 August 2021). Methodology for the update of the Global Health Expenditure Database, 2000-2018: Technical note. Version December 2020 (https://apps.who.int/nha/database/DocumentationCentre/GetFile/58717361/en, accessed 16 August 2021). World Health Organization. Global Health Expenditure Database (https://apps.who.int/nha/database, accessed 16 August 2021). Global spending on health: a world in transition. Geneva: World Health Organization; 2019 (WHO/HIS/HGF/ HFWorkingPaper/19.4). Licence: CC BY-NC-SA 3.0 IGO (https://www.who.int/health_financing/documents/ health-expenditure-report-2019.pdf, accessed 17 August 2021). Organisation for Economic Co-operation and Development (OECD), Eurostat, and World Health Organization. A system of health accounts 2011. OECD; 2011 (https://www.who.int/health-accounts/methodology/sha2011. pdf, accessed 18 August 2021). Existing data collection tool OECD and World Health Organization. Guidelines for the implementation of the SHA 2011 framework for accounting health care financing. OECD; 2014 (https://www.who.int/health-topics/health-accounts#tab=tab_1, accessed 18 August 2021) [Can be found in the Guidelines Tab]. 35 Indicator15 Per capita total health expenditure (and PHC specific) Financing Indicator short name Per capita total health expenditure (and PHC-specific) Indicator long name PHC expenditure per capita (as disaggregation of total health expenditure. Domain Financing Sub-domain Funding and allocation of resources M/E domain Structures Definition Per capita health expenditure (total and PHC-specific) PHC expenditure is calculated as follows based upon data from the SHA2011: 4 • General outpatient curative care (HC.1.3.1) - such as visits to a general practitioner or nurse • Dental outpatient curative care (HC.1.3.2) - such as visits for regular control and other oral treatment • Curative outpatient care not elsewhere classified. (HC.1.3.nec), excluding specialized outpatient care • Home-based curative care (HC.1.4), such as home visits by a general practitioner or nurse • Outpatient (HC.3.3) and home-based (HC.3.4) long-term health care • Preventive care (HC.6), such as immunization, health check-ups, health education, disease detection, monitoring and emergency response programmes • Part of medical goods provided outside healthcare services (80% of HC.5) • Part of health system administration and governance costs (80% of HC.7) The medical goods category under the HC classification includes medicines purchased outside the inpatient and outpatient setting (in pharmacies and markets) or paid for separately from the consultation fee. The PHC com- ponent of medical goods includes only those for general outpatient use and self-prescribed medicine. It does not include medical goods for specialized outpatient and inpatient services. Following these criteria and assum- ing most spending recorded for medical goods is for PHC, 80% of medical goods spending was attributed to PHC spending under this global definition. Governance functions are mainly related to the administration, development and implementation of policies, and the administration of health financing. Policy development, implementation and coordination are popu- lation-based interventions in the broader public health scope and so are considered as PHC. According to this criterion, 80% of spending in the governance category is counted as PHC spending. Disaggregation(s) PHC-specific expenditure Source of funding (e.g., GGHE-D, private, external) Numerator Total health expenditure and Total current PHC expenditure (in U.S. dollars) Denominator Population count Preferred data source NHA Rationale This indicator calculates the average expenditure on health per person. It contributes to understanding the health expenditure relative to the population size, facilitating international comparison. The per capita expenditure for PHC demonstrates levels of health expenditure that are used for PHC. 36 Reference(s) 2018 Global reference list of 100 core health indicators (plus health-related SDGs). Geneva: World Health Organization; 2018 (https://apps.who.int/iris/bitstream/handle/10665/259951/WHO-HIS-IER-GPM-2018.1-eng. pdf?sequence=1&isAllowed=y, accessed 16 August 2021). World Health Organization. Methodology for the update of the Global Health Expenditure Database, 2000- 2018: Technical note. Version December 2020 (https://apps.who.int/nha/database/DocumentationCentre/ GetFile/58717361/en, accessed 16 August 2021). World Health Organization. Global Health Expenditure Database (https://apps.who.int/nha/database, accessed 16 August 2021). Global spending on health: a world in transition. Geneva: World Health Organization; 2019 (WHO/HIS/HGF/ HFWorkingPaper/19.4). License: CC BY-NC-SA 3.0 IGO (https://www.who.int/health_financing/documents/ health-expenditure-report-2019.pdf, accessed 17 August 2021). Organisation for Economic Co-operation and Development (OECD), Eurostat, and World Health Organization. A system of health accounts 2011. OECD; 2011 (https://www.who.int/health-accounts/methodology/sha2011. pdf, accessed 18 August 2021). Existing data collection tool OECD and World Health Organization. Guidelines for the implementation of the SHA 2011 framework for accounting health care financing. OECD; 2014 (https://www.who.int/health-topics/health-accounts#tab=tab_1, accessed 18 August 2021) [Can be found in the Guidelines Tab]. 37 Indicator16 Government PHC spending as percentage of government health expenditure Financing Indicator short name Government PHC spending as percentage of government health expenditure Indicator long name Government PHC spending as percentage of total government health expenditure Domain Financing Sub-domain Funding and allocation of resources M/E domain Structures Definition Domestic general government expenditure on PHC as a share of domestic general government health expenditure PHC expenditure is calculated as follows, based upon data from the SHA2011:4 • General outpatient curative care (HC.1.3.1), such as visits to a general practitioner or nurse • Dental outpatient curative care (HC.1.3.2), such as visits for regular control and other oral treatment • Curative outpatient care not elsewhere classified. (HC.1.3.nec), excluding specialized outpatient care • Home-based curative care (HC.1.4), such as home visits by a general practitioner or nurse • Outpatient (HC.3.3) and home-based (HC.3.4) long-term health care • Preventive care (HC.6), such as immunization, health check-ups, health education, disease detection, monitoring and emergency response programmes • Part of medical goods provided outside health care services (80% of HC.5) • Part of health system administration and governance costs (80% of HC.7) The medical goods category under the HC classification includes medicines purchased outside the inpatient and outpatient setting (in pharmacies and markets) or paid for separately from the consultation fee. The PHC com- ponent of medical goods includes only those for general outpatient use and self-prescribed medicine. It does not include medical goods for specialized outpatient and inpatient services. Following these criteria and assum- ing most spending recorded for medical goods is for PHC, 80% of medical goods spending was attributed to PHC spending under this global definition. Governance functions are mainly related to the administration, development and implementation of policies, and the administration of health financing. Policy development, implementation and coordination are popu- lation-based interventions in the broader public health scope and so are considered as PHC. According to this criterion, 80% of spending in the governance category is counted as PHC spending. Disaggregation(s) Not applicable Numerator Government expenditure on PHC Denominator General government expenditure on health Preferred data source NHA Rationale The amount of government spending on health devoted to PHC reflects the level of prioritization of PHC by the government as well as the sustainability of financing for PHC. Public funding should be prioritized to ensure equity of access and financial protection through a PHC approach. 38 Reference(s) 2018 Global reference list of 100 core health indicators (plus health-related SDGs). Geneva: World Health Organization; 2018 (https://apps.who.int/iris/bitstream/handle/10665/259951/WHO-HIS-IER-GPM-2018.1-eng. pdf?sequence=1&isAllowed=y, accessed 16 August 2021). World Health Organization. Methodology for the update of the Global Health Expenditure Database, 2000- 2018: Technical note. Version December 2020 (https://apps.who.int/nha/database/DocumentationCentre/ GetFile/58717361/en, accessed 16 August 2021). World Health Organization. Global Health Expenditure Database (https://apps.who.int/nha/database, accessed 16 August 2021). Global spending on health: a world in transition. Geneva: World Health Organization; 2019 (WHO/HIS/HGF/ HFWorkingPaper/19.4). Licence: CC BY-NC-SA 3.0 IGO (https://www.who.int/health_financing/documents/ health-expenditure-report-2019.pdf, accessed 17 August 2021). Organisation for Economic Co-operation and Development (OECD), Eurostat, and World Health Organization. A system of health accounts 2011. OECD; 2011 (https://www.who.int/health-accounts/methodology/sha2011. pdf, accessed 18 August 2021). Existing data collection tool OECD and World Health Organization. Guidelines for the implementation of the SHA 2011 framework for accounting health care financing. OECD; 2014. (https://www.who.int/health-topics/health-accounts#tab=tab_1, accessed 18 August 2021) [Can be found in the Guidelines Tab]. 39 Indicator17 Sources of expenditure on health (and PHC-specific) Indicator short name Sources of expenditure on health (and PHC-specific) Indicator long name Sources of expenditure on health including out-of-pocket (and PHC-specific) Domain Financing Sub-domain Funding and allocation of resources M/E domain Structures Definition Distribution of expenditure on health by source (private (including (out of pocket), domestic government, external) Expenditure on PHC from pre-paid sources: Proportion of expenditure from pre-paid sources (all sources but out-of- pocket), including change in this proportion over time as a measure of promotion of the use of PHC by making PHC a priority to make financially accessible. PHC expenditure is calculated as follows, based upon data from the SHA2011:4 • General outpatient curative care (HC.1.3.1), such as visits to a general practitioner or nurse • Dental outpatient curative care (HC.1.3.2), such as visits for regular control and other oral treatment • Curative outpatient care not elsewhere classified. (HC.1.3.nec), excluding specialized outpatient care • Home-based curative care (HC.1.4), such as home visits by a general practitioner or nurse • Outpatient (HC.3.3) and home-based (HC.3.4) long-term health care • Preventive care (HC.6), such as immunization, health check-ups, health education, disease detection, monitoring and emergency response programmes • Part of medical goods provided outside health care services (80% of HC.5) • Part of health system administration and governance costs (80% of HC.7) The medical goods category under the HC classification includes medicines purchased outside the inpatient and outpatient setting (in pharmacies and markets) or paid for separately from the consultation fee. The PHC component of medical goods includes only those for general outpatient use and self-prescribed medicine. It does not include medical goods for specialized outpatient and inpatient services. Following these criteria and assuming most spending recorded for medical goods is for PHC, 80% of medical goods spending was attributed to PHC spending under this global definition. Governance functions are mainly related to the administration, development and implementation of policies, and the administration of health financing. Policy development, implementation and coordination are population- based interventions in the broader public health scope and so are considered as PHC. According to this criterion, 80% of spending in the governance category is counted as PHC spending. Disaggregation(s) PHC-specific expenditure Source: out of pocket, domestic government, external Numerator Total expenditure on health from each relevant source (government schemes, compulsory contributory health care financing, voluntary health care payment schemes, household out-of-pocket, rest of world financing schemes, other) Denominator Total expenditure on health Preferred data source NHA Financing 40 Rationale The distribution of sources for expenditure on health reflects the mix of resources available to support a country’s health system. The share of domestic general government resources used to fund health expenditures out of total current health expenditures indicates what proportion of public sector spending is devoted to health. Public sources include domestic revenue (such as internal transfers and grants, transfers, subsidies to voluntary health insurance beneficiaries, NPISH or enterprise financing schemes) as well as compulsory prepayment and social health insurance contributions. All these transfers and subsidies represent public sources for health and indicate the government’s overall contribution to funding health care relative to other sources of funding from domestic private and external sources. The share of domestic private expenditures on health of the total current health expenditures indicates how much is funded domestically by the private sector. Private sector funds stem from households, corporations and non-profit organizations. Such expenditures can be either prepaid to voluntary health insurance or paid directly to health care providers. This indicator describes the role of the private sector in funding health care relative to public or external sources. Out-of-pocket expenditure estimates how much households in each country are spending on health directly out of pocket. The share of external sources spent on health as a percentage of total current health expenditures indicates how much the health system is dependent on external funding sources relative to domestic sources. External sources compose of direct foreign transfers and foreign transfers distributed by government encompassing all financial inflows into the national health system from outside the country. Reference(s) 2018 Global reference list of 100 core health indicators (plus health-related SDGs). Geneva: World Health Organization; 2018 (https://apps.who.int/iris/bitstream/handle/10665/259951/WHO-HIS-IER-GPM-2018.1-eng. pdf?sequence=1&isAllowed=y, accessed 16 August 2021). World Health Organization. Methodology for the update of the Global Health Expenditure Database, 2000- 2018: Technical note. Version December 2020 (https://apps.who.int/nha/database/DocumentationCentre/ GetFile/58717361/en, accessed 16 August 2021). World Health Organization. Global Health Expenditure Database (https://apps.who.int/nha/database, accessed 16 August 2021). Global spending on health: a world in transition. Geneva: World Health Organization; 2019 (WHO/HIS/HGF/ HFWorkingPaper/19.4). Licence: CC BY-NC-SA 3.0 IGO (https://www.who.int/health_financing/documents/ health-expenditure-report-2019.pdf, accessed 17 August 2021). Organisation for Economic Co-operation and Development, Eurostat, and World Health Organization. A system of health accounts 2011. OECD; 2011 (https://www.who.int/health-accounts/methodology/sha2011.pdf, accessed 18 August 2021). Existing data collection tool OECD and World Health Organization. Guidelines for the implementation of the SHA 2011 framework for accounting health care financing. OECD; 2014 (https://www.who.int/health-topics/health-accounts#tab=tab_1, accessed 18 August 2021) [Can be found in the Guidelines Tab]. 41 Indicator18 Contingency funds available for emergencies Indicator short name Contingency funds available for emergencies Indicator long name Contingency funds are available for emergencies Domain Financing Sub-domain Funding and allocation of resources M/E domain Structures Definition Contingency funds available for emergencies, measured against the following criteria: • An emergency contingency fund exists at the national, regional or international level, with which a national or subnational authority can coordinate the reception and distribution of funds for responding to emergencies is in place at the national, intermediate and local levels. (IHR. SPAR C1.3). • Contingency funding having explicit coverage on maintenance of essential health services, including primary care services. • Financing can be executed and monitored in a timely and coordinated manner at all levels and for all relevant sectors, with an emergency contingency fund in place, for response to an acute public health emergency. (IHR JEE P1.3 Sustainable capacity) Disaggregation(s) National and subnational Numerator Not applicable Denominator Not applicable Preferred data source Qualitative assessment based on interview with key informant and/or desk review of country documents Rationale Contingency funds for emergencies that allow WHO to access funds to respond to emergencies, often in 24 hours or less, are a critical part of emergency response preparedness. Ability to quickly respond to emergencies can stave off unnecessary suffering and save lives. This emergency fund also serves to support continuity of services during an emergency when there are gaps in other donor funds. Reference(s) Health emergency and disaster risk management framework. Geneva: World Health Organization; 2019 (https://apps.who.int/iris/handle/10665/326106, accessed 16 August 2021). (caveat: does not cover funding “maintenance of essential health services” aspects. World Health Organization. State Party Annual Report for IHR (e-SPAR) (https://extranet.who.int/e-spar, accessed 16 August 2021). Joint External Evaluation Tool: International Health Regulations (2005) – 2nd ed. Geneva: World Health Organization, 2018 (https://apps.who.int/iris/handle/10665/259961, accessed 19 August 2021). Existing data collection tool World Health Organization. IHR (2005) State Party Self-Assessment Annual Reporting Tool (SPAR). Geneva: World Health Organization; 2018 (https://www.who.int/publications/i/item/WHO-WHE-CPI-2018-16, accessed 16 August 2021). Financing 42 Indicator19 Services included in health benefits package (including primary care) Financing Indicator short name Services included in HBP (including primary care) Indicator long name Explicit definition of HBP (including primary care services) to be prioritized for UHC and financed from public sources Domain Financing Sub-domain Purchasing and payment systems M/E domain Structures Definition UHC package (health benefits package) defines a set of services to be financed from public sources that have been assessed for inclusion in the benefit package as part of a systematic, transparent process including criteria on economic evidence and budget impact/cost-effectiveness. • There is a set of explicitly defined benefits for the entire population • Decisions on those services to be publicly funded made transparently, using explicit criteria and participatory processes • Entitlements and conditions of access are clearly defined and communicated to the population • User charges are clear and include mechanisms to exempt vulnerable persons • Participation in the development of the HBP includes broad range of stakeholders, including: Other relevant sectoral ministries Members of parliamentary health committee Civil society organizations (advocacy groups, population groups, including vulnerable, marginalized and excluded populations) Patients Health workers Health insurance bodies Provider organizations/associations Disaggregation(s) Type of service: e.g., prevention, promotion, treatment/rehabilitation, palliation Disease area/life-course need Delivery platform: e.g., (primary care (including community-based care), referral care, home care, long-term care, etc. Numerator Not applicable Denominator Not applicable Preferred data source Qualitative assessment based on interview with key informant and/or desk review of country documents 43 Rationale Benefit policy comprises decisions on population entitlements (i.e., publicly funded services) and medicines and other medical products. Also, part of benefit policy decisions are decisions on the conditions of access, such as the need for a co-payment or adherence to a referral system. Together, these two aspects can shape the way in which publicly funded services are delivered, and how they are accessed. International experience shows that general declarations of UHC or benefit entitlements for the population are not enough to make real progress; in contrast, being explicit and clear about entitlements and any related conditions of access, reduces uncertainty for the population (which generally constitutes a barrier to accessing services) is a move in a positive direction. Increasing transparency does not mean defining benefits in detail, as this can be confusing, especially where covered services are defined in long complicated lists. Many countries are becoming more explicit about what the population is, and is not, entitled to - for example, through packages of essential services. While benefit design can influence health system performance, and should be rooted in evidence, difficult choices on trade-offs will need to be made and hence many decisions are also inherently political. A transparent process which considers both technical evidence and societal values is important to make priorities with widespread support. Many countries are now establishing such processes. Overarching concerns which guide decisions include efficiency, equity, and financial protection, but the balance between these will vary across countries. Incorporating population demands or preferences is also important, as is the budget impact of any decisions; funding public or semi-public goods is also of critical importance. Reference(s) Included in Stage 2 – benefits and conditions of access in the health financing progress matrix. Assessing country health financing systems: the health financing progress matrix. Geneva: World Health Organization; 2020 (https://www.who.int/teams/health-systems-governance-and-financing/health-financing/ diagnostics/health-financing-progress-matrix, accessed 16 August 2021). The health financing progress matrix: country assessment guide. Geneva: World Health Organization; 2020 (https://www.who.int/teams/health-systems-governance-and-financing/health-financing/diagnostics/health- financing-progress-matrix, accessed 16 August 2021). Existing data collection tool World Health Organization. Web Annex. Data collection template. In: The health financing progress matrix: country assessment guide. Geneva: World Health Organization; 2020 (https://www.who.int/teams/health- systems-governance-and-financing/health-financing/diagnostics/health-financing-progress-matrix, accessed 16 August 2021). 44 Indicator20 Purchasing and provider payment methods are in place (including in primary care) Financing Indicator short name Purchasing and provider payment methods are in place (including in primary care) Indicator long name Purchasing and provider payment methods are in place (including in primary care) Domain Financing Sub-domain Purchasing and payment systems M/E domain Structures Definition Appropriate provider payment methods are in place as measured against the following criteria: • Payment of providers is driven by information on the health needs of the population they serve • Provider payments harmonized within and across purchasers to ensure coherent incentives for providers • Purchasing arrangements promote quality of care • Provider payment methods and complementary administrative mechanisms address potential over- or under- provision of services • Information on providers’ activities captured by purchasers adequate to guide purchasing decisions • Providers have financial autonomy and are held accountable Disaggregation(s) Not applicable Numerator Not applicable Denominator Not applicable Preferred data source Qualitative assessment based on interview with key informant and/or desk review of country documents. Rationale The way in which providers are paid is one of the most powerful ways to influence the performance of providers, from several perspectives, including the quality and efficiency of services provided. Depending on the type of provider payment system in place, providers have different incentives for health services delivery. For example, when a payment system is based on the quantity of services (fee-for-service), quality and efficiency might not get the same level of importance. To ensure that patients get the highest-quality care, appropriate provider payments need to be implemented. Reference(s) The health financing progress matrix: country assessment guide. Geneva: World Health Organization; 2020 (https://www.who.int/teams/health-systems-governance-and-financing/health-financing/diagnostics/health- financing-progress-matrix, accessed 16 August 2021). Operational framework for primary health care: transforming vision into action. Geneva: World Health Organization and the United Nations Children’s Fund (UNICEF), 2020 (https://www.who.int/publications/i/ item/9789240017832, accessed 17 August 2021). Analytical guide to assess a mixed provider payment system. Geneva: World Health Organization; 2019 (https:// apps.who.int/iris/handle/10665/311020, accessed 25 August 2021). Existing data collection tool World Health Organization. Web Annex. Data collection template. In: The health financing progress matrix: country assessment guide. Geneva: World Health Organization; 2020 (https://www.who.int/teams/health- systems-governance-and-financing/health-financing/diagnostics/health-financing-progress-matrix, accessed 16 August 2021). 45 Indicator21 Health financing follows established guidelines Financing Indicator short name Health financing follows established guidelines Indicator long name Health financing (or access to health benefits package/insurance scheme) follows established guidelines Domain Financing Sub-domain Purchasing and payment systems M/E domain Structures Definition Health financing (or access to HBP or insurance scheme) follows WHO-recommended guidelines, including following criteria: • Population entitlements and conditions of access defined explicitly and in easy-to-understand terms • User charges are designed to ensure financial obligations are clear and have functioning protection mechanisms for patients • Defined benefits aligned with available revenues, available health services, and purchasing mechanisms Disaggregation(s) Not applicable Numerator Not applicable Denominator Not applicable Preferred data source Qualitative assessment based on interview with key informant and/or desk review of country documents. Rationale Benefit policy comprises decisions on population entitlements (i.e., publicly funded services) and medicines and other medical products. Also, part of benefit policy decisions are decisions on the conditions of access, such as the need for a co-payment or adherence to a referral system. Together, these two aspects can shape the way in which publicly funded services are delivered, and how they are accessed. Coverage policy, in terms of both entitlements and conditions of access, must be clearly defined and easy to understand for the population; when unsure, patients may decide not to seek the care they need. Transparency is hence a key objective of health systems, and requires avoiding overly detailed, differentiated and complicated entitlements and conditions of access. It means avoiding technical language and generally keeping things simple but clear. Fixed amount co-payments are easy for people to understand and reduce uncertainty about the payment required. Additional policy measures which protect patients against excessive payments include annual caps on total co-payments and the use of exemptions; in both cases implementation will be difficult where administrative capacity is weak, and detailed information is not available. Simpler approaches such as targeted exemptions for certain services, or geographical areas, are more likely to be administratively feasible. Decisions by policymakers on benefit design (i.e., both entitlements and conditions of access) can be one of the most powerful instruments or levers through which health system performance can be improved, especially when realistically aligned with available revenues and coordinated with complementary reinforcing policies such as the development of programme budgets and improvements in strategic purchasing. Reference(s) Included in Stage 2 – benefits and conditions of access in the health financing progress matrix. Assessing country health financing systems: the health financing progress matrix. Geneva: World Health Organization; 2020 (https://www.who.int/teams/health-systems-governance-and-financing/health-financing/ diagnostics/health-financing-progress-matrix, accessed 16 August 2021). The health financing progress matrix: country assessment guide. Geneva: World Health Organization; 2020 (https://www.who.int/teams/health-systems-governance-and-financing/health-financing/diagnostics/health- financing-progress-matrix, accessed 16 August 2021). Existing data collection tool World Health Organization. Web Annex. Data collection template. In: The health financing progress matrix: country assessment guide. Geneva: World Health Organization; 2020 (https://www.who.int/teams/health- systems-governance-and-financing/health-financing/diagnostics/health-financing-progress-matrix, accessed 16 August 2021). 46 Indicator22 Health facility density/distribution (including primary care) Physical infrastructure Indicator short name Health facility density/distribution (including primary care) Indicator long name Health facility density/distribution (including primary care) Domain Physical infrastructure Sub-domain Physical infrastructure M/E domain Inputs Definition Total number of health facilities (and primary care facilities) per 10 000 population, disaggregated by managing authority. Disaggregation(s) Facility type (as relevant to context): including, primary care facilities (e.g., GP practices, health centres, community health posts), specialty outpatient facilities (including polyclinics), first-level hospitals, second-level hospitals, specialty hospitals, long-term care facilities, continuing care facilities, traditional medicine, etc. Managing authority: public, private Sub-National Urban/rural Numerator Number of facilities in public and private sectors Denominator Total population Preferred data source Routine facility information system – facility database/master facility list, geospatial modelling Rationale Provides an idea of geographic accessibility to health services. Availability of health facilities, especially facilities that provide primary health care services is critical for achieving UHC. This indicator is also a key measure of equity as it demonstrates the levels of physical access to health services. Reference(s) 2018 Global reference list of 100 core health indicators (plus health-related SDGs). Geneva: World Health Organization; 2018 (https://apps.who.int/iris/bitstream/handle/10665/259951/WHO-HIS-IER-GPM-2018.1-eng. pdf?sequence=1&isAllowed=y, accessed 16 August 2021). Existing data collection tool Routine health information system 47 2.4 Physical infrastructure indicators Indicator23 Availability of basic water, sanitation and hygiene amenities Physical infrastructure Indicator short name Availability of basic water, sanitation and hygiene (WASH) amenities Indicator long name Percentage of facilities with availability of basic WASH amenities (potable water, toilet, sink, waste management, cleaning) Domain Physical infrastructure Sub-domain Physical infrastructure M/E domain Inputs Definition Percentage of facilities that have basic WASH amenities: • Water: available from an improved source, on premises • Sanitation: Improved facilities are usable, with at least one toilet for staff, one sex-separated with menstrual hygiene facilities and at least one accessible for those with limited mobility • Hand hygiene: functional hand hygiene facility (water with soap and/or ABHR) at points of care and within 5 metres of toilets • Health care waste: waste is safely segregated into three bins and sharps and infectious waste and treated and disposed of safely • Cleaning: basic protocols for cleaning are available and staff with cleaning responsibilities have received training Disaggregation(s) Facility type: hospital, non-hospital Managing authority: government, non-government Urban/rural Numerator Number of health facilities that meet basic WASH standards Denominator Total number of facilities examined Preferred data source Facility survey Rationale WASH services in health care facilities are fundamental to providing quality care, adhering to infection prevention and control standards and to the acceptability of health facilities. Reference(s) Core questions and indicators for monitoring WASH in health care facilities in the Sustainable Development Goals. Geneva: World Health Organization and the UNICEF; 2018 (https://www.who.int/water_sanitation_ health/publications/monitoring-wash-in-health-care-facilities-aug-2018.pdf, accessed 16 August 2021). Global progress report on WASH in health care facilities: Fundamentals first. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/9789240017542, accessed 16 August 2021). WHO/UNICEF Joint Monitoring Programme. Latest database: (http://washdata.org/data/healthcare, accessed 16 August 2021). Existing data collection tool From existing health facility survey tools such as World Health Organization’s Service Availability and Readiness Assessments (SARA) and Harmonized Health Facility Assessments (HHFA), World Bank’s Service Delivery Indicators (SDI), and DHS program’s Service Provision Assessment (SPA). World Health Organization. Service Availability and Readiness Assessment (https://www.who.int/data/data- collection-tools/service-availability-and-readiness-assessment-(sara)?ua=1, accessed 16 August 2021). World Health Organization. Harmonized Health Facility Assessment. March 2021 (https://www.who.int/data/ data-collection-tools/harmonized-health-facility-assessment/introduction, accessed 16 August 2021). The DHS Program. Service Provision Assessment. September 2020 (https://dhsprogram.com/publications/ publication-spaq1-spa-questionnaires-and-manuals.cfm, accessed 18 August 2021). World Bank. Service Delivery Indicators (https://www.sdindicators.org/, accessed 19 August 2021). To note: WHO is currently revising its facility survey modules to incorporate additional elements of PHC measurement and will provide recommended scoring methodology. 48 49 Indicator24 Availability of power Physical infrastructure Indicator short name Availability of power Indicator long name Percentage of facilities with availability of power Domain Physical infrastructure Sub-domain Physical infrastructure M/E domain Inputs Definition Percentage of facilities that use - at least some of the time - any source of electrical power, excluding standalone medical devices Disaggregation(s) Facility type (as relevant to context): including primary care facilities (e.g., GP practices, health centres, community health posts), first-level hospitals, second-level hospitals, specialty hospitals, long-term care facilities, continuing care facilities, etc.) Managing authority: public, private Subnational Urban/rural Numerator Number of health facilities with Denominator Total number of facilities Preferred data source Facility survey Rationale Access to electricity is a prerequisite for powering medical devices for diagnosis, disease prevention and treatment. It is required for the operation of critical medical devices, such as vaccine refrigeration, oxygen concentrators, foetal heart monitors, neonatal infant warmers and basic surgical and diagnostic equipment, as well as for lighting, clean water, communication and several other services. Reference(s) Operational framework for primary health care: transforming vision into action. Geneva: World Health Organization and the United Nations Children’s Fund (UNICEF), 2020 (https://www.who.int/publications/i/ item/9789240017832, accessed 17 August 2021). World Health Organization. Access to modern energy services for health facilities in resource-constrained settings: a review of status, significance, challenges and measurement. Geneva: World Health Organization; 2014 (https://apps.who.int/iris/handle/10665/156847, accessed 23 August 2021). Existing data collection tool From existing health facility survey tools such as World Health Organization’s SARA and HHFA, World Bank’s SDI, and DHS program’s SPA. World Health Organization. Service Availability and Readiness Assessment (https://www.who.int/data/data- collection-tools/service-availability-and-readiness-assessment-(sara)?ua=1, accessed 16 August 2021). The DHS Program. Service Provision Assessment. September 2020 (https://dhsprogram.com/publications/ publication-spaq1-spa-questionnaires-and-manuals.cfm, accessed 18 August 2021). World Bank. Service Delivery Indicators (https://www.sdindicators.org/, accessed 19 August 2021). World Health Organization. Harmonized Health Facility Assessment. March 2021 (https://www.who.int/data/ data-collection-tools/harmonized-health-facility-assessment/introduction, accessed 16 August 2021). To note: WHO is currently revising its facility survey modules to incorporate additional elements of PHC measurement. Indicator25 Availability of communications Physical infrastructure Indicator short name Availability of communications Indicator long name Percentage of facilities with a communication system in place Domain Physical infrastructure Sub-domain Physical infrastructure M/E domain Inputs Definition Percentage of facilities of that have access to communication systems as measured by the following attributes: • Facility ownership of telephone, radio and computer • Functioning telephone that is available to call outside at all times client services are offered • Functioning shortwave radio for radio calls • Functioning computer • Access to email or internet Disaggregation(s) Facility type (as relevant to context): including primary care facilities (e.g., GP practices, health centres, community health posts), first-level hospitals, second-level hospitals, specialty hospitals, long-term care facilities, continuing care facilities, etc.) Managing authority: public, private Subnational Urban/rural Numerator Number of health facilities with communication system Denominator Total number of facilities surveyed Preferred data source Facility survey Rationale Communication services in health care facilities are fundamental to providing quality care, enabling digital health capacities, and providing connectivity to patients, families and other health facilities. Reference(s) Operational framework for primary health care: transforming vision into action. Geneva: World Health Organization and the United Nations Children’s Fund (UNICEF), 2020 (https://www.who.int/publications/i/ item/9789240017832, accessed 17 August 2021). Access to modern energy services for health facilities in resource-constrained settings: a review of status, significance, challenges and measurement. Geneva: World Health Organization; 2014 (https://apps.who.int/iris/ handle/10665/156847, accessed 23 August 2021). Existing data collection tool From existing health facility survey tools such as World Health Organization’s SARA and HHFA, World Bank’s service delivery indicators, and DHS program’s SPA. World Health Organization. Service Availability and Readiness Assessment (https://www.who.int/data/data- collection-tools/service-availability-and-readiness-assessment-(sara)?ua=1, accessed 16 August 2021). The DHS Program. Service Provision Assessment. September 2020 (https://dhsprogram.com/publications/ publication-spaq1-spa-questionnaires-and-manuals.cfm, accessed 18 August 2021). World Bank. Service Delivery Indicators (https://www.sdindicators.org/, accessed 19 August 2021). World Health Organization. Harmonized Health Facility Assessment. March 2021 (https://www.who.int/data/ data-collection-tools/harmonized-health-facility-assessment/introduction, accessed 16 August 2021). To note: WHO is currently revising its facility survey modules to incorporate additional elements of PHC measurement. 50 51 Indicator26 Access to emergency transport for interfacility transfer Physical infrastructure Indicator short name Access to emergency transport for interfacility transfer Indicator long name Percentage of facilities with access to emergency transport for interfacility transfer Domain Physical infrastructure Sub-domain Physical infrastructure M/E domain Inputs Definition Percentage of facilities that have access to emergency transport measured by having key components: • Access to a functional ambulance or other vehicle for emergency transportation for patients that is either available by call or stationed at facility. • Emergency vehicle, emergency care health worker and a driver are available 24 hours Disaggregation(s) Facility type (as relevant to context): including primary care facilities (e.g., GP practices, health centres, community health posts), first-level hospitals, second-level hospitals, specialty hospitals, long-term care facilities, continuing care facilities, etc.) Managing authority: public, private Subnational Urban/rural Numerator Number of health facilities with emergency transport Denominator Total number of facilities examined Preferred data source Facility survey Rationale Emergency transport for interfacility transfer is important to improve the timely management of time-sensitive urgent/emergent conditions that cannot be adequately or completely managed in some facilities. Reference(s) World Health Organization. WHO Emergency Care System Framework (https://www.who.int/publications/i/item/ who-emergency-care-system-framework, accessed 17 August 2021). Operational framework for primary health care: transforming vision into action. Geneva: World Health Organization and the United Nations Children’s Fund (UNICEF), 2020 (https://www.who.int/publications/i/ item/9789240017832, accessed 17 August 2021). Existing data collection tool From existing health facility survey tools such as World Health Organization’s SARA and HHFA, World Bank’s service delivery indicators, and DHS program’s SPA. World Health Organization. Service Availability and Readiness Assessment (https://www.who.int/data/data- collection-tools/service-availability-and-readiness-assessment-(sara)?ua=1, accessed 16 August 2021). The DHS Program. Service Provision Assessment. September 2020 (https://dhsprogram.com/publications/ publication-spaq1-spa-questionnaires-and-manuals.cfm, accessed 18 August 2021). World Bank. Service Delivery Indicators (https://www.sdindicators.org/, accessed 19 August 2021). World Health Organization. Harmonized Health Facility Assessment (HHFA). March 2021 (https://www.who.int/ data/data-collection-tools/harmonized-health-facility-assessment/introduction, accessed 16 August 2021). To note: WHO is currently revising its facility survey modules to incorporate additional elements of PHC measurement. Indicator27 Health worker density and distribution Health workforce Indicator short name Health worker density and distribution Indicator long name Health worker density per 10 000 population and distribution (by occupation, health facility type, managing authority, location, GINI) Domain Health workforce Sub-domain Health workforce M/E domain Inputs Definition Number of health workers per 10 000 population by occupation Total population as estimated by the UN Statistics Division. In case of other methodology used, WHO recalculates densities according to the UN Statistics population data to harmonize the densities and ensure comparability. Disaggregation(s) By activity level the following categories are recommended: practising health workers, professionally active health workers, and health workers licensed to practise. The PHC workforce includes all occupations engaged in providing health promotion, disease prevention, treatment, rehabilitation and palliative care services, the public health workforce, and those engaged in addressing the social determinants of health with a specific focus on general medical practitioners, nurses, midwives and community health workers (CHWs). It also includes caregivers and volunteers, the majority of whom are women, who complement the work of salaried workers. By Occupation: (ISCO-08 codes included in parentheses) Medical Doctors (221) • Generalist medical practitioners (2211) • Specialist medical practitioners (2212) Nursing and midwifery professionals (222) • Nursing professionals (2221) • Midwifery professionals (2222) Traditional and complementary medicine professionals (223) Other health professionals (226) • Dentists (2261) • Pharmacists (2262) • Environmental and occupational health and hygiene professionals (2263) • Physiotherapists (2264) • Dietitians and nutritionists (2265) • Audiologists and speech therapists (2266) • Optometrists and ophthalmic opticians (2267) • CHWs (3253) By health facility types based on the classification of NHWA (NHWA indicator 1-06): • Hospitals (HP.1) • Residential long-term care facilities (HP.2) • Providers of ambulatory health care (HP.3) (including facilities, community services, individual providers) • Ancillary services (HP.4) (including transportation, emergency rescue, laboratories and others) • Retailers (HP.5) (including pharmacies) • Providers of preventive care (HP.6) 52 2.5 Health workforce indicators 53 Density of family medicine practitioners per 100 000 population (NHWA 8-05) Family medicine practitioners are part of the generalist medical practitioners classified in ISCO-08 with code 2212. They are referred to as general practitioners in some countries, and as a specialization in others. They should provide person-centred, continuous and comprehensive medical care to individuals and families in their communities. This group does not include resident medical officers, medical interns or other generalist medical practitioners not in general practice activities. Gender (NHWA indicator 1-04) Age (NHWA indicator 1-03) Managing authority (public/private) (NHWA indicator 1-05) Location (district, province, national, etc) (NHWA indicator 1-02) Gini index of subnational (first administrative level) To better understand the stock and distribution of health workforce-supporting integrated health services em- phasizing primary care and public health functions, disaggregation by both occupation and health facility type are particularly helpful. The occupations and facility types that should be considered as part of public health and primary care will vary according to national context, established models of care and relative roles and re- sponsibilities of service delivery platforms. Understanding the density of family medicine practitioners relative to other practitioners is one way to demonstrates the relative staffing of primary care in relationship to other service delivery platforms. Numerator Number of health workers by occupation Denominator Total population as estimated by the UN Statistics Division. In case of other methodology used, WHO recalcu- lates densities according to the UN Statistics population data in order to harmonize the densities and ensure comparability Preferred data source NHWA Rationale The concept of a multidisciplinary primary care workforce that was articulated in the Declaration of Alma-Ata is as valid and relevant today as it was 40 years ago. To progress toward UHC, countries will need a health workforce that is aligned with population and community health needs and which can adjust to the growing demand for health care driven by rapid demographic, epidemiological, economic, social and political changes. The primary health care workforce includes all occupations engaged in providing health promotion, disease prevention, treatment, rehabilitation and palliative care services, the public health workforce, and those engaged in addressing the social determinants of health with a specific focus on general medical practitioners, nurses, midwives and CHWs. It also includes caregivers and volunteers, the majority of whom are women, who complement the work of salaried workers. Ensuring that all occupations play an effective role in the PHC team, including through role optimization and role substitution, can transform traditional models of service provision. Preparing the health workforce to work toward the attainment of a country’s health objectives represents one of the most important challenges for its health system. Methodologically, there are no gold standards for assessing the sufficiency of the health workforce to address the health care needs of a given population. It has been estimated, however, in the World Health Report 2006, that countries with fewer than 23 physicians, nurses and midwives per 10 000 population generally fail to achieve adequate coverage rates for selected PHC interventions as prioritized by the Millennium Development Goals framework. Reference(s) Building the primary health care workforce of the 21st century. Geneva: World Health Organization; 2018 (https://apps.who.int/iris/handle/10665/328072, accessed 16 August 2021). National Health Workforce Accounts: a handbook. Geneva: World Health Organization; 2017 (https://apps. who.int/iris/bitstream/handle/10665/259360/9789241513111-eng.pdf?sequence=1, accessed 16 August 2021). Existing data collection tool WHO National Health Workforce Accounts (https://apps.who.int/nhwaportal/, accessed 19 August 2021). Indicator28 Accreditation mechanisms for education and training institutions Health workforce Indicator short name Accreditation mechanisms for education and training institutions Indicator long name Existence of national and/or subnational mechanisms for accreditation of education and training institutions and their programmes Domain Physical infrastructure Sub-domain Physical infrastructure M/E domain Inputs Definition There are national and/or subnational mechanisms for accreditation of education and training institutions, health care organizations and their programmes, measured against the following criteria: • National and/or subnational mechanisms for accreditation of health workforce education and training institutions and their programmes have been established • National and/or subnational mechanisms for accreditation of health workforce education and training institutions and their programmes are compulsory • Additional, non-compulsory, national and/or subnational mechanisms for accreditation of health workforce education and training institutions and their programmes exist • National and/or subnational mechanisms for accreditation of health workforce education and training institutions and their programmes take into account national education plans for the health workforce: Match health worker competencies with population, health systems, and health labour market needs Take into account efforts to scale up transformative education and training? Recognized institutes such as national public health institutes, universities and collaborating centres offer training courses on the implementation and monitoring of Health in All Policies and related concepts? Strategic steps are taken when considering and taking into account the workforce market needs and absorptive capacities for the education plan development Disaggregation(s) By Occupation: (ISCO-08 codes included in parentheses) • Medical Doctors (221) Generalist medical practitioners (2211) Specialist medical practitioners (2212) • Nursing and midwifery professionals (222) Nursing professionals (2221) Midwifery professionals (2222) • Traditional and complementary medicine professionals (223) • Other health professionals (226) Dentists (2261) Pharmacists (2262) Environmental and occupational health and hygiene professionals (2263) Physiotherapists (2264) Dietitians and nutritionists (2265) Audiologists and speech therapists (2266) Optometrists and ophthalmic opticians (2267) CHWs (3253) Family medicine practitioners 54 55 Numerator Not applicable Denominator Not applicable Preferred data source NHWA Rationale The accreditation of medical education and training - the certification of the suitability of health care education programmes, and of the competence of training institution in the delivery of training and education - ensures patient safety, quality of care and competent health care providers. For PHC, the focus for accreditation of medical education and training programmes will be for general medical practitioners, nurses and midwives. Reference(s) Building the primary health care workforce of the 21st century. Geneva: World Health Organization; 2018 (https://apps.who.int/iris/handle/10665/328072, accessed 16 August 2021). National Health Workforce Accounts: a handbook. Geneva: World Health Organization; 2017 (https://apps. who.int/iris/bitstream/handle/10665/259360/9789241513111-eng.pdf?sequence=1, accessed 16 August 2021). Existing data collection tool WHO National Health Workforce Accounts (https://apps.who.int/nhwaportal/, accessed 19 August 2021). Indicator29 National systems for continuing professional development Health workforce Indicator short name National systems for continuing professional development (CPD) Indicator long name Existence of national systems for CPD Domain Health workforce Sub-domain Health workforce M/E domain Inputs Definition There is a national system for CPD, measured against the following criteria: • It is compulsory • It is linked to re-licensure • It is integrated into national education plans for the health workforce, for that occupation (see NHWA indicator 09_04) Disaggregation(s) By Occupation: (ISCO-08 codes included in parentheses) • Medical Doctors (221) Generalist medical practitioners (2211) Specialist medical practitioners (2212) • Nursing and midwifery professionals (222) Nursing professionals (2221) Midwifery professionals (2222) • Traditional and complementary medicine professionals (223) • Other health professionals (226) Dentists (2261) Pharmacists (2262) Environmental and occupational health and hygiene professionals (2263) Physiotherapists (2264) Dietitians and nutritionists (2265) Audiologists and speech therapists (2266) Optometrists and ophthalmic opticians (2267) CHWs (3253) Family medicine practitioners Numerator Not applicable Denominator Not applicable Preferred data source NHWA Rationale CPD is critical for learning about new medical advances as well as maintaining knowledge. It will enable the workforce to deliver quality care and thus strengthens population health outcomes. For PHC, the focus on CPD will be on general medical practitioners, nursing and midwifery professionals. Reference(s) National Health Workforce Accounts: a handbook. Geneva: World Health Organization; 2017 (https://apps. who.int/iris/bitstream/handle/10665/259360/9789241513111-eng.pdf?sequence=1, accessed 16 August 2021). Existing data collection tool WHO National Health Workforce Accounts (https://apps.who.int/nhwaportal/, accessed 19 August 2021). 56 57 Indicator30 Regulatory mechanisms for medicines Medicines and other health products Indicator short name Regulatory mechanisms for medicines Indicator long name Regulatory mechanisms for medicines are established Domain Medicines and other health products Sub-domain Medicines and other health products M/E domain Inputs Definition There are regulatory mechanisms for medicines, measured against the following criteria: • National regulatory authority • Marketing authorization • Licensing of manufacturers • Licensing of importers, exporters, wholesalers and distributors • Licensing pharmacies and retail outlets • Registration of pharmacy personnel • Post-marketing surveillance and controls • Control of drug promotion and advertising • Pharmacovigilance • Regulation of clinical trials • Regulatory inspections • Laboratory quality control • Control of narcotics, psychotropic substances and precursors Disaggregation(s) Not applicable Numerator Not applicable Denominator Not applicable Preferred data source Qualitative/Key informant Rationale PHC relies on access to health products including medicines, vaccines, medical devices, in vitro diagnostics, protective equipment and vector-control tools, and assistive devices. These must be of assured safety, efficacy/ performance and quality. In addition, they must be appropriate, available and affordable. Poor or inadequate regulation can lead to the prevalence of poor standard, counterfeit, harmful and ineffective drugs on national markets and in the international commerce. This can result in serious harm to the health of individual consumers and even to the health of a wider population. Therefore, countries must continuously strengthen key drug regulatory responsibilities to ensure the safety, quality and efficacy of drugs and the accuracy of product information. Reference(s) WHO Expert Committee on Specifications for Pharmaceutical Preparations: fifty-fourth report. Geneva: World Health Organization; 2020 (WHO technical report series; no. 1025) (https://www.who.int/publications/i/ item/978-92-4-000182-4, accessed 23 August 2021). Good governance for medicines: model framework, updated version 2014. Geneva: World Health Organization; 2014 (https://apps.who.int/iris/handle/10665/129495, accessed 30 August 2021). Existing data collection tool WHO Data Collection Tool for the Review of Drug Regulatory Systems. Geneva: World Health Organization; 2007 (https://www.who.int/medicines/areas/quality_safety/regulation_legislation/ENdatacollectiontool. pdf?ua=1, accessed 16 August 2021). 2.6 Medicines and other health products indicators Indicator31 Availability of essential medicines Medicines and other health products Indicator short name Availability of essential medicines Indicator long name Percentage of health facilities that have a core set of relevant essential medicines available and affordable on a sustainable basis (SDG indicator) Domain Medicines and other health products Sub-domain Medicines and other health products M/E domain Inputs Definition Percentage of health facilities that have a core set of relevant essential medicines available and affordable on a sustainable basis The indicator is a multidimensional index reported as a proportion (%) of health facilities that have a defined core set of quality-assured medicines that are available and affordable relative to the total number of surveyed health facilities at national level. A medicine is available in a facility when it is found in this facility by the interviewer on the day of data collection (based on the following list): Category Medicines Noncommunicable diseases (NCD) respiratory Salbutamol; Beclomethasone NCD Diabetes Gliclazide, Metformin, insulin regular [soluble] NCD Cardiovascular Any two of the following hypertensives: Amlodipine, Enalapril, Hydrochlorothiazide or Chlorthalidone, Bisoprolol; NCD Cardiovascular Simvastatin, Acetylsalicylic acid (aspirin), Furosemide Pain and palliative care Morphine, paracetamol, ibuprofen for adults Central nervous system Fluoxetine; Phenytoin or Carbamazepine Anti-infective Gentamicin, Amoxicillin for adults, Ceftriaxone, Procaine benzylpenicillin or Benzathine benzylpenicillin Contraception - maternal child health (MCH) One of the following contraceptives: Ethinylestradiol + Levonorgestrel, Levonorgestrel (30 mcg cap/tab), Medroxyprogesterone acetate injection, progesterone-releasing implant (Etonogestrel or Levonorgestrel), Levonorgestrel (750 mcg or 1.5 mg tablet) MCH Oral rehydration salts, zinc sulphate, Oxytocin, magnesium sulphate, folic acid Anti-malarial One of the artemisinin-based combination therapies (ACT): Artemether + Lumefantrine, Artesunate + Amodiaquine, Artesunate + Mefloquine, Dihydroartemisinin + Piperaquine, Artesunate + Sulfadoxine + Pyrimethamine; Anti-malarial Artesunate Antiretroviral (ARV) One of combination ARV first-line treatment for HIV: Efavirenz + Emtricitabine + Tenofovir disoproxil fumarate, Efavirenz + Lamivudine + Tenofovir disoproxil fumarate Neonatal care Chlorohexidine Nutrition Ready-to-use therapeutic food (RUTF) Antituberculosis Isoniazid + pyrazinamide + rifampicin Chronic kidney disease Erythropoietin 58 59 Antiallergics and medicine used in anaphylaxis (optional) One of the following: Epinephrine injection, Dexamethasone injection Anti-fungal medicines (optional) Fluconazole, Nystatin Thyroid hormones (optional) Levothyroxine A medicine is affordable when no extra daily wages are needed for the lowest-paid unskilled government sector worker to purchase a monthly dose treatment of this medicine after fulfilling basic needs represented by the national poverty line. Affordability is measured as a ratio of 1) the sum of the national poverty line and the price per daily dose of treatment of the medicine, over 2) the lowest-paid government worker salary. This measures the number of extra daily wages needed to cover the cost of the medicines in the core set and that can vary between 0 and infinity. Disaggregation(s) Facility type (as relevant to context): including primary care facilities (e.g., GP practices, health centres, community health posts), first-level hospitals, second-level hospitals, specialty hospitals, long-term care facilities, continuing care facilities, etc. Managing authority: public, private Subnational Urban/rural Numerator Number of facilities that have a core set of relevant essential medicines available and affordable Denominator Total number of surveyed facilities per country Preferred data source Facility survey Rationale Access to medicines is a composite multidimensional concept that is composed of the availability of medicines and the affordability of their prices. Information on these two dimensions has been collected and analysed since the 54th World Health Assembly in 2001, when Member States adopted the WHO Medicines Strategy (resolution WHA54.11). This resolution led to the launch of the joint project on Medicine Prices and Availability by WHO and the international non-governmental organization Health Action International (HAI/WHO), as well as a proposed HAI/WHO methodology for collecting data and measuring components of access to medicines. To this day, this methodology has been widely implemented to produce useful analyses of availability and affordability of medicines, however the two dimensions have been evaluated separately. Reference(s) Operational framework for primary health care: transforming vision into action. Geneva: World Health Organization and the United Nations Children’s Fund (UNICEF), 2020 (https://www.who.int/publications/i/ item/9789240017832, accessed 17 August 2021). Model List of Essential Medicines, 21st List, 2019. Geneva: World Health Organization; 2019 (https://www. who.int/publications/i/item/WHOMVPEMPIAU2019.06, accessed 23 August 2021). United Nations Department of Economic and Social Affairs Statistics Division. United Nations Sustainable Development Goals Indicators Metadata repository (https://unstats.un.org/sdgs/metadata/, accessed 20 April 2021). 2018 Global reference list of 100 core health indicators (plus health-related SDGs). Geneva: World Health Organization; 2018 (https://apps.who.int/iris/bitstream/handle/10665/259951/WHO-HIS-IER-GPM-2018.1-eng. pdf?sequence=1&isAllowed=y, accessed 18 August 2021). Existing data collection tool While existing health facility survey tools such as the World Health Organization’s facility survey assessments, World Bank’s SD), and DHS program’s SPA measure availability of essential medicines, they are not all fully aligned to the SDG definition and they also do not collect information on affordability. World Health Organization. Service Availability and Readiness Assessment (https://www.who.int/data/data- collection-tools/service-availability-and-readiness-assessment-(sara)?ua=1, accessed 16 August 2021). World Health Organization. World Health Organization. Harmonized Health Facility Assessment (HHFA). March 2021 (https://www.who.int/ data/data-collection-tools/harmonized-health-facility-assessment/introduction, accessed 16 August 2021). The DHS Program. Service Provision Assessment. September 2020 (https://dhsprogram.com/publications/ publication-spaq1-spa-questionnaires-and-manuals.cfm, accessed 18 August 2021). World Bank. Service Delivery Indicators (https://www.sdindicators.org/, accessed 19 August 2021). To note: WHO is currently revising its facility survey modules to incorporate/address PHC-specific elements. 60 Indicator32 Availability of essential in vitro diagnostics Medicines and other health products Indicator short name Availability of essential in vitro diagnostics (IVDs) Indicator long name Percentage of health facilities with availability of essential IVDs Domain Medicines and other health products Sub-domain Medicines and other health products M/E domain Inputs Definition Percentage of health facilities with availability of appropriate set of essential IVDs and associated laboratory equipment and consumables for their health care facility level on a sustainable basis, based on the WHO’s model list of essential IVDs (EDL 3) and priority medical devices listed in the WHOMEDEVIS An in vitro diagnostic test and its associated laboratory equipment (when applicable) and consumables are available in a community setting or health facility when it is found in this setting/facility by the interviewer on the day of data collection (based on the following list): The EDL is presented by health care facility level in two tiers: I. Community and health settings without laboratories, with two sections: Ia. General IVDs for community and health settings without laboratories • Blood typing A, B and O blood groups and Rhesus (Rh) factor (Slide agglutination test) • Clinical chemistry Albumin ( dipstick) Bilirubin ( dipstick) Glucose ( dipstick/glucose meter) Ketones ( dipstick) Urinalysis test strips ( dipstick) • Haematology Erythrocyte sedimentation rate (Westergren) Haemoglobin (Haemoglobinometer) • Pregnancy testing Human chorionic gonadotrophin - rapid diagnostic test (RDT) Ib. Disease-specific IVDs for community and health settings without laboratories (See WHO EDL 3 for detailed information) • Trypanosoma cruzi IgG antibody (RDT) • Vibrio cholerae antigen (RDT) • SARS-CoV-2 antigen (RDT/Benchtop point of care (POC) instrument) • Haemoglobin A1c (Handheld analyser/POC) • Hepatitis B surface antigen (RDT) • Hepatitis B e antigen (RDT) • Antibodies to hepatitis C virus (RDT)HIV 1/2 antibody (RDT) • Combined HIV antibody/p24 antigen (RDT) • Qualitative HIV nucleic acid test (POC NAT) • CD4 cell enumeration (POC flow cytometer platform) • Cryptococcal antigen (RDT) • Influenza A and B antigen (RDT/Benchtop instrument-based POC immunoassay) • Influenza A and B nucleic acid test (POC NAT) • Plasmodium spp. antigens; species-specific (RDT) • Group A Streptococcus antigen (RDT) • Sickle cell Testing (RDT) 61 • Antibodies to Treponema pallidum (RDT) • Combined antibodies to T. pallidum and HIV-1/2 (RDT) • Tuberculin skin test/Mantoux test (Intradermal test) • Lipoarabinomannan antigen (RDT) • Recombinant K39 antigen (RDT) Laboratory equipment (from the WHO Priority Medical Devices list in MEDEVIS) • Clinical chemistry analyser/Clinical chemistry point of care (POC) analyser • Blood glucose meter/Glucometer • Haemoglobinometer • Dipstick analyser • Nucleic acid testing platform with accessories, closed system/POC NAT • Dedicated flow cytometer, with accessories/POC flow cytometer platform • Handheld analyser/POC for HbA1c • Benchtop instrument based POC immunoassay for Influenza A and B antigen • Benchtop instrument for POC use for COVID-19 • Laboratory bench top centrifuge for separation of samples • Westergren tubes • Rack, ESR • Microplates • Micro plate shaker • Rack, test tube • Tourniquets • Timer Consumable Supplies • Swab-pad, alcohol • Intravenous needle, child • Needles, sterile, single use • Syringes, single use • Venepuncture kit • Tube containing EDTA anticoagulant • Lancet, blood, safety, sterile • Container, sample • Biosafe, puncture-proof waste disposal box, for used syringes/needles, sharps • Swabs (nasal, nasopharyngeal, throat, rectal) • Medical mask • Gloves, examination • Protective goggles Disaggregation(s) Facility type (as relevant to context): including primary care facilities (e.g., GP practices, health centres, community health posts), first-level hospitals, long-term care facilities, continuing care facilities, etc.) Managing authority: public, private Subnational Urban/rural Numerator Number of surveyed health facilities with an appropriate set of essential in vitro diagnostic tests and associated laboratory equipment and consumables available Denominator Total number of surveyed facilities Preferred data source Facility survey Rationale The crucial role of IVDs has become widely acknowledged in a diverse range of areas including case finding, treatment, test of cure, outbreak response, surveillance, disease elimination, certification, and vaccine efficacy evaluation. Access to essential in vitro diagnostics is a central component of quality health services and indispensable to advance UHC, address health emergencies and promote healthier populations. 62 Reference(s) The selection and use of essential in vitro diagnostics: report of the third meeting of the WHO Strategic Advisory Group of Experts on In Vitro Diagnostics, 2020 (including the third WHO model list of essential in vitro diagnostics). Geneva: World Health Organization; 2021 (https://apps.who.int/iris/handle/10665/339064, accessed 19 August 2021). World Health Organization. Electronic Model List of Essential In Vitro Diagnostics Platform (https://edl.medevis. test.evidenceprime.com/, accessed 06 September 2021). World Health Organization. MEDEVIS Platform (https://medevis.test.evidenceprime.com/search?, accessed 06 September 2021). Existing data collection tool From existing health facility survey tools such as World Health Organization’s SARA and World Bank’s SDI, and DHS program’s SPA. World Health Organization. Service Availability and Readiness Assessment (https://www.who.int/data/data- collection-tools/service-availability-and-readiness-assessment-(sara)?ua=1, accessed 16 August 2021). The DHS Program. Service Provision Assessment. September 2020 (https://dhsprogram.com/publications/ publication-spaq1-spa-questionnaires-and-manuals.cfm, accessed 18 August 2021). World Bank. Service Delivery Indicators (https://www.sdindicators.org/, accessed 19 August 2021). World Health Organization. Harmonized Health Facility Assessment (HHFA). March 2021 (https://www.who.int/ data/data-collection-tools/harmonized-health-facility-assessment/introduction, accessed 16 August 2021). To note: WHO is currently revising its facility survey modules to incorporate additional elements of PHC measurement. 63 Indicator33 Availability of priority medical equipment and other medical devices Medicines and other health products Indicator short name Availability of essential medical equipment and consumables Indicator long name Percentage of health facilities with availability of priority medical equipment and other medical devices Domain Medicines and other health products Sub-domain Medicines and other health products M/E domain Inputs Definition Percentage of health facilities with current stock of the below equipment and products that are available and functional (* indicates specific to referral facility or hospital) Examination equipment • Scale, adult • Blood pressure measurement device, automated • Thermometer, digital • Stethoscope • Light, examination • Scale, child • Scale, infant • Height board/stadiometer • Pulse oximeter • Measuring tape • Otoscope • Ophthalmoscope Oxygen • Oxygen concentrator • Oxygen tank with pressure gauge and regulator • Flowmeter, oxygen therapy • Humidifier • Oxygen delivery devices (connecting ties, mask, nasal prongs) Consumable Supplies • Suture, absorbable • Needles, suturing • Suture, non-absorbable • Infusion set, intravenous • Blood giving set • Intravenous cannula (any size) • Intravenous needle, child • Needles, sterile (any size) • Syringes, single use • Splinting set, extremities • Casts, set and materials • Examination gloves, latex, single use • Alcohol swabs • Sterile gauze, swabs • Adhesive tape • Condoms, male • Urinary catheter, straight • Urinary catheter, with bulb • Urine collection bag • Endotracheal tube (adult) • Endotracheal tube (paediatric) 64 Diagnostic imaging technology (often reported as density per million population) • X-ray, general; fixed/mobile/portable • Ultrasound scanner • Electrocardiogram (ECG) Medical Equipment for treatments • Phototherapy device • Incubator, newborn • Anaesthesia system* • Table, operating • Surgical instruments, basic surgery set • Defibrillator • General equipment: • Autoclave, electric • Dry-heat sterilizer • Refrigerators (vaccines, medicines, blood) • Lamp, Surgical (for outpatient surgeries) *hospital-oriented equipment and health products Disaggregation(s) Type of equipment, supply, commodity Facility type (as relevant to context): including primary care facilities (e.g., GP practices, health centres, community health posts), first-level hospitals, long-term care facilities, continuing care facilities, etc.) Managing authority: public, private Subnational Urban/rural Numerator Total number of facilities with the equipment, supply or commodity For diagnostic technologies: Total count of medical devices available in the country (by type) Denominator Total number of facilities surveyed Preferred data source Facility survey Rationale Access to good quality, affordable, and appropriate health products is indispensable to advance UHC, address health emergencies, and promote healthier populations. Reference(s) Operational framework for primary health care: transforming vision into action. Geneva: World Health Organization and the United Nations Children’s Fund (UNICEF), 2020 (https://www.who.int/publications/i/ item/9789240017832, accessed 17 August 2021). World Health Organization. Management and safe use of medical devices (https://www.who.int/teams/health- product-and-policy-standards/assistive-and-medical-technology/medical-devices/management-use, accessed 23 August 2021). World Health Organization. MEDEVIS Platform (https://www.who.int/teams/health-product-and-policy- standards/assistive-and-medical-technology/medical-devices/management-use, accessed 23 August 2021). World Health Organization. MeDevIS (Priority Medical Devices Information System) open access WHO electronic database of Medical Devices (https://medevis.test.evidenceprime.com/, accessed on 6 September 2021). Interagency list of priority medical devices for essential interventions for reproductive, maternal, newborn and child health. World Health Organization, 15 June 2016 (https://www.who.int/publications/i/ item/9789241565028, accessed on 6 September 2021). WHO list of priority medical devices for cancer management. World Health Organization, 17 February 2017 (https://www.who.int/publications/i/item/9789241565462, accessed on 6 September 2021. WHO List of Priority Medical Devices for management of cardiovascular diseases and diabetes. World Health Organization, 2021 (https://apps.who.int/iris/bitstream/handle/10665/341967/9789240027978-eng.pdf, accessed on 6 September 2021). WHO List of Priority medical devices list for the COVID-19 response and associated technical specifications. World Health Organization, 19 November 2020 (https://www.who.int/publications/i/item/WHO-2019-nCoV- MedDev-TS-O2T.V2, accessed on 6 September 2021). 65 World Health Organization. WHO general medical devices (https://www.who.int/health-topics/medical- devices#tab=tab_1, accessed on 6 September 2021). World Health Organization. WHO prioritizing medical devices (https://www.who.int/activities/prioritizing- medical-devices, accessed on 6 September 2021. Existing data collection tool From existing health facility survey tools such as World Health Organization’s SARA and HHFA, World Bank’s service delivery indicators, and DHS program’s SPA (fully or partially). World Health Organization. Service Availability and Readiness Assessment (https://www.who.int/data/data- collection-tools/service-availability-and-readiness-assessment-(sara)?ua=1, accessed 16 August 2021). The DHS Program. Service Provision Assessment. September 2020 (https://dhsprogram.com/publications/ publication-spaq1-spa-questionnaires-and-manuals.cfm, accessed 18 August 2021). World Bank. Service Delivery Indicators (https://datatopics.worldbank.org/sdi/, accessed 19 August 2021). World Health Organization. Harmonized Health Facility Assessment. March 2021 (https://www.who.int/data/ data-collection-tools/harmonized-health-facility-assessment/introduction, accessed 16 August 2021). To note: WHO is currently revising its facility survey modules to incorporate additional elements of PHC measurement and will provide recommended scoring methodology. 66 Indicator34 Health information Indicator short name Completeness of reporting by facilities Indicator long name Percentage of completeness of reporting by facilities Domain Health information Sub-domain Health information M/E domain Inputs Definition Percentage of facilities that use information systems for capturing and reporting comprehensive patient and facility data and report according to district and/or national requirements within the required deadline. Disaggregation(s) Facility type (as relevant to context): including primary care facilities (e.g., GP practices, health centres, community health posts), first-level hospitals, second-level hospitals, specialty hospitals, long-term care facilities, continuing care facilities, etc.) Managing authority: public, private Subnational Urban/rural Service/Programme: e.g., immunization, maternal child health, noncommunicable diseases, etc. Numerator Number of reports received Denominator Total number of facilities included in the national reporting Preferred data source RHIS Rationale Facilities generate data on a continuous, routine basis that can be used to produce regular (e.g., monthly, quarterly or annual) summary statistics on service availability, utilization and performance; health care resources; and individual client care. These data can be used at local, district and national levels for client management, facility management, disease surveillance, sector planning, and monitoring and management at all levels. A high level of reporting is required. Reference(s) 2018 Global Reference List of 100 Core Health Indicators (plus health-related SDGs). Geneva: World Health Organization; 2018 (https://apps.who.int/iris/handle/10665/259951, accessed 20 April 2021). Score for health data technical package: assessment methodology, 2020. Geneva: World Health Organization; 2021 (https://cdn.who.int/media/docs/default-source/medicines/regulatory-updates/gbt/2021-fair-pricing-forum/ who_2021-04-16_methodology-score_web.pdf?sfvrsn=2a91f846_1, accessed 16 August 2021). Existing data collection tool Country health information systems At the global level, this information can be compiled through the World Health Organization’s SCORE for health data assessment: World Health Organization. SCORE Assessment Instrument (https://www.who.int/data/data-collection-tools/ score/dashboard#/downloads, accessed 19 August 2021). Completeness of reporting by facilities 2.7 Health information indicators 67 Indicator35 Health information Indicator short name Percentage of facilities using patient records Indicator long name Percentage of facilities using single, comprehensive patient records Domain Health information Sub-domain Information systems M/E domain Inputs Definition Percentage of facilities using single, comprehensive patient records that should provide a longitudinal health history of patients across time and for all health conditions (horizontal integration) and include: • Unique patient identification • Family and social history (including socioeconomic determinants) • Problem lists • Care history and notes • Medication lists and allergies • Referrals and results of referrals/counter-referrals • Laboratory/radiology and other test results • Always available • Accessible to patient Disaggregation(s) Facility type (as relevant to context): including primary care facilities (e.g., GP practices, health centres, community health posts), first-level hospitals, second-level hospitals, specialty hospitals, long-term care facilities, continuing care facilities, etc.) Managing authority: public, private Subnational Urban/rural Numerator Number of facilities using comprehensive patient records Denominator Total number of facilities surveyed Preferred data source Facility survey Rationale Comprehensive personal care records record the history and clinical “story” of a patient, summarizing their experiences with the health system over time in one place. While health management information systems (HMIS) and CRVS systems are invaluable for planning, managing, and decision-making at the facility, subregional, subnational and national decisions, personal care records play an important role in fostering quality, continuous, and coordinated care. Health care workers in primary care and other levels of the health system and patients can review and act on the complete information in personal care records to better assess, diagnose, monitor, treat, and/or refer a patient. By maintaining relevant information in one place, personal care records make it easier to identify and follow trends, understand chronic conditions, and address any gaps in care. Reference(s) Global strategy on digital health 2020-2025. Geneva: World Health Organization; 2021 (https://www.who.int/ docs/default-source/documents/gs4dhdaa2a9f352b0445bafbc79ca799dce4d.pdf, accessed 23 August 2021). Digital technologies: shaping the future of primary health care. Geneva: World Health Organization; 2018 (https://apps.who.int/iris/handle/10665/326573, accessed 30 August 2021). Existing data collection tool To note: WHO is currently revising its facility survey modules to incorporate additional elements of PHC measurement and will provide recommended scoring methodology. Percentage of facilities using comprehensive patient records 68 Indicator36 Health information Indicator short name Regular system of facility and patient surveys Indicator long name Country has a regular system of facility and patient surveys to independently monitor health services and patient perspectives Domain Health information Sub-domain Information systems M/E domain Inputs Definition Country has a regular system of facility and patient surveys (or accreditation systems) to independently monitor health services and patient perspectives that includes the following criteria: • Regular independent assessments of service availability, readiness and quality of care at least once every two years • Regular independent assessments of patient satisfaction and or experiences at least once every five years Disaggregation(s) Not applicable Numerator Not applicable Denominator Not applicable Preferred data source Qualitative assessment based on interview with key informant and/or desk review of country documents. Rationale A system of external review through facility surveys or accreditation systems provides assurances that health care facilities have quality systems in place and can demonstrate the required level of service provision. Depending on the comprehensiveness of the standards against which health service performance is being measured, external reviews can contribute to quality improvement, risk mitigation, patient safety, improved efficiency and accountability and can contribute to the sustainability of the health-care system. Reference(s) Score for health data technical package: essential interventions. Geneva: World Health Organization; 2020 (https://apps.who.int/iris/bitstream/handle/10665/334006/9789240009851-eng.pdf, accessed 19 August 2021). Existing data collection tool World Health Organization. SCORE Assessment Instrument (https://www.who.int/data/data-collection-tools/ score/dashboard#/downloads, accessed 19 August 2021). Regular system of facility and patient surveys 69 Indicator37 Health information Indicator short name Functional national human resources information system and NHWA Indicator long name Functional national human resources information system and NHWA exist Domain Health information Sub-domain Information systems M/E domain Inputs Definition National human resources information system is in place and functional and can generate: • Information for reporting on outputs from education and training institutions • Information to track entrants to the labour market • Information to track active stock on the labour market • Information to track exits from the labour market • Geocode information on the location of health facilities • Information to report on IHR • Information to report on implementation of the WHO Global Code of Practice on the International Recruitment of Health Personnel Disaggregation(s) Not applicable Numerator Not applicable Denominator Not applicable Preferred data source NHWA Rationale The availability, quality, comprehensiveness and interoperability of health workforce data are often limited, with availability often restricted to a few core health occupations, to the public sector only, or to employed workers only. In many cases, information from routine administrative sources is not updated. Moreover, even when data quantity and quality are adequate, there are limitations to its effective use. NHWA can help countries address these problems by progressively improving the availability, quality and use of workforce data through using a set of core indicators. This can help standardize countries’ health workforce information systems to improve interoperability and data sharing among national stakeholders; support tracking of health workforce policy performance in relation to UHC; and facilitate comparability of health workforce data nationally and globally. As the implementation of NHWA is by nature progressive, some of the benefits for countries will be immediate, while others will become available over the longer term. Reference(s) National Health Workforce Accounts: better data and evidence. Geneva: World Health Organization; 2019 (https://apps.who.int/iris/handle/10665/311853, accessed 19 August 2021). National Health Workforce Accounts: a handbook. Geneva: World Health Organization; 2017 (https://apps. who.int/iris/handle/10665/311853, accessed 19 August 2021). Existing data collection tool WHO National Health Workforce Accounts (https://apps.who.int/nhwaportal/, accessed 19 August 2021). Functional national human resource information system and national health workforce accounts 70 Indicator38 Health information Indicator short name Completeness of birth registration Indicator long name Completeness of birth registration Domain Health information Sub-domain Information systems M/E domain Inputs Definition 1. Percentage of births that are registered 2. Proportion of children under 5 years of age whose births have been registered with a civil authority Both these definitions are used. Definition 1 is used for countries that have robust CRVS systems. For countries with CRVS systems that are not mature, a survey-based method has been proposed to calculate completeness of birth registration. Both these methods are valid. Disaggregation(s) Subnational Numerator 1. Number of registered births 2. Number of children under the age of 5 whose births are reported as being registered with the relevant national civil authorities. Denominator 1. Actual number of births 2. Total number of children under the age of 5 Preferred data source 1. CRVS 2. Population-based surveys Rationale Birth registration is an SDG indicator and is defined as the “continuous, permanent and universal recording within the civil registry, or the occurrence and characteristics of birth in accordance with the legal requirement of a country” (UN SDG definition). Having a birth registered with the accompanying birth certificate is an essential requirement for safeguarding children’s rights by giving them legal recognition and universal access to health and social services, a key component of PHC. Reference(s) 2018 Global Reference List of 100 Core Health Indicators (plus health-related SDGs). Geneva: World Health Organization; 2018 (https://apps.who.int/iris/handle/10665/259951, accessed 20 April 2021). Existing data collection tool CRVS When this data is measured through surveys, it can be collected through UNICEF’s Multiple Indicator Cluster Survey. This measure is also compiled by WHO through the SCORE for health data assessment. UNICEF. Multiple Indicator Cluster Survey. 2021 (https://mics.unicef.org/, accessed 19 August 2021). World Health Organization. SCORE Assessment Instrument (https://www.who.int/data/data-collection-tools/ score/dashboard#/downloads, accessed 19 August 2021). Completeness of birth registration 71 Indicator39 Health information Indicator short name Completeness of death registration Indicator long name Percentage of deaths that are registered Domain Health information Sub-domain Information systems M/E domain Inputs Definition Percentage of deaths that are registered (with age and sex)) and include valid cause-of-death Disaggregation(s) Subnational Numerator Number of deaths registered Denominator Total number of deaths Preferred data source CRVS Rationale Death registration and to know what people are dying of gives a critical view of health status in a country and can support planning of heath service delivery, including PHC. CRVS systems generate administrative data that serve as the basis for other databases or population registers and can be used to produce vital statistics. Countries with a strong CRVS can reliably and continuously track fertility rates, mortality rates, cause-of-death distribution and life expectancy. Reference(s) 2018 Global Reference List of 100 Core Health Indicators (plus health-related SDGs). Geneva: World Health Organization; 2018 (https://apps.who.int/iris/handle/10665/259951, accessed 20 April 2021). Score for health data technical package: essential interventions. Geneva: World Health Organization; 2020 (https://apps.who.int/iris/bitstream/handle/10665/334006/9789240009851-eng.pdf, accessed 19 August 2021). Existing data collection tool CRVS; in country. This measure is also compiled by WHO through the SCORE for health data assessment. World Health Organization. SCORE Assessment Instrument (https://www.who.int/data/data-collection-tools/ score/dashboard#/downloads, accessed 19 August 2021). Completeness of death registration 72 Indicator40 Health information Indicator short name Regular system of population-based health surveys Indicator long name Existence of a system of regular population-based health surveys Domain Health information Sub-domain Information systems M/E domain Inputs Definition Country can generate regular, comprehensive, high-quality, nationally representative statistics with equity dimensions on population health status, health-related behaviours and risk factors, access to health interventions and out-of-pocket spending on health Disaggregation(s) Not applicable Numerator Not applicable Denominator Not applicable Preferred data source Qualitative assessment based on interview with key informant and/or desk review of country documents. Rationale Population-based health surveys are a significant source of data for many health and health-related SDG and UHC indicators. They are often the only data source for indicators of health-related behaviours and risk factors, for example breastfeeding practices or tobacco use. Population surveys also capture measures of mental health and well-being and are an important means for collecting biomarkers. In the absence of functioning civil registration or reliable facility reporting systems, surveys can provide data for indicators of mortality, health service coverage and use. Surveys also provide critical information from other sectors (such as education, water and sanitation, housing, nutrition, and security) and are among the data sources used to determine out-of-pocket expenditure in national health accounts. Population-based surveys are also among the most important instruments for assessing equity, since they provide disaggregated data (including sex, age, wealth, education and geographic location) for almost all indicators. Although routine health facility reporting systems (also known as HMIS) are an important source of data, population-based surveys include individuals who may not be accessing health care and thus provide a population-level understanding of a country’s disease burden and risk factors. In some contexts, special- population surveys may also be needed to target populations that cannot be specifically identified in a population-based survey (WHO’s Study on Global Ageing and Adult Health is one). Reference(s) International Household Survey Network (https://www.ihsn.org/, accessed 19 August 2021). World Health Organization. World Health Survey Plus (https://www.who.int/data/data-collection-tools/world- health-survey-plus, accessed 19 August 2021). Score for health data technical package: essential interventions. Geneva: World Health Organization; 2020 (https://apps.who.int/iris/bitstream/handle/10665/334006/9789240009851-eng.pdf, accessed 19 August 2021). Existing data collection tool World Health Organization. SCORE Assessment Instrument (https://www.who.int/data/data-collection-tools/ score/dashboard#/downloads, accessed 19 August 2021). Regular system of population-based health surveys 73 Indicator41 Health information Indicator short name Existence of effective surveillance system Indicator long name Existence of effective surveillance system Domain Health information Sub-domain Surveillance M/E domain Structures Definition Country has an effective surveillance system based on the average of two SPAR indicators: C6.1 Early warning function: indicator- and event-based surveillance Level Attributes 1 The surveillance system for diseases/syndromes/events (reporting, feedback, communication) is under development 2 Standard operating procedures (SOPs) and/or other written technical guidelines for surveillance have been developed and implemented at the national, intermediate and local levels of the surveil- lance system 3 Surveillance data/information are collected via either indicator-based or event-based surveillance on ad hoc basis 4 Surveillance data/information are collected via both indicator-and event-based surveillance with regular reporting and immediate notification taking place in a systematic manner 5 Surveillance system is regularly evaluated and updated C6.2 Mechanism for event management (verification, risk assessment, analysis investigation) Level Attributes 1 There is unstructured mechanism for event management 2 SOPs and/or other written technical guidelines for event management are developed and dissemi- nated to national, intermediate and local levels 3 Event verification, risk assessment, investigation and analysis are systematically performed and guide a response by national and intermediate levels AND Findings are disseminated by production of periodical epidemiological reports 4 Event verification, risk assessment, investigation and analysis are systematically performed and guide a response by national, intermediate and local levels AND Results of all events that may constitute potential public health events of international concern are communicated to WHO and epidemiological reports are shared with all relevant sectors, and partners 5 Event management system is evaluated and updated on a regular basis Indicator-based surveillance is the systematic (regular) collection, monitoring, analysis and interpretation of structured data, i.e., of indicators produced by several well-identified, mostly health-based, formal sources, such as when health care facilities (including primary care settings) regularly report the numbers of cases and deaths caused certain priority diseases that are predefined and mandated. Event-based surveillance is the organized collection, monitoring, assessment and interpretation of mainly unstructured ad hoc information regarding health events or risks which may represent an acute risk to human health. It is a functional component of the early warning and response system (such as media screening that is conducted in a systematized manner to identify events of public health interest). All surveillance data are systematically analysed for informed decision-making and dissemination. Existence of effective surveillance system 74 Disaggregation(s) Not applicable Numerator Not applicable Denominator Not applicable Preferred data source WHO/WHO/another international database Rationale Public health surveillance is a critical intervention for identifying emerging threats to population health and is an essential public health function and component of the PHC Operational framework. The IHR 2005 require countries to maintain an integrated, national system for public health surveillance and response, and set out the core national capabilities necessary for monitoring, surveillance and investigation of public health threats. Reference(s) Guidance document for the State Party self-assessment annual reporting tool -International Health Regulations (2005). Geneva: World Health Organization; 2018 (https://apps.who.int/iris/handle/10665/272438, accessed 19 August 2021). Primary health care and health emergencies. Geneva: World Health Organization; 2018 (https://apps.who.int/ iris/handle/10665/328105, accessed 25 August 2021). Primary health care: closing the gap between public health and primary care through integration. Geneva: World Health Organization; 2018 (https://apps.who.int/iris/handle/10665/326458, 30 August 2021). Existing data collection tool World Health Organization. Electronic State Parties Self-Assessment Annual Reporting Tool (https://extranet. who.int/e-spar, accessed 30 July 2021). 75 Indicator42 Digital technologies for health Indicator short name National eHealth strategy Indicator long name Existence of a valid/up-to-date national eHealth strategy Domain Digital technologies for health Sub-domain Digital technologies for health M/E domain Inputs Definition National eHealth/digital health strategy exists, measured against the following criteria: • Includes discussion of health data architecture • Includes description of health data standards and exchange • Includes a strategy/policy on telehealth/telemedicine • Includes handling of data security issues • Includes specifications for data confidentiality and data storage • Specifies access to data • Specifies alignment/is integrated with national HIS strategy • Specifies financing • Specifies organizational roles and responsibilities Disaggregation(s) Not applicable Numerator Not applicable Denominator Not applicable Preferred data source Qualitative assessment based on interview with key informant and/or desk review of country documents. Rationale The World Health Organization defines eHealth as the use of information and communication technologies (ICT). While electronic information can have a positive impact on health service delivery, it can also fail to support and promote population health if information is fragmented and is not appropriately managed. Having a strategy for eHealth will enable a country to logically lay out a plan to achieve its eHealth goals. The use of digital health data should be strategic, support national health goals and be closely linked to the national M&E and HIS plans. Reference(s) Global strategy on digital health 2020-2025. Geneva: World Health Organization; 2021 (https://apps.who.int/ iris/handle/10665/344249, accessed 25 August 2021). World Health Organization & International Telecommunication Union. National eHealth strategy toolkit. Geneva: International Telecommunication Union; 2012 (https://apps.who.int/iris/handle/10665/75211, accessed 19 August 2021). Digital technologies: shaping the future of primary health care. Geneva: World Health Organization; 2018 (https://apps.who.int/iris/handle/10665/326573, accessed 30 August 2021). Existing data collection tool World Health Organization. SCORE Assessment Instrument (https://www.who.int/data/data-collection-tools/ score/dashboard#/downloads, accessed 19 August 2021). National eHealth strategy 2.8 Digital technologies for health indicators 76 Indicator43 Digital technologies for health Indicator short name Telemedicine access Indicator long name Percentage of people that have had at least one virtual health consultation in the past 12 months Domain Digital technologies for health Sub-domain Digital technologies for health M/E domain Inputs Definition Percentage of patients that have had at least one virtual health consultation in the past 12 months; Average number of virtual health consultations in the past 12 months The definition of virtual health consultations/telemedicine (used interchangeably here) has been adapted from the global digital health strategy (1) to mean “the delivery of health care services, where distance is a critical factor, by all health care professionals using ICT for the exchange of valid information for diagnosis and treatment.” (The remaining part of the definition that includes prevention, research and evaluation, continuing education are not explicitly included in this definition while acknowledging these are critical part of advancing digital health service delivery to individuals and communities). It is also more in line with the definition used in the OECD Working paper on the use of telemedicine in OECD countries. Disaggregation(s) Age Gender Subnational Urban/rural Socioeconomic status Numerator 1. Number of people that have at least one virtual health consultation in the past 12 months 2. Average number of virtual health consultations Denominator Total number of people interviewed Preferred data source Population-based survey Rationale There is need to support or develop innovative health service delivery platforms that can provide improved access to health care for the population, and especially the vulnerable. Many people do not have access to health care services due to issues of geographic access, physical or financial barriers, or being part of stigmatized groups. Receiving health care remotely can mitigate some of these barriers. It will be important for government to use advances in ICT to improve access to health on the path to UHC. While there are different enablers and barriers to the implementation of telemedicine, this indicator measures to which degree people are currently using telemedicine for their health care needs. Reference(s) Global strategy on digital health 2020-2025. Geneva: World Health Organization; 2021 (https://apps.who.int/ iris/handle/10665/344249, accessed 25 August 2021). Operational framework for primary health care: transforming vision into action. Geneva: World Health Organization and the United Nations Children’s Fund (UNICEF), 2020 (https://www.who.int/publications/i/ item/9789240017832, accessed 17 August 2021). Digital technologies: shaping the future of primary health care. Geneva: World Health Organization; 2018 (https://apps.who.int/iris/handle/10665/326573, accessed 30 August 2021). Hashiguchi, Tiago Cravo Oliviera. Bringing health care to the patient. An overview of the use of telemedicine in OECD countries. OECD Health Working Papers No. 116; 2020 (https://doi.org/10.1787/8e56ede7-en, accessed 22 September 2021). Existing data collection tool To note: WHO is in the process of developing survey modules to incorporate additional elements of PHC measurement and will provide recommended scoring methodology. Telemedicine access 77 Indicator44 Digital technologies for health Indicator short name Percentage of facilities using electronic health records Indicator long name Percentage of facilities using electronic health records with the essential attributes Domain Digital technologies for health Sub-domain Digital technologies for health M/E domain Inputs Definition Percentage of facilities with a system of electronic capture of patient level health data (patient records system) that have the following attributes: • Information recorded should be standardized across health facilities • Interoperable • Integrated with aggregated routine HIS • Links to clinical systems such as: automatic vaccination alerting systems pathology information systems picture archiving and communication systems pharmacy information systems laboratory information systems • Can be shared among multiple providers/facilities and within facilities • Covers multiple diseases/conditions Disaggregation(s) Facility type (as relevant to context): including primary care facilities (e.g., GP practices, health centres, community health posts), first-level hospitals, second-level hospitals, specialty hospitals, long-term care facilities, continuing care facilities, etc.) Managing authority: public, private Subnational Urban/rural Numerator Number of facilities that have an electronic capture of patient level data with the relevant attributes Denominator Total number of facilities surveyed. Preferred data source Facility survey Rationale Electronic health record systems can enable individuals to have an electronic record of their key characteristics and health concerns, as well as their history of encounters with the health system and the treatments that they have received from a variety of health providers. This record can then be shared among health providers to support the provision of the most appropriate care. The existence of such records opens a promising new frontier for advancing patient care, in the same way that advancements in the use of information technologies have revolutionised most other industries. Unique patient identifiers are crucial to the development of longitudinal electronic health records, to ensure that the data within the record is complete and accurate, as patients move among health care providers, health insurers, and regions within their country and over time. They are also important for statistical purposes, to identify unique patients and to conduct, where approved, linkages of data across more than one data source. (See indicator on criteria for patient records) Reference(s) Global strategy on digital health 2020-2025. Geneva: World Health Organization; 2021 (https://www.who.int/ docs/default-source/documents/gs4dhdaa2a9f352b0445bafbc79ca799dce4d.pdf, accessed 23 August 2021). Score for health data technical package: essential interventions. Geneva: World Health Organization; 2020 (https://apps.who.int/iris/bitstream/handle/10665/334006/9789240009851-eng.pdf, accessed 19 August 2021). Percentage of facilities using electronic health records 78 Existing data collection tool WHO’s SCORE for health data assessment tool collects information on the extent availability of electronic patient records system, and thus offers an approximation of this measure. However, it does not provide a representative estimate of coverage, which would be through a health facility survey. Some parts of this indicator are also measured by WHO’s HHFA, though not all elements are covered. World Health Organization. SCORE Assessment Instrument (https://www.who.int/data/data-collection-tools/ score/dashboard#/downloads, accessed 19 August 2021). World Health Organization. Harmonized Health Facility Assessment. March 2021 (https://www.who.int/data/ data-collection-tools/harmonized-health-facility-assessment/introduction, accessed 16 August 2021). To note: WHO is currently revising its facility survey modules to incorporate additional elements of PHC measurement and will provide recommended scoring methodology. 79 Indicator45 Models of care Indicator short name Service package meeting criteria Indicator long name Service package for essential health services and public health functions developed and meets criteria Domain Models of care Sub-domain Selection and planning of services M/E domain Processes Definition Service package of essential health services (including primary care services) and public health functions is developed and meets following criteria: • Addresses comprehensive essential health services including: Health protection Prevention Promotion Management (diagnosis, treatment, rehabilitation, resuscitation) Palliation • Includes key life course needs and disease programmes Foundations of care management of emergency syndromes and common presentations in primary care Reproductive and sexual health, including pregnancy, childbirth, and family planning Growth, development, disability and ageing Communicable diseases Noncommunicable diseases Mental health, neurological and substance use disorders Violence and injury • The package addresses disease burden and other national priorities including risk factor profiles and projections • The process for development of the service package involves a wide range of stakeholders • The package is based on an evaluation of existing resources • Is routinely revised as part of national planning processes • The package includes and designates key services related to emergency events for which the country is at risk Disaggregation(s) Not applicable Numerator Not applicable Denominator Not applicable Preferred data source Qualitative/Key informant survey and/or desk review with verification from key country documents Rationale The concept of PHC is rooted in a whole-of-society approach that ensures meeting population health needs throughout the life course but also addresses different health service needs such as prevention and promotion of health services. To meet this broad requirement, countries must formulate a service package that addresses these health service delivery functions. The exercise of specifying a core package is a value-laden process, looking to decision-makers and system stewards to establish a strategic policy position and equitable framework for protected access to health services when faced with competing priorities. A package meeting the essential attributes will ensure that a fair process was undertaken in the development of this service package, including the involvement of many different stakeholders. Service package meeting criteria 2.9 Models of care indicators 80 Reference(s) Operational framework for primary health care: transforming vision into action. Geneva: World Health Organization and the United Nations Children’s Fund (UNICEF), 2020 (https://www.who.int/publications/i/ item/9789240017832, accessed 17 August 2021). World Health Organization. UHC Compendium (https://www.who.int/universal-health-coverage/compendium, accessed 17 August 2021). Making fair choices on the path to universal health coverage. Final report of the WHO Consultative Group on Equity and Universal Health Coverage. Geneva: World Health Organization; 2014 (http://apps.who.int/iris/ bitstream/handle/10665/112671/9789241507158_eng.pdf?sequence=1, accessed 17 August 2021). Integrating health services: brief. Geneva: World Health Organization; 2018 (https://apps.who.int/iris/ handle/10665/326459, 30 August 2021). Primary health care: closing the gap between public health and primary care through integration. Geneva: World Health Organization; 2018 (https://apps.who.int/iris/handle/10665/326458, accessed 30 August 2021). Existing data collection tool To note: qualitative assessment tool with recommended scoring methodology is under development by WHO and will be forthcoming end 2022. 81 Indicator46 Models of care Indicator short name Roles and functions of service delivery platforms and settings defined Indicator long name Roles and functions of service delivery platforms and settings defined Domain Models of care Sub-domain Selection and planning of services M/E domain Processes Definition The roles and functions of service delivery platforms are: 1) defined within the context of integrated health service delivery networks; and 2) include the minimum services listed below. For this, good distribution of roles and responsibilities needs to be defined for existing facilities/organizations in countries. • Community-based services Self-testing and self-care services Community based services CHW visits at home or health posts • General outpatient services in a clinical setting (e.g., facility at primary care level) General outpatient services in clinic setting (at a minimum, health facility staffed by nurse or mid- level provider Periodic schedulable services delivered by skilled health worker in home, schools, workplace, or public space • Prehospital emergency care services Services at the scene Ambulance transport • First referral level (e.g., district or general hospital) Outpatient services at first referral level Emergency unit services at first referral level Inpatient services at first referral level Diagnostic laboratory and medical imaging services within a first referral level • Second referral level and above (e.g., regional, specialized or national hospitals) Advanced outpatient services at second referral level and above Advanced emergency unit services at second referral level and above Advanced inpatient services at second referral level and above Advanced diagnostic laboratory and medical imaging services within a second level referral and above Disaggregation(s) Not applicable Numerator Not applicable Denominator Not applicable Preferred data source Qualitative/Key informant survey and/or desk review with verification from key country documents Roles and functions of service delivery platforms and settings defined 82 Rationale Service delivery platforms are the modes or channels of health service delivery. The platforms can include public and private health facilities (for example health posts, clinics, health centres, mobile clinics, emergency care units, first and second referral facilities, other entities (for example, home-based care, schools, community centres, long-term care facilities) and outreach services, campaigns or digital platforms. These can be classified in a variety of ways. Examples are community-based services; individual-oriented clinical services at different levels (primary level, first referral level and second referral level). The organization of service delivery platforms should promote integrated health services, strategically prioritizing primary care and public health functions and ensuring adequate coordination between them. At the level of individual health care services, health systems need to be reoriented to facilitate access to services closer to where people live (for example, home-based and community-based care, primary care in long-term care facilities, step-down units for rehabilitation in local hospitals, dedicated emergency care units at comprehensive health centres and first-level hospitals), taking into consideration context (for example, living conditions, public transport, availability of emergency transportation and pre-hospital care), people’s preferences and cost-effectiveness. Reference(s) Operational framework for primary health care: transforming vision into action. Geneva: World Health Organization and the United Nations Children’s Fund (UNICEF), 2020 (https://www.who.int/publications/i/ item/9789240017832, accessed 17 August 2021). World Health Organization. UHC Compendium (https://www.who.int/universal-health-coverage/compendium, accessed 17 August 2021). Integrating health services: brief. Geneva: World Health Organization; 2018 (https://apps.who.int/iris/ handle/10665/326459, accessed 30 August 2021). The transformative role of hospitals in the future of primary health care. Geneva: World Health Organization; 2018 (https://apps.who.int/iris/handle/10665/326296, accessed 30 August 2021). Existing data collection tool To note: qualitative assessment tool with recommended scoring methodology is under development by WHO and will be forthcoming end 2022. 83 Indicator47 Models of care Indicator short name Existence of an empanelment system Indicator long name Existence of an empanelment system Domain Models of care Sub-domain Service design M/E domain Processes Definition An empanelment system exists and that is measured by the following attributes: • Proportion of the population that is empanelled to a provider, care team or facility • Frequency at which patient panes are updated • Patients can choose and/or switch the facility/provider/team to which they are empanelled Disaggregation(s) Not applicable Numerator Not applicable Denominator Not applicable Preferred data source Qualitative/Key informant survey and/or desk review with verification from key country documents. Rationale Having a defined practice population by means of a registered patient list system creates an incentive for primary care providers as well as the population to provide and receive services on a continuous basis with the same provider. Registering with a specific practitioner has been found to contribute to accountability by making clear who is responsible for service coordination. Ongoing services from the same provider contributes to quality of care. Patient list systems can be defined based on geographic empanelment, insurance-based empanelment and individual choice or based on specific diagnoses. Reference(s) Operational framework for primary health care: transforming vision into action. Geneva: World Health Organization and the United Nations Children’s Fund (UNICEF), 2020 (https://www.who.int/publications/i/ item/9789240017832, accessed 17 August 2021). Bearden T, Ratcliffe HL, Sugarman JR et al. Empanelment: A foundational component of primary health care [version 1; peer review: approved] Gates Open Research 2019, 3:1654 (https://doi.org/10.12688/ gatesopenres.13059.1, accessed 4 October 2021). Existing data collection tool Primary Health Care Performance Initiative. Primary Health Care Progression Model Assessment Tool (measure 27 – empanelment). 2019 (https://improvingphc.org/sites/default/files/PHC-Progression%20Model%202019- 04-04_FINAL.pdf; accessed 20 April 2021). Indicator passport - WHO European Primary Health Care, Impact, Performance and Capacity Tool. Copenhagen: World Health Organization Regional Office for Europe; 2019 (https://www.euro.who.int/en/health-topics/ Health-systems/health-services-delivery/publications/2019/indicator-passport-who-european-primary-health- care,-impact,-performance-and-capacity-tool-phc-impact-2019, accessed 20 April 2021). To note: WHO is working with partners to incorporate additional elements of PHC measurement and will provide recommended scoring methodology. Existence of an empanelment system 84 Indicator48 Models of care Indicator short name System to promote first contact accessibility Indicator long name System to promote first contact through primary care providers Domain Models of care Sub-domain Service design M/E domain Process of care Definition Governance and financing policies/mechanisms promote primary care providers as the first point of contact for most health needs. Those include: • Gatekeeping mechanisms/Conditional access to specialist care • Financial incentives that promote primary care (e.g., removal of out-of-pocket payments and fee structures) as first point of contact There are other measures in this framework such as: having a comprehensive essential package of services; be easily accessible; empanelment that promotes first contact accessibility. These are not included here as they are measured separately, but this indicator should be examined in that holistic context. Disaggregation(s) Not applicable Numerator Not applicable Denominator Not applicable Preferred data source Qualitative/Key informant survey and/or desk review with verification from key country documents Rationale First contact accessibility measures the ability and capacity of a PHC system to ensure primary care workers can serve as the first point of contact for most conditions and are responsible for the delivery of primary care services as well as the coordination and referral of care to other sites and platforms. The ease of access to a primary provider will ensure health services are provided at the appropriate levels and reduce or remove use of emergency and tertiary services for PHC, which can be costly and inefficient. Reference(s) Operational framework for primary health care: transforming vision into action. Geneva: World Health Organization and the United Nations Children’s Fund (UNICEF), 2020 (https://www.who.int/publications/i/ item/9789240017832, accessed 17 August 2021). Continuity and coordination of care: a practice brief to support implementation of the WHO Framework on integrated people-centred health services. Geneva: World Health Organization; 2018 (https://apps.who.int/iris/ handle/10665/274628, 30 August 2021). Existing data collection tool Qualitative assessment tool with recommended scoring methodology is under development by WHO and will be forthcoming end 2022. System to promote first contact accessibility 85 Indicator49 Models of care Indicator short name Protocols for patient referral, counter-referral and emergency transfer Indicator long name Existence of explicit protocols for patient referral, counter-referral system and emergency transfer Domain Models of care Sub-domain Service design M/E domain Process Definition Explicit protocols and structured communication mechanisms for referral, counter-referral and emergency transfer are in place to promote reporting and feedback between primary care practitioners and other levels of care (or within facility) to promote coordination and information continuity. These protocols provide guidance on the following elements: For referral: • individual’s identification information • reason for referral (e.g., investigation, diagnosis, treatment, reassurance, etc.) and services needed at referral site • information related to illness (e.g., history, findings, etc.) • information related to relevant investigations already undertaken • medication list • socio-psychological factors • practitioner’s contact details For counter referral: • assessment of current problem • investigation undertaken • medication prescribed • next steps in the care of the individual For emergency transfer: • provision of medical screening examination and stabilizing treatment • condition of patient • timing of transfer • mode of transfer • level of care during transfer • destination of patient • inclusion of pertinent records and images Disaggregation(s) Not applicable Numerator Not applicable Denominator Not applicable Preferred data source Qualitative/Key informant survey and/or desk review with verification from key country documents Rationale The delivery of coordinated health services depends on the accessibility and exchange of information among those involved in the care of an individual. The use of referral letters can facilitate this. Having protocols regarding the content of the referral letter is important in assessing the quality of a referral, which impacts the quality of care. Good communication can avoid problems related to polypharmacy, duplication of investigations, etc. Protocols for patient referral, counter-referral and emergency transfer 86 Reference(s) Operational framework for primary health care: transforming vision into action. Geneva: World Health Organization and the United Nations Children’s Fund (UNICEF), 2020 (https://www.who.int/publications/i/ item/9789240017832, accessed 17 August 2021). Continuity and coordination of care: a practice brief to support implementation of the WHO Framework on integrated people-centred health services. Geneva: World Health Organization 2018 (https://apps.who.int/iris/ handle/10665/274628, accessed 23 August 2021). Existing data collection tool Adapted from World Health Organization. Indicator Passport. WHO European Primary Health Care, Impact, Performance and Capacity Tool. Copenhagen: World Health Organization Regional Office for Europe; 2019 (https://www.euro.who.int/en/health-topics/Health-systems/health-services-delivery/publications/2019/indicator- passport-who-european-primary-health-care,-impact,-performance-and-capacity-tool-phc-impact-2019, accessed 17 August 2021). Qualitative assessment tool with recommended scoring methodology is under development by WHO and will be forthcoming end 2022. 87 Indicator50 Models of care Indicator short name Existence of care pathways for tracer conditions Indicator long name Care pathways are developed for common conditions requiring coordination. Domain Models of care Sub-domain Service design M/E domain Process Definition A management plan exists that maps care pathways through the health system for individuals: • For the following key tracer conditions: Chronic heart disease (ischemic, heart failure) Diabetes mellitus (type 1 and type 2) Cancer – breast Cancer – cervical Cancer – colorectal Asthma Chronic obstructive pulmonary disease Depression Febrile illness Complications of pregnancy Sepsis Acute respiratory distress in childhood Road traffic injury • Includes pathways for assessing multimorbidity • And includes the following attributes: Key care elements are based on evidence and best practice Details on communication among the team members and with patients and families are included Roles and responsibilities, including sequencing of activities across the multidisciplinary care team, patients and their relatives are defined Guidance on monitoring and evaluation of variances and outcomes is included Disaggregation(s) Not applicable Numerator Not applicable Denominator Not applicable Preferred data source Qualitative/Key informant survey and/or desk review with verification from key country documents Rationale Care pathways are standardized, processed, and developed to address care for patients presenting with same/ similar conditions. Clearly designed care has been found to contribute to improvements in service provision, including minimizing discrepancies in core services in terms of both what is provided and how care is delivered. Care pathways have also been found to support the delivery of relevant services in a timely manner, to reduce complications, and to enable better discharge planning. Existence of care pathways for tracer conditions 88 Reference(s) Operational framework for primary health care: transforming vision into action. Geneva: World Health Organization and the United Nations Children’s Fund (UNICEF), 2020 (https://www.who.int/publications/i/ item/9789240017832, accessed 17 August 2021). Continuity and coordination of care A practice brief to support implementation of the WHO Framework on integrated people-centred health services. Geneva: World Health Organization; 2018 (https://apps.who.int/ iris/bitstream/handle/10665/274628/9789241514033-eng.pdf?sequence=1&isAllowed=y, accessed 23 August 2021). Improving healthcare quality in Europe. Characteristics, effectiveness and implementation of different strategies. United Kingdom: World Health Organization and OECD, 2019 (https://www.ncbi.nlm.nih.gov/books/ NBK549276/pdf/Bookshelf_NBK549276.pdf, accessed 4 October 2021). Existing data collection tool Qualitative assessment tool with recommended scoring methodology is under development by WHO and will be forthcoming end 2022. 89 Indicator51 Models of care Indicator short name Professionalization of management Indicator long name System for professionalization of management capability for health care organizations Domain Models of care Sub-domain Organization and facility management M/E domain Process Definition The conditions are in place nationally (and subnationally) to ensure professionalized management and leadership in health care organization. This is achieved by ensuring adequate numbers, competencies and deployment of managers throughout the health system, and creating an enabling environment that contributes to managers’ motivation and enables them to perform well, as measured by: • Ensuring adequate numbers of managers through: The listing of management posts in the HRHIS system The increase in the number of qualified managers through training The establishment of plans and procedures for filling management posts • Ensuring competency of managers through the existence of Developed formal post descriptions for all management/leadership positions Formal training curriculum (competency-based, accredited) for health service management A system of competency-based transparent selection process • Increasing managers’ motivation and creating an enabling environment through: The existence of a governing board with clear terms of reference Ensuring effective participation of community representatives in health services management Promoting a work environment that supports manager autonomy Implementing supportive supervision for and by top and mid-level managers Performance assessments that are linked to career development and continuing learning opportunities The term “manager” should in the first instance be used for staff who have a major management role with a significant proportion of their time being spent on this role. Each country can define “health manager” differently. However, a useful starting point is the following definition: a health manager is someone who spends a substantial proportion of his/her time managing: • Volume and coverage of services (planning, implementation and evaluation) • Resources (e.g., staff, budgets, drugs, equipment, buildings, information) • External relations and partners, including service users (1) Disaggregation(s) Not applicable Numerator Not applicable Denominator Not applicable Preferred data source Qualitative/Key informant survey and/or desk review with verification from key country documents Rationale Leadership and management are complex concepts which are relevant to many different parts of the health system, including the private and public sectors; health facilities, district health offices and central ministries; and support systems related to pharmaceutical, finances and information. Leadership and management are also human resource issues - specifically, the skilled and motivated managers and leaders needed to work throughout a health system. Effective health care management and leadership is necessary for improving performance of health service delivery and requires a trained workforce to fill managerial roles. Good managers are also necessary to deliver quality health services. Having an enabling environment that has key characteristics supports the development of managerial and leadership capacity. Professionalization of management 90 Reference(s) Operational framework for primary health care: transforming vision into action. Geneva: World Health Organization and the United Nations Children’s Fund (UNICEF), 2020 (https://www.who.int/publications/i/ item/9789240017832, accessed 17 August 2021). Linnader, EL, Mantopoulos, JM, Allen N, Nembhard IM, Bradley, EH. Professionalizing health care management: a descriptive case study. Int J Health Policy Manag 2017, 6(10), 555-560 (https://www.ijhpm.com/article_3346. html, accessed 1 September 2021). 2. Making Health Systems Work: Working Paper No. 1. WHO/EIP/healthsystems/2005.1 (https://www.who.int/ management/general/overall/Strengthening%20Management%20in%20Low-Income%20Countries.pdf, accessed 1 September 2021). 3. World Health Organization. Towards better leadership and management in health: report on an international consultation on strengthening leadership and management in low-income countries. WHO/ HSS/healthsystems/2007.3 Working Paper No. 10 (https://www.who.int/management/wp10.pdf, accessed 1 September 2021). 4. PHCPI PHC Progression model assessment tool (measure 30 – Facility management capability and leadership) (https://improvingphc.org/sites/default/files/PHC-Progression%20Model%202019-04-04_FINAL.pdf). Existing data collection tool To note: a qualitative assessment tool with recommended scoring methodology is currently under development by WHO and will be forthcoming by end 2022. 91 Indicator52 Models of care Indicator short name Management capability and leadership Indicator long name Percentage of facilities with managers or teams that have decision-making responsibilities (including in primary care facilities) Domain Models of care Sub-domain Organization and facility management M/E domain Process Definition Percentage of facilities with a manager/management team that has decision-making responsibilities that include the following areas: • Procurement of equipment, medicines and commodities • Staff recruitment • Staff promotion (where applicable) • Disciplinary action against health workers • Approval of staff absence • Minor facility repairs/maintenance (such as painting walls, fixing equipment) • Selecting facility staff to attend relevant training • Budget/financial management • Health facility performance management • Linkages with community organisations Disaggregation(s) Facility type (as relevant to context): including primary care facilities (e.g., GP practices, health centres, community health posts), first level hospitals, second level hospitals, specialty hospitals, long-term care facilities, continuing care facilities, etc.) Managing authority: public, private Sub-National Urban/rural Numerator Number of facilities with trained managers Denominator Total number of facilities Preferred data source Facility survey Rationale Management and leadership capability within a facility requires key staff to have some level of autonomy in decision-making in domains such as coordination of day-to-day operations, target setting, human resources, and external relations. While this indicator does not measure the competency of the manager in making decisions, it demonstrates the level of autonomy available at an individual facility level. In combination with the system level ability to foster managers as measured by the previous indicator, this indicator shows how some of the attributes of management manifest in practice. Reference(s) Making Health Systems Work: Working Paper No. 1. WHO/EIP/healthsystems/2005.1 (https://www.who.int/ management/general/overall/Strengthening%20Management%20in%20Low-Income%20Countries.pdf, accessed 1 September 2021). World Health Organization. Towards better leadership and management in health: report on an international consultation on strengthening leadership and management in low-income countries. WHO/ HSS/healthsystems/2007.3 Working Paper No. 10 (https://www.who.int/management/wp10.pdf, accessed 1 September 2021). PHCPI PHC Progression model assessment tool (measure 30 – Facility management capability and leadership) (https://improvingphc.org/sites/default/files/PHC-Progression%20Model%202019-04-04_FINAL.pdf). Management capability and leadership 92 Existing data collection tool From existing health facility survey tools such as World Health Organization’s SARA and HHFA, World Bank’s SDI, and DHS program’s SPA+ (fully or partially). World Health Organization. Service Availability and Readiness Assessment (https://www.who.int/data/data- collection-tools/service-availability-and-readiness-assessment-(sara)?ua=1, accessed 16 August 2021). The DHS Program. Service Provision Assessment. September 2020 (https://dhsprogram.com/publications/ publication-spaq1-spa-questionnaires-and-manuals.cfm, accessed 18 August 2021). World Bank. Service Delivery Indicators (https://datatopics.worldbank.org/sdi/, accessed 19 August 2021). World Health Organization. Harmonized Health Facility Assessment (HHFA). March 2021 (https://www.who.int/ data/data-collection-tools/harmonized-health-facility-assessment/introduction, accessed 16 August 2021). To note: WHO is currently revising its facility survey modules to incorporate additional elements of PHC measurement and will provide recommended scoring methodology. 93 Indicator53 Models of care Indicator short name Multidisciplinary team-based service delivery Indicator long name Health service delivery through multidisciplinary teams in primary care settings Domain Models of care Sub-domain Organization and facility management M/E domain Process Definition Percentage of facilities that have adopted multidisciplinary team approaches (looking at extent and scope) for the delivery of services in primary care settings as measured by: • Proportion of professional staff who are integrated in multidisciplinary care • Number of attributes of multidisciplinary team-based approaches that are met, including: A team identity (team members see themselves as part of one larger, cohesive unit with shared methods, ideals, and goals Regular team meetings Clearly defined roles and responsibilities that are uniformly understood by all team members Shared goals of providing quality care that individual teammates cannot achieve on their own. Goals should include providing the highest quality care for the broadest range of undifferentiated patients presenting for care, regardless of age, gender, health issue, organ system, or disease Mutual accountability structures in which each team member can be held accountable by any other team member. • Composition of teams (number of different professions represented) • Caseload (proportion of patients cared for through multidisciplinary care programmes) Multidisciplinary care teams can range from the basic unit of general medical practitioners and nurses to larger, multisectoral teams that engage health and social care workers. Across-sector teams can allow for improved collaboration and knowledge exchange between providers working in different settings. with a mix of health and social care workers, which could include other generalist medical practitioners, nurse, social worker, psychologist, dietician, pharmacist, or public health professional. Multidisciplinary care programs can be made available to only a limited number of patients, those with multiple comorbidity and complex health and social needs (e.g., for long-term conditions) or with targeted conditions (e.g., diabetes clinic in a primary care centre). In other cases, a multidisciplinary approach is systematically available to all patients (i.e., patients are registered or empanelled to teams and not to individuals). Disaggregation(s) Facility type (as relevant to context): including primary care facilities (e.g., GP practices, health centres, community health posts), first-level hospitals, second-level hospitals, specialty hospitals, long-term care facilities, continuing care facilities, etc.) Managing authority: public, private Subnational Urban/rural Numerator Not applicable Denominator Not applicable Preferred data source Facility survey Rationale Across-sector teams can allow for improved collaboration and knowledge exchange between providers working in different settings. Close collaboration between different primary care professionals optimizes the treatment of individuals and therefore increases the strength of primary care. Regardless of the mode of teamwork that is applied, there should be some form of structural communication among primary care professionals treating the same individual. Multidisciplinary team-based service delivery 94 Reference(s) Operational framework for primary health care: transforming vision into action. Geneva: World Health Organization and the United Nations Children’s Fund (UNICEF), 2020 (https://www.who.int/publications/i/ item/9789240017832, accessed 17 August 2021). Building the primary health care workforce of the 21st century. Geneva: World Health Organization; 2018 (https://apps.who.int/iris/handle/10665/328072, accessed 16 August 2021). Existing data collection tool WHO is currently revising its facility survey modules to incorporate/address PHC-specific elements. 95 Indicator54 Models of care Indicator short name Existence of supportive supervision system Indicator long name Percentage of providers that receive supportive supervision Domain Models of care Sub-domain Organization and facility management M/E domain Process Definition Percentage of providers that receive supportive supervision for PHC (not just specific disease areas) that include the following attributes: • There is collaborative problem-solving and open dialogue • Routine mentoring to address gaps in performance, knowledge or skills • Support in setting individual goals and reviewing progress towards their achievement • Receipt of specific technical expertise when required A provider can be an individual health care worker, a team, or a health centre. Disaggregation(s) If provider is defined as a facility, please include the following disaggregations: Facility type (as relevant to context): including primary care facilities (e.g., GP practices, health centres, community health posts), first-level hospitals, second-level hospitals, specialty hospitals, long-term care facilities, continuing care facilities, etc.) Managing authority: public, private Subnational Urban/rural Health care worker type (e.g., CHW, midwife, nurse, medical doctor, etc) if individual health care workers are surveyed Numerator Number of facilities meeting the key attributes for supportive supervision Denominator Total number of facilities Preferred data source Facility survey or provider survey Rationale Supportive supervision of individual providers is a key component of performance measurement and management. Rather than using punitive or corrective action, supportive supervision is focused on collective problem-solving and identifying gaps and opportunities to fill them. This approach strengthens relations between staff and builds pathways to improvement through active collaboration between providers and supervisors. This can lead to improved quality of care when combined with other quality-related interventions. Reference(s) Adapted from PHCPI PHC Progression model assessment tool (measure 33 – Supportive supervision) Primary Health Care Performance Initiative. Primary Health Care Progression Model. 2019 (https://improvingphc. org/primary-health-care-progression-model, accessed 17 August 2021). Building the primary health care workforce of the 21st century. Geneva: World Health Organization; 2018 (https://apps.who.int/iris/handle/10665/328072, accessed 16 August 2021). Existing data collection tool From existing health facility survey tools such as World Health Organization’s SARA and HHFA, and DHS program’s SPA assess external supervision but not supportive supervision. To note: WHO is currently revising its facility survey modules to incorporate additional elements of PHC measurement and will provide recommended scoring methodology. Existence of supportive supervision system 96 Indicator55 Models of care Indicator short name Existence of facility budgets and expenditures meeting criteria Indicator long name Existence of facility budgets and expenditures meeting criteria Domain Models of care Sub-domain Organization and facility management M/E domain Process Definition Percentage of facilities that have budgets and expenditures that include the following attributes: • Line-item funds and/or global budgets as relevant • Billing/insurance/other patient financial coverage tracked use expenses (if present) • Internally generated funds from user fees or other fees collected at the point of care • Flexibility to use and/or re-allocate funds across budgetary lines to fit evolving financial needs and to retain fees collected at service level • Use of a comprehensive annual budget to engage in a systematic forecasting exercise Line-item funds:– funding amounts from government source for specific types of regular expenses, such as supplies, equipment, staff, or income, such as from service-specific fees Global budgets: a pre-specified amount of funds for a given period of time per patient Billing/insurance/other financial coverage tracked-use expenses:– refers most often to reimbursements by government or private insurance mechanisms for services provided to patients Internally generated funds: funds generated at and by the facility, most often from user fees or other fees that are collected at the point of care Systematic forecasting exercise: projecting expected costs and income for a future period, based on past data, to enable strategic planning Disaggregation(s) Facility type (as relevant to context): including primary care facilities (e.g., GP practices, health centres, community health posts), first-level hospitals, second-level hospitals, specialty hospitals, long-term care facilities, continuing care facilities, etc.). Managing authority: public, private Subnational Urban/rural Numerator Number of facilities that are able to use/re-allocate funds across budgetary lines Denominator Total number of facilities surveyed Preferred data source Facility survey Rationale Facility budgets set out how much money comes into the facility, where it comes from, and how much money is spent and on what. Budgets should be flexible to allow re-allocations. Budgets can simply track the flow of funds as they move in real time/retroactively, but at higher levels of performance facilities can also use budgets to proactively plan for future activities and expenditures. These forecasting exercises provide the information facilities need to make strategic decisions such as what and how many medicines and supplies to buy, which staff to hire, etc. Reference(s) Primary Health Care Performance Initiative. Primary Health Care Progression Model Assessment Tool (measure 22 - Facility budgets; measure 23 - Financial management information system). 2019 (https://improvingphc.org/ sites/default/files/PHC-Progression%20Model%202019-04-04_FINAL.pdf; accessed 20 April 2021). Operational framework for primary health care: transforming vision into action. Geneva: World Health Organization and the United Nations Children’s Fund (UNICEF), 2020 (https://www.who.int/publications/i/ item/9789240017832, accessed 17 August 2021). Existence of facility budgets and expenditures meeting criteria 97 Existing data collection tool From existing health facility survey tools such as World Health Organization’s SARA and HHFA, World Bank’s SDI, and DHS program’s SPA+ (fully or partially). World Health Organization. Service Availability and Readiness Assessment (https://www.who.int/data/data- collection-tools/service-availability-and-readiness-assessment-(sara)?ua=1, accessed 16 August 2021). The DHS Program. Service Provision Assessment. September 2020 (https://dhsprogram.com/publications/ publication-spaq1-spa-questionnaires-and-manuals.cfm, accessed 18 August 2021). World Bank. Service Delivery Indicators (https://datatopics.worldbank.org/sdi/, accessed 19 August 2021). World Health Organization. Harmonized Health Facility Assessment (HHFA). March 2021 (https://www.who.int/ data/data-collection-tools/harmonized-health-facility-assessment/introduction, accessed 16 August 2021). To note: WHO is currently revising its facility survey modules to incorporate additional elements of PHC measurement and will provide recommended scoring methodology. 98 Indicator56 Models of care Indicator short name Collaboration between facility-based and community-based services Indicator long name Formal linkages exist between facility-based and community-based primary care providers Domain Models of care Sub-domain Community linkages and engagement M/E domain Process Definition Percentage of primary care facilities and first referral hospitals that have established formal linkages with community-based service providers (including CHWs). These linkages include the following key attributes: • There are clear roles and responsibilities established between the facility and community-based providers on the appropriate provision of care at the different levels • There are effective two-way communication channels between community-based and facility • Community-based providers are integrated in the facility management structures, facility teams, and data systems • Supportive supervision and training opportunities are made available by primary-care facility to the community- based service providers • The community and facility organizations are in close geographic proximity to each other • The facility refers patients to the community-based providers and receive referrals from community-based providers Evidence for formal linkages can be defined as either clear national or regional guidelines that define the roles between the different service delivery platforms or ad hoc written agreements that formalize this relationship locally Disaggregation(s) Managing authority: public, private Subnational Urban/rural Numerator Number of primary care facilities and first-referral hospitals with the key attributes defining facility-community linkages Denominator Total number of facilities surveyed Preferred data source Facility survey Rationale Creating sustainable, effective linkages between facilities and community settings can improve people’s use of promotion and preventive services, their timely access to facility-based services and their adherence to treatment. These positive outcomes are achieved when community-based service providers are trusted by the community they serve and by facility-based providers and when they are partnering to ensure continuity of care and improved clinical quality (i.e., through training or formative supervision). In addition, community- based providers have a role to alert facility-based providers of public health issues and help carry the voice of the people they serve to improve responsiveness of primary care services. They can act as an effective broker between communities and district or facility managers. These linkages connect clinical providers, community organizations, and public health agencies. While this indicator focuses on the linkages with primary care providers (including first-referral hospitals), it is also essential that hospitals are fully embedded within the communities they serve, working closely with other health care and social service providers. Hospitals should transition from being “the last link in a chain” of health service providers to being actively and continuously engaged with their communities and with providers of primary care. Reference(s) Operational framework for primary health care: transforming vision into action. Geneva: World Health Organization and the United Nations Children’s Fund (UNICEF), 2020 (https://www.who.int/publications/i/ item/9789240017832, accessed 17 August 2021). WHO community engagement framework for quality, people-centred and resilient health services. Geneva: World Health Organization; 2017 (https://apps.who.int/iris/handle/10665/259280, accessed 30 August 2021). Collaboration between facility-based and community- based service providers 99 Existing data collection tool The World Health Organization’s HHFA includes information on community linkages for HIV, TB, and malaria that include the delivery of a certain set of services. However, these are not designed in terms of the attributes of facility-community linkage. World Health Organization. Harmonized Health Facility Assessment. March 2021 (https://www.who.int/data/ data-collection-tools/harmonized-health-facility-assessment/introduction, accessed 16 August 2021). To note: WHO is currently revising its facility survey modules to incorporate /address PHC-specific elements. 100 Indicator57 Models of care Indicator short name Community engagement in service planning and organization Indicator long name Community voices to inform planning and organization of services at the local level (district or local health systems and facilities) Domain Models of care Sub-domain Community linkage and engagement M/E domain Process Definition There is a system to ensure local service planning is informed by community voices included but not limited to the following activities and demonstrates involvement of vulnerable groups in the planning process: • Community health needs and asset assessment • Participatory processes for priority setting • Patient and relatives’ surveys • Training of patient advocates • Membership of community representatives in advisory boards at the local level (e.g., council boards) or in supervisory boards of facilities Disaggregation(s) Not applicable Numerator Not applicable Denominator Not applicable Preferred data source Qualitative/Key informant survey and/or desk review with verification from key country documents Rationale Community engagement is the inclusion of local health system users and community members in all aspects of health planning, provision, and governance. It is a central component of ensuring that the services delivered are tailored to population needs, priorities and values, which can be achieved through the involvement of communities in the design, financing, governance, and implementation of PHC. To ensure that the needs of all community members are met, it is important that community engagement efforts include representation from diverse members of the community. This may require multiple mediums for engagement, to best capture the needs and opinions of traditionally underrepresented community members. Reference(s) WHO community engagement framework for quality, people-centred and resilient health services. Geneva: World Health Organization; 2017 (https://apps.who.int/iris/handle/10665/259280, accessed 4 October 2021). Indicator passport - WHO European Primary Health Care, Impact, Performance and Capacity Tool. Copenhagen: World Health Organization Regional Office for Europe; 2019 (https://www.euro.who.int/en/health-topics/ Health-systems/health-services-delivery/publications/2019/indicator-passport-who-european-primary-health- care,-impact,-performance-and-capacity-tool-phc-impact-2019, accessed 20 April 2021). Primary Health Care Performance Initiative. Primary Health Care Progression Model Assessment Tool (measure 26 – community engagement). 2019 (https://improvingphc.org/sites/default/files/PHC-Progression%20 Model%202019-04-04_FINAL.pdf; accessed 20 April 2021). Voice, agency, empowerment-handbook on social participation for universal health coverage. Geneva: World Health Organization; 2021 (https://www.who.int/publications/i/item/9789240027794, accessed 27 September 2021). Community Engagement: A health promotion guide for universal health coverage in the hands of the people. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/9789240010529, accessed 27 September 2021). Existing data collection tool A qualitative assessment tool with recommended scoring methodology is under development by WHO and will be forthcoming end 2022. Community engagement in service planning and organization 101 Indicator58 Models of care Indicator short name Proactive population outreach Indicator long name Health system engages in proactive population outreach Domain Models of care Sub-domain Community linkages and engagement M/E domain Process Definition Percentage of facilities that actively provide services to communities according to local health needs and priorities; Average number of services provided by the facilities. Proactive outreach activities include: • Mobile health units • Available transport systems • Home-based care • Telemedicine • Proactive follow-up with chronic disease patients • Health promotion activities • Health education • Identification of acute cases • Pregnant women needing referrals • Family planning provision • Chronic disease adherence follow-up Disaggregation(s) Facility type (as relevant to context): including primary care facilities (e.g., GP practices, health centres, community health posts), first-level hospitals, second-level hospitals, specialty hospitals, long-term care facilities, continuing care facilities, etc.) Managing authority: public, private Subnational Urban/rural Numerator 1. Number of facilities actively providing services to communities 2. Average number of proactive outreach activities Denominator Facility survey Preferred data source Qualitative assessment based on interview with key informant and /or desk review of country documents Rationale Proactive population outreach is when health systems actively reach out to provide care in homes and communities rather than exclusively in facilities. The health services are initiate by the health system and include preventive and promotive health services. Services delivered by CHWs are often classified under proactive population outreach. These services are often preventive or promotive (though may also be curative) and initiated by the health system rather than by patients. Such services are often provided by CHWs or similar occupations. Examples of common proactive outreach services include community engagement interventions, health promotion activities, health education, identification of acute cases and of pregnant women needing referrals to health facilities, family planning provision, and chronic disease adherence follow-up. Reference(s) Operational framework for primary health care: transforming vision into action. Geneva: World Health Organization and the United Nations Children’s Fund (UNICEF), 2020 (https://www.who.int/publications/i/ item/9789240017832, accessed 17 August 2021). Primary Health Care Performance Initiative. Primary Health Care Progression Model Assessment Tool 2019 (https://improvingphc.org/sites/default/files/PHC-Progression%20Model%202019-04-04_FINAL.pdf; accessed 20 April 2021). Proactive population outreach 102 Existing data collection tool The World Health Organization’s HHFA measures some of these individual items but it does not measure all the attributes. World Health Organization. Harmonized Health Facility Assessment (HHFA). March 2021. (https://www.who. int/data/data-collection-tools/harmonized-health-facility-assessment/introduction; accessed 16 August 2021). To note: WHO is currently revising its facility survey modules to incorporate additional elements of PHC measurement and will provide recommended scoring methodology. 103 Indicator59 Models of care Indicator short name Services for self-care and health literacy in primary care Indicator long name Percentage of facilities that promote self-care and health literacy in primary care Domain Models of care Sub-domain Community linkages and engagement M/E domain Process Definition Percentage of facilities that promote self-care and health literacy that include the following services, and average number of self-care and health literacy services provided by health facilities: • Routine use of telephone-based services • Routine use of computer-based programmes (e.g., internet-based chat rooms, virtual support group) • Routine distribution of printed resources (e.g., pictograms, pamphlets, brochures, etc.) • Routine support on use of in-home electronic aids (e.g., blood pressure cuff, blood glucose device etc.) • One-on-one patient education (e.g., a dedicated health care worker who is responsible for providing this support) • Established peer support groups Disaggregation(s) Facility type (as relevant to context): including primary care facilities (e.g., GP practices, health centres, community health posts), first-level hospitals, second-level hospitals, specialty hospitals, long-term care facilities, continuing care facilities, etc.) Managing authority: public, private Subnational Urban/rural Numerator Number of facilities that have the key attributes for improved self-management and health literacy Denominator Number of facilities surveyed Preferred data source Facility survey Rationale Strengthening health literacy enables people to make important health service decisions and to communicate, assert and enact these decisions. Strengthened health literacy improves health outcomes, the effective use of health services and reduces health inequities. Low levels of health literacy are associated with unhealthy choices and lifestyle and riskier behaviours. An important part of patient education is increasing awareness about the importance of disease prevention and health promotion as patients with certain co-morbidities are at increased risk for other related conditions. Services that work to link patients with peers can increase access to expert advice about how to manage both clinical and social aspects of a condition. It can also help to overcome feelings of isolation. Reference(s) National Committee for Quality Assurance: Measuring Quality, improving health care. Emergency Department Utilization (EDU) (https://www.ncqa.org/hedis/measures/emergency-department-utilization/, accessed 23 August 2021). Agency for Health care Research and Quality. 2015. Measures of Care Coordination: Preventable Emergency Department Visits (https://www.ahrq.gov/research/findings/nhqrdr/chartbooks/carecoordination/measure2.html, accessed 23 August 2021). World Health Organization Regional Office for Europe. Indicator passport - WHO European Primary Health Care, Impact, Performance and Capacity Tool. Copenhagen: World Health Organization Regional Office for Europe; 2019 (https://www.euro.who.int/en/health-topics/Health-systems/health-services-delivery/ publications/2019/indicator-passport-who-european-primary-health-care,-impact,-performance-and-capacity- tool-phc-impact-2019, accessed 20 April 2021). Existing data collection tool WHO is currently revising its facility survey modules to incorporate/address PHC-specific elements. Services for self-care and health literacy in primary care 104 Indicator60 Systems for improving quality of care Indicator short name Percentage of facilities with systems to support the improvement of quality of care and safety Indicator long name Percentage of facilities with systems to support the improvement of quality of care and safety Domain Systems for improving quality of care Sub-domain Systems for improving quality of care M/E domain Process Definition Percentage of health facilities with systems to support and implement quality improvement, measured against the following criteria • Existence of a focal person for quality improvement and patient safety • Dedicated resources for action on quality and safety • Regular application of quality improvement methods (e.g., performance measurement and management, quality improvement cycles, audit and feedback, learning systems) • Processes for clinical audits and mortality reviews (e.g., neonatal and maternal death review and response systems) • Availability of clinical guidelines/protocols and checklists • Systems for adverse event reporting including medication harm • Existence of an up-to-date risk management protocol • System or mechanism to measure patient experience/patient voices Disaggregation(s) Facility type (as relevant to context): including primary care facilities (e.g., GP practices, health centres, community health posts), first-level hospitals, second-level hospitals, specialty hospitals, long-term care facilities, continuing care facilities, etc.) Managing authority: public, private Subnational Urban/rural Numerator Number of facilities with systems to support quality improvement meeting defined criteria Denominator Total number of facilities surveyed Preferred data source Facility survey Rationale Facility-level action on quality and safety requires a multifaceted approach with strong linkages to district management and national strategic direction. Facility leadership and facility improvement teams drive activity and ensure relevant stakeholders are engaged. Key areas of activity span organizational aspects with focused attention to clinical improvement, reducing harm and engagement with patients, families and communities. The listed criteria in the definition represent a translation of quality interventions to the facility level in four areas - systems environment, reducing harm, improving clinical care and patient, family and community engagement, as outlined by WHO, the World Bank and OECD. Reference(s) Quality health services: a planning guide. Geneva: World Health Organization; 2020 (https://apps.who.int/iris/ handle/10665/336661, accessed 18 August 2021). World Health Organization, Organisation for Economic Co-operation and Development & International Bank for Reconstruction and Development. Delivering quality health services: a global imperative for universal health coverage. Geneva: World Health Organization; 2018 (https://apps.who.int/iris/handle/10665/272465, accessed 26 July 2021). Quality in primary health care. Geneva: World Health Organization; 2018 (https://apps.who.int/iris/ handle/10665/326461, accessed 30 August 2021). Existing data collection tool World Health Organization. Harmonized Health Facility Assessment. March 2021 (https://cdn.who.int/media/ docs/default-source/world-health-data-platform/hhfa/hhfa_-questionnaire_combined_core_2021.03.07. pdf?sfvrsn=698754fa_5&download=true, accessed 16 August 2021). WHO is currently revising its facility survey modules to incorporate /address PHC-specific elements. To note, however, the HHFA captures many of these attributes. Percentage of facilities with systems to support quality improvement 2.10 Systems for improving quality of care indicators 105 Indicator61 Resilient health facilities and services Indicator short name Percentage of facilities meeting criteria for resilient health facilities and services Indicator long name Percentage of facilities meeting criteria for resilient health facilities and services Domain Resilient health facilities and services Sub-domain Resilient health facilities and services M/E domain Processes Definition Percentage of health facilities that are able to demonstrate the following: • Defined health facility emergency management plan including service continuity, with availability or access to a budget line • Designated team or focal persons for emergency management and service continuity • Prioritised primary care services to be maintained during emergencies (according to national protocols) are identified • Up-to-date protocols for case management for priority health emergencies and disasters • Staff trained on emergency and disaster risk management (including prevention, preparedness, response and recovery) and service continuity • Recent (once in past five years) assessment of risks and structural, non-structural, functionality and preparedness of health care facilities • Simulation exercises to routinely test the functionality of health facility structures, mechanisms and functions for emergency management and service continuity • Post-emergency reviews (at facility or subnational level) to evaluate the performance of the facility in emergency management and service continuity and use lessons to effect recovery and strengthen capacities for current and future risks. Disaggregation(s) Facility type (as relevant to context): including primary care facilities (e.g., GP practices, health centres, community health posts), first-level hospitals, second-level hospitals, specialty hospitals, long-term care facilities, continuing care facilities, etc.) Managing authority: public, private Subnational Urban/rural Numerator Number of health facilities meeting attributes for resilient health facilities and services Denominator Total number of facilities surveyed Preferred data source Facility survey Rationale Reducing the health risks and consequences of emergencies is vital to local, national and global health security and to build the resilience of communities, countries and health systems. There are many cross-cutting, system- wide capacities that contribute to community and country resilience, including the critical roles of resilient health facilities and their functionality to provide health services in both day-to-day and emergency situations. Various system-wide attributes of resilience can be found in other indicators of this framework. This indicator focuses on emergency and disaster risk management, the continuity of services and functions, and the use of reviews and lessons learnt to facilitate recovery and strengthen capacities for current and future risks, as key attributes of resilient health facilities and services. Percentage of facilities meeting criteria for resilient health facilities and services 2.11 Resilient health facilities and services indicators 106 Reference(s) Service availability and readiness assessment. Geneva: World Health Organization; 2014 (https://apps.who.int/ iris/handle/10665/149025, accessed 20 April 2021). Comprehensive safe hospital framework. Geneva: World Health Organization; 2015 (https://www.who.int/ publications/i/item/comprehensive-safe-hospital-framework, accessed 19 August 2021). World Health Organization and Pan American Health Organization. Hospital safety index: guide for evaluators, 2nd ed. 2015 (https://apps.who.int/iris/handle/10665/258966, accessed 19 August 2021). State Party self-assessment annual reporting tool. Geneva: World Health Organization; 2018 (https://www.who. int/ihr/publications/WHO-WHE-CPI-2018.16/en/, accessed 20 April 2021). Health Emergency and Disaster Risk Management Framework. Geneva: World Health Organization; 2019 (https://www.who.int/hac/techguidance/preparedness/health-emergency-and-disaster-risk-management- framework-eng.pdf?ua=1, accessed 28 July 2021). United Nations and United Nations Office for Disaster Risk Reduction. Sendai Framework for Disaster Risk Reduction 2015-2030. 2015 (https://www.undrr.org/publication/sendai-framework-disaster-risk- reduction-2015-2030, accessed 20 April 2021). Primary health care and health emergencies. Geneva: World Health Organization;2018 (https://apps.who.int/ iris/handle/10665/328105, accessed 25 August 2021). World Health Organization. WHO Health Systems Resilience Indicators (forthcoming). Existing data collection tool World Health Organization. Harmonized Health Facility Assessment. March 2021 (https://www.who.int/data/ data-collection-tools/harmonized-health-facility-assessment/introduction, accessed 16 August 2021). WHO is currently revising its facility survey modules to incorporate/address PHC-specific elements. To note, however, the HHFA captures some of these attributes. 107 Indicator62 Access and availability Indicator short name Geographical access to services Indicator long name Percentage of population living within 5 km (or 1 hour) of a comprehensive primary care provider and 2 hours of an emergency care unit/provider Domain Access and availability Sub-domain Accessibility, affordability, acceptability M/E domain Outputs Definition Percentage of population who live within 5km of a comprehensive primary care facility or provider Percentage of population who live within 2 hours of an emergency care unit Disaggregation(s) Urban/rural Subnational Numerator Number of people who live within 5km of a primary care facility/provider Denominator Total population count Preferred data source Routine facility information system – facility database/master facility list, geospatial modelling Rationale Access to health services is critical for the health status of a population and analysis of its variance is important in the effective allocation of national health resources. The indicator contributes to the measurement of facility infrastructure management such as physical availability and accessibility of health services. Reference(s) 2018 Global Reference List of 100 Core Health Indicators (plus health-related SDGs). Geneva: World Health Organization; 2018 (https://apps.who.int/iris/handle/10665/259951, accessed 20 April 2021). Existing data collection tool Country information system Geographical access to services 2.12 Access and availability indicators 108 Indicator63 Access and availability Indicator short name Perceived barriers to access (geographical, financial, sociocultural) Indicator long name Perceived barriers to access (geographical, financial, sociocultural) Domain Access and availability Sub-domain Accessibility, affordability, acceptability M/E domain Outputs Definition Percentage of target population who report problems in accessing care when they have a health care need, by problem. Disaggregation(s) Wealth quintile Education Urban/rural Age Gender Subnational Numerator Number of people interviewed who report having had a problem accessing care when they had a health care need: • Getting permission to go for treatment • Getting money for treatment • Distance to the health facility • Not wanting to go alone Denominator Number of people interviewed who reported having a health care need Preferred data source Population-based survey Rationale Perceived barriers to access can negatively impact the use of health services, especially for marginalized and vulnerable populations. A perceived barrier during one visit can impact on future use of services. Addressing barriers to access and use of health services is critical for ensuring equitable delivery and use of health services. Assessments of barriers to health services can be one example of PHC-oriented research that contributes to the reduction of health inequities Reference(s) Operational framework for primary health care: transforming vision into action. Geneva: World Health Organization and the United Nations Children’s Fund (UNICEF), 2020 (https://www.who.int/publications/i/ item/9789240017832, accessed 17 August 2021). Existing data collection tool The Demographic and Health Surveys Program. Demographic and Health Surveys (https://dhsprogram.com/ Methodology/Survey-Types/DHS.cfm, accessed 19 August 2021). Perceived barriers to access (geographical, financial, sociocultural) 109 Indicator64 Access and availability Indicator short name Access to emergency surgery Indicator long name Access to emergency surgery Domain Access and availability Sub-domain Accessibility, affordability, acceptability M/E domain Outputs Definition Percentage of the population that can access, within 2 hours, a facility that can perform emergency caesarean section, laparotomy and open fracture fixation Disaggregation(s) Urban/rural Subnational Numerator Total count of population that can access, within 2 hours, a facility that can perform emergency caesarean section, laparotomy and open fracture fixation Denominator Total population Preferred data source Routine facility information system – facility database/master facility list, geospatial modelling; facility survey Rationale Emergency surgical care is unplanned surgery care that is needed to treat acute illness or trauma that is presented at the emergency department of a health facility (mainly hospitals but also larger polyclinics). Emergency surgical care is necessary for common or less-common emergency conditions that can become life- threatening if not addressed in time, e.g., appendicitis. Availability of and access to emergency surgery is critical for meeting population health needs and is a critical component of PHC. Capacity to perform the 3 defined procedures (“Bellwether procedures”) predicts accomplishment of many other essential surgical procedures; 2 hours is a threshold of deaths from complication of childbirth. Access to health services is critical for the health status of a population and analysis of its variance is important in the effective allocation of national health resources. The indicator contributes to the measurement of facility infrastructure management, such as physical availability and accessibility of health services. Reference(s) 2018 Global Reference List of 100 Core Health Indicators (plus health-related SDGs). Geneva: World Health Organization; 2018 (https://apps.who.int/iris/handle/10665/259951, accessed 20 April 2021). 2. World Health Organization. WHO Emergency Care System Framework (https://www.who.int/publications/i/ item/who-emergency-care-system-framework, accessed 17 August 2021). 3. Global surgery 2030: Core indicators for monitoring universal access to safe, affordable surgical and anaesthesia care when needed. https://www.lancetglobalsurgery.org/ (see “Measure and plan”). Existing data collection tool Country health information system; World Health Organization. Harmonized Health Facility Assessment. March 2021 (https://www.who.int/data/ data-collection-tools/harmonized-health-facility-assessment/introduction, accessed 16 August 2021). Access to emergency surgery 110 Indicator65 Access and availability Existence of a system for post-crash care Indicator short name Existence of a system for post-crash care Indicator long name Existence of a system for post-crash care Domain Access and availability Sub-domain Accessibility, affordability, acceptability M/E domain Outputs Definition Existence of a system for post-crash care that is assessed by the presence of the following attributes: • National emergency care access number • Trauma registry • Formal certification pathway for prehospital providers (e.g., for medics, technicians, nurses) • Comprehensive assessment of emergency care systems conducted at the national level comprising prehospital and facility-based emergency care systems • Policy specifying national (or subnational) target(s) and parameters for maximum time interval between a road crash resulting in injury and the provision of first professional emergency care • Existence of Good Samaritan laws to protect bystanders, other laypeople, or non-clinical first responders, such as police Disaggregation(s) Not applicable Numerator Not applicable Denominator Not applicable Preferred data source Qualitative assessment or policy review Rationale Delays in detecting and providing care for those involved in a road traffic crash increase the severity of injuries. Care of injuries after a crash has occurred is extremely time-sensitive: delays of minutes can make the difference between life and death. Improving post-crash care requires ensuring access to timely prehospital care and improving the quality of both prehospital and hospital care, such as through specialist training programmes. Reference(s) WHO status report on road safety 2018. Geneva: World Health Organization; 2018 (https://www.who.int/ publications/i/item/9789241565684, accessed 7 September 2021). Existing data collection tool A national assessment tool developed by WHO to collect data for the WHO status report on road safety 2018 measures some of the attributes. WHO is in the process of revising this assessment to incorporate additional elements in 2022. 111 Indicator66 Access and availability Percentage of facilities offering services according to national defined service package Indicator short name Percentage of facilities offering core services according to national defined service package Indicator long name Percentage of facilities offering core services according to national defined service package Domain Access and availability Sub-domain Accessibility, affordability, acceptability M/E domain Outputs Definition Percentage of primary care facilities/units offering services according to national defined service package. Specific services depend on the country context and should align with the core package of services, for example: • Communicable diseases Communicable disease prevention Immunization Communicable diseases (excluding NTDs) HIV counselling and testing; HIV/AIDS care and support services; Antiretroviral prescription and client management; Sexually transmitted infections diagnosis or treatment; Tuberculosis services (diagnosis, treatment prescription or treatment follow-up) Malaria diagnosis or treatment; Childhood respiratory infections and diarrheal diseases Neglected Tropical Diseases • Foundations of care Core functions Integrated approach to common conditions • Growth, development and ageing Infant, child and adolescent growth and development Nutrition, physical activity and sleep Special considerations at the end of life Palliative care services Special considerations in older people Disabilities • Noncommunicable diseases Blood disorders Cancers Cervical cancer screening Cardiovascular disease Chronic musculoskeletal disorders Chronic respiratory diseases Congenital abnormalities Digestive diseases Endocrine, metabolic, and autoimmune disorders Genitourinary disorders Sense organ diseases Skin and hair diseases Skin and subcutaneous diseases 112 • Mental health, neurological and substance abuse disorders Mental disorders Neurological disorders Substance use disorders • Reproductive and sexual health Pregnancy and birth Family planning, Antenatal care, Prevention of mother-to-child transmission of HIV; Basic emergency obstetric and neonatal care (BEmONC); Comprehensive emergency obstetric and neonatal care (CEmONC), post-abortion care; Essential newborn care; Sexual health and family planning • Violence and injury Injury Envenomation injuries; Mechanical injury; Poisoning, toxic and environmental injuries (including drowning); Interpersonal violence; • Rehabilitative services • Basic and comprehensive surgical care, including caesarean section, laparotomy and open fracture • Services available 24 hours a day (for emergencies) with either a health care worker present at the facility at all times or officially on call for the facility at all times • Emergency units with acuity-based triage • Nutrition services Disaggregation(s) Facility type (as relevant to context): including primary care facilities (e.g., GP practices, health centres, community health posts), first-level hospitals, second-level hospitals, specialty hospitals, long-term care facilities, continuing care facilities, etc.) Managing authority: public, private Subnational Urban/rural Numerator Number of facilities offering the total package of core services; number of facilities offering each service Denominator Total number of facilities examined Preferred data source Facility survey or facility census or RHIS Rationale Availability of health services should be aligned with a country’s defined package of essential health services and public health functions. This measures assess the extent to which specific services are offered and available in the relevant health care settings (for example, primary care, hospital and long-term care). Reference(s) World Health Organization. WHO Universal Health Coverage compendium: a global repository of interventions for UHC. 2021 (https://www.who.int/universal-health-coverage/compendium, accessed 1 July 2021). Existing data collection tool From existing health facility survey tools such as World Health Organization’s SARA and Harmonized Health Facility Assessments (HHFA, and DHS program’s SPA. World Health Organization. Service Availability and Readiness Assessment (https://www.who.int/data/data- collection-tools/service-availability-and-readiness-assessment-(sara)?ua=1, accessed 16 August 2021). The DHS Program. Service Provision Assessment. September 2020 (https://dhsprogram.com/publications/ publication-spaq1-spa-questionnaires-and-manuals.cfm, accessed 18 August 2021). World Health Organization. Harmonized Health Facility Assessment. March 2021 (https://www.who.int/data/ data-collection-tools/harmonized-health-facility-assessment/introduction, accessed 16 August 2021). To note: WHO is currently revising its facility survey modules to incorporate additional elements of PHC measurement and will provide recommended scoring methodology. 113 Indicator67 Access and availability Provider availability (absence rate) Indicator short name Provider availability (absence rate) Indicator long name Provider availability (absence rate) Domain Access and availability Sub-domain Service availability and readiness M/E domain Outputs Definition Percentage of clinical staff who are expected to be at facility but are not present at a facility during an unannounced visit compared to the expected number of staff at a given time. Disaggregation(s) Facility type (as relevant to context): including primary care facilities (e.g., GP practices, health centres, community health posts), first-level hospitals, second-level hospitals, specialty hospitals, long-term care facilities, continuing care facilities, etc.) Managing authority: public, private Subnational Urban/rural Numerator Number of health professionals that are not off duty who are absent from the facility on an unannounced visit Denominator Ten randomly sampled workers who are supposed to be on duty at the facility on the day of the assessment. The only health workers that are removed from the denominator are those on shift work (i.e., not present because it is not their shift) or those doing fieldwork (mainly community and public health professionals). Preferred data source Facility survey Rationale Health worker density and distribution measures one dimension of staff availability. Provider absence measures another dimension of staff availability. Presence of medical staff is a critical component for health service delivery and quality. Low levels of staff availability may preclude people from accessing the care that they require. Reference(s) World Bank. World Bank Service Delivery Indicators (https://www.sdindicators.org/, accessed 19 August 2021). Existing data collection tool World Bank. World Bank Service Delivery Indicators (https://www.sdindicators.org/, accessed 19 August 2021). To note: WHO is currently revising its facility survey modules to incorporate additional elements of PHC measurement and will provide recommended scoring methodology. 114 Indicator68 Access and availability Percentage of facilities meeting minimum standards to deliver tracer services Indicator short name Percentage of facilities meeting minimum standards to deliver tracer services Indicator long name Percentage of facilities meeting minimum standards to deliver tracer services Domain Access and availability Sub-domain Service availability and readiness M/E domain Outputs Definition Percentage of facilities offering the service that have appropriate (according to tracer services): • Staff and guidelines • Equipment • Diagnostics • Medicines and commodities Disaggregation(s) Facility type (as relevant to context): including primary care facilities (e.g., GP practices, health centres, community health posts), first-level hospitals, second-level hospitals, specialty hospitals, long-term care facilities, continuing care facilities, etc.) Managing authority: public, private Subnational Urban/rural Numerator Number of health facilities that have the recommended staff, guidelines, equipment, diagnostics, medicines and commodities to provide tracer services, such as for reproductive, maternal, newborn, child and adolescent health, communicable diseases, and noncommunicable diseases. Denominator Total number of facilities surveyed Preferred data source Facility survey Rationale One of the goals of UHC is the ability to provide quality health services to the population that meet their needs without financial hardships. Service readiness (as defined by facilities meeting minimum standards to deliver services) is a necessary component of quality health services. The ability of facilities to provide quality services to those accessing care is dependent on the facility having adequate supplies and staffing. Some of the components of these indicators are measured separately as part of this framework. However, this measure combines the different components to give a combined measure of service readiness as well as examining separately the different components to see where minimum standards are (or are not) being met. Reference(s) 2018 Global Reference List of 100 Core Health Indicators (plus health-related SDGs). Geneva: World Health Organization; 2018 (https://apps.who.int/iris/handle/10665/259951, accessed 20 April 2021). Existing data collection tool From existing health facility survey tools such as World Health Organization’s SARA and HHFA, and DHS program’s SPA. World Health Organization. Service Availability and Readiness Assessment (https://www.who.int/data/data- collection-tools/service-availability-and-readiness-assessment-(sara)?ua=1, accessed 16 August 2021). The DHS Program. Service Provision Assessment. September 2020 (https://dhsprogram.com/publications/ publication-spaq1-spa-questionnaires-and-manuals.cfm, accessed 18 August 2021). World Health Organization. Harmonized Health Facility Assessment. March 2021 (https://www.who.int/data/ data-collection-tools/harmonized-health-facility-assessment/introduction, accessed 16 August 2021). To note: WHO is currently revising its facility survey modules to incorporate additional elements of PHC measurement and will provide recommended scoring methodology. 115 Indicator69 Access and availability Percentage of facilities compliant with IPC measures Indicator short name Percentage of facilities compliant with IPC measures Indicator long name Percentage of facilities compliant with IPC measures Domain Access and availability Sub-domain Service availability and readiness M/E domain Outputs Definition Percentage of facilities meeting standards (inadequate, basic, intermediate, advanced) based on the eight core components of IPCAF: • IPC programme Trained IPC link person, with dedicated (part-) time in each PHC facility One IPC-trained health care officer at the next administrative level (for example, district) to supervise the IPC link professionals in PHC facilities • IPC guidelines Evidence-based facility-adapted SOPs based on the national IPC guidelines Routine monitoring of the implementation of at least some of the IPC guidelines/SOPs • IPC education and training All front-line clinical staff and cleaners must receive education and training on the facility IPC guidelines/SOPs upon employment. All IPC link persons in primary care facilities and IPC officers at the district level (or other administrative level) need to receive specific IPC training • HAI surveillance HAI surveillance should follow national or sub-national plans (where available and applicable) • Multimodal strategies Use of multimodal strategies – at the very least to implement interventions to improve hand hygiene, safe injection practices, decontamination of medical instruments, devices and environmental cleaning • Monitoring/audit of IPC practices and feedback Monitoring of IPC structural and process indicators should be put in place at primary care level, based on IPC priorities identified in the other components. • Workload, staffing and bed occupancy Reduce overcrowding with a system for patient flow, a triage system (including referral system) and a system for the management of consultations should be established according to existing guidelines, if available Optimize staffing levels by assessment of appropriate staffing levels, depending on the categories identified when using WHO/national tools (national norms on patient/staff ratio), and development of an appropriate plan • Built environment, materials and equipment for IPC at the facility level Water should always be available from a source on the premises A minimum of two functional, improved sanitation facilities should be available on site, one for patients and the other for staff; both should be equipped with menstrual hygiene facilities Functional hand hygiene facilities should always be available at points of care/toilets and include soap, water and single-use towels (or if unavailable, clean reusable towels) or alcohol-based hand rub at points of care and soap, water and single-use towels (or if unavailable, clean reusable towels) within 5 metres of toilets Sufficient and appropriately labelled bins to allow for health care waste segregation should be available and used 116 The facility layout should allow adequate natural ventilation, decontamination of reusable medical devices, triage and space for temporary cohorting/isolation/physical separation if necessary Sufficient and appropriate IPC supplies and equipment (for example, mops, detergent, disinfectant, personal protective equipment and sterilization) and power/energy (for example, fuel) should be available for performing all basic IPC measures according to minimum requirements/SOPs, including all standard precautions, as applicable; lighting should be available during working hours for providing care Isolation areas Disaggregation(s) Facility type (as relevant to context): including primary care facilities (e.g., GP practices, health centres, community health posts), first-level hospitals, second-level hospitals, specialty hospitals, long-term care facilities, continuing care facilities, etc.) Managing authority: public, private Subnational Urban/rural Numerator Number of health facilities meeting IPC standards Denominator Total number of facilities surveyed Preferred data source Facility survey Rationale Preventing harm to patients, health workers and visitors due to infection in health care facilities is fundamental to achieve quality care, patient safety, health security and the reduction of health care-associated infections and antimicrobial resistance. Reference(s) Minimum Requirements for infection prevention and control programmes. Geneva: World Health Organization; 2019 (https://www.who.int/publications/i/item/9789241516945, accessed 19 August 2021). Improving infection prevention and control at the health facility level: interim practical manual supporting implementation of the WHO guidelines on core components of infection prevention and control programmes. Geneva: World Health Organization; 2018 (https://apps.who.int/iris/handle/10665/279788, accessed 19 August 2021). Existing data collection tool Infection prevention and control assessment framework at the facility level. Geneva: World Health Organization; 2018 (https://apps.who.int/iris/handle/10665/330072, accessed 19 August 2021). A number of the specific items can also be found in existing facility survey tools such as World Health Organization’s SARA and HHFA, and DHS program’s SPA. World Health Organization. Service Availability and Readiness Assessment (https://www.who.int/data/data- collection-tools/service-availability-and-readiness-assessment-(sara)?ua=1, accessed 16 August 2021). The DHS Program. Service Provision Assessment. September 2020 (https://dhsprogram.com/publications/ publication-spaq1-spa-questionnaires-and-manuals.cfm, accessed 18 August 2021). World Health Organization. Harmonized Health Facility Assessment. March 2021 ( https://www.who.int/data/ data-collection-tools/harmonized-health-facility-assessment/introduction, accessed 16 August 2021). To note: WHO is currently revising its facility survey modules to incorporate additional elements of PHC measurement and will provide recommended scoring methodology. 117 Indicator70 Access and availability Outpatient visits Indicator short name Outpatient visits Indicator long name Outpatient visits (primary care) per person per year Domain Access and availability Sub-domain Utilization of services M/E domain Outputs Definition Number of outpatient health facility visits (e.g., to facilities or doctors) per person per year Disaggregation(s) Subnational Age Gender Numerator Total number of visits Denominator Per person in a given year Preferred data source Population-based survey; can also be collected through RHIS if the RHIS includes all facilities in the country (public and private) Rationale Utilization of care can be a predictor of access to primary care. While cultural factors and incentive structures can play a role in how often people seek care, low utilization can signal issues related to access to care. For example, OECD average for doctor’s consultation is between 6.5 and 6.8 visits per person in a year (OECD Health at a glance 2019). During public health events outpatient visit utilization needs frequent monitoring to assure timely detection of service disruption. Reference(s) National Committee for Quality Assurance: Measuring Quality, improving health care. Emergency Department Utilization (https://www.ncqa.org/hedis/measures/emergency-department-utilization/, accessed 23 August 2021). Agency for Healthcare Research and Quality. 2015. Measures of Care Coordination: Preventable Emergency Department Visits (https://www.ahrq.gov/research/findings/nhqrdr/chartbooks/carecoordination/measure2.html, accessed 23 August 2021). Existing data collection tool Country health information systems The DHS have a health care utilization module though it is not part of their core module but can be accessed through individual country reports online. The Demographic and Health Surveys Program. Demographic and Health Surveys (https://dhsprogram.com/Methodology/Survey-Types/DHS.cfm, accessed 19 August 2021). 118 Indicator71 Access and availability Emergency unit visits Indicator short name Emergency unit visits Indicator long name Emergency unit visits per 1000 population Domain Access and availability Sub-domain Utilization of services M/E domain Outputs Definition Number of emergency department visits per 1 000 population Disaggregation(s) Subnational Age Gender Numerator Number of patients who seek care at the emergency department Denominator Per 1 000 population Preferred data source RHIS – if the RHIS included all facilities offering emergency unit services in the country (public and private) Could also be collected through population-based survey Rationale Utilization of emergency primarily shows the access to emergency services for acute time-sensitive conditions. However, in some settings emergency services can be used for preventable or treatable conditions. It is important to capture this, as emergency department services are costly services that can burden the health system if used for non-time-sensitive conditions. During public health events emergency unit utilization needs frequent monitoring to assure timely detection of service disruption. Reference(s) National Committee for Quality Assurance: Measuring Quality, improving health care. Emergency Department Utilization (https://www.ncqa.org/hedis/measures/emergency-department-utilization/, accessed 23 August 2021). Agency for Healthcare Research and Quality. 2015. Measures of Care Coordination: Preventable Emergency Department Visits (https://www.ahrq.gov/research/findings/nhqrdr/chartbooks/carecoordination/measure2.html, accessed 23 August 2021). Existing data collection tool Country health information systems 119 Indicator72 Access and availability Hospital discharges Indicator short name Hospital discharges Indicator long name Hospital discharges per 1 000 population Domain Access and availability Sub-domain Utilization of services M/E domain Outputs Definition Number of patients who are admitted to or leave a hospital after staying at least one night per 1 000 population (includes death following inpatient care but excludes same-day discharges) Disaggregation(s) Subnational Age Gender Numerator Number of patients who are admitted or leave a hospital after staying at least one night Denominator Per 1 000 population Preferred data source RHIS - if the RHIS included all facilities offering inpatient services in the country (public and private) Population based survey Rationale Hospital admissions (discharges) is another measure of utilization of health services. High hospital admission/ discharge rates can also signal a failure of PHC service delivery that has necessitated hospital admissions (a measure of this is also captured in the indicator “admissions for ambulatory-sensitive conditions”. During public health events hospital admissions need frequent monitoring to assure timely detection of service disruption. Reference(s) 2018 Global Reference List of 100 Core Health Indicators (plus health-related SDGs). Geneva: World Health Organization; 2018 (https://apps.who.int/iris/handle/10665/259951, accessed 20 April 2021). Health at a Glance 2019: OECD Indicators. Paris: OECD Publishing; 2019. https://doi.org/10.1787/4dd50c09-en (https://www.oecd-ilibrary.org/social-issues-migration-health/health-at-a-glance-2019_4dd50c09-en, accessed 20 April 2021). Existing data collection tool Country health information systems Indicator73 Access and availability Leading diagnoses (primary care/outpatient visits, inpatient diagnoses at discharge) Indicator short name Leading diagnoses (primary care/outpatient visits, inpatient diagnoses at discharge) Indicator long name Leading diagnoses for primary care/outpatient visit, inpatient diagnoses at discharge Domain Access and availability Sub-domain Utilization of services M/E domain Outputs Definition Number, Rate per 1 000 population and percentage distribution of the main diagnostic categories Disaggregation(s) Subnational Age Gender Service type: outpatient, inpatient discharges Numerator Number of new cases /discharges by diagnosis Denominator Rate: Total population; Percentage distribution: total number of outpatient visits; total number of discharge diagnoses Preferred data source RHIS Rationale Leading diagnoses captures the key conditions seen by service providers. This information is important for PHC services as it can support targeting of health services as well as guide preventive efforts at the population level. During public health events, utilization for leading diagnosis need frequent monitoring to assure timely detection of service disruption. (Note that these rates are different from the incidence and/or prevalence of the conditions in the population.) Reference(s) 2018 Global Reference List of 100 Core Health Indicators (plus health-related SDGs). Geneva: World Health Organization; 2018 (https://apps.who.int/iris/handle/10665/259951, accessed 20 April 2021). Existing data collection tool Country health information systems 121 Indicator74 Quality care Patient-reported experiences Indicator short name Patient-reported experiences Indicator long name Index of patient-reported experiences (including in primary care facilities) Domain Quality care Sub-domain Core primary care functions (first-contact accessibility, continuity, comprehensiveness, coordination, people-centredness) M/E domain Outputs Definition Percentage of patients that meet the key attributes of patient experience that include first-contact accessibility, continuity, coordination and people-centredness Patient-reported experiences addresses some of the key domains of core primary care functions through the lens of the patient. It includes the following domains: • First contact accessibility Where appointment systems are in place: Ease of appointment booking Waiting time for appointment (in settings where this can be measured) Where appointment systems are not in place: Non-use of care due to perceived length of waiting time for consultation • Continuity Percentage of patients who saw the same health provider (includes a primary care practice with a single or multiple clinicians) Percentage of patients who reported their provider having knowledge of their prior visits and test results • Coordination Percentage of patients with two or more conditions that reported to have one provider coordinating care • People-centredness Communication: percentage of patients who reported their providers provided clear explanations Respect Percentage of patients who reported their provider communicated with respect as their last visit Percentage of patients who reported respectful communication from other clinic staff Autonomy: Percentage of patients who are provided with information on treatment options and are consulted about preferences Confidentiality: Percentage of patients who reported they were satisfied with the level of confidentiality provided during their consultation. Social support received during stay at facility (esp. in hospitals) (In relation to patient-experiences, patient-reported outcome measures are also reported) Disaggregation(s) When collected through population-based survey and facility surveys: Age Gender Subnational Urban/rural For exit interview during facility surveys only: Facility type (as relevant to context): including primary care facilities (e.g., GP practices, health centres, community health posts), first-level hospitals, second-level hospitals, specialty hospitals, long-term care facilities, continuing care facilities, etc.) 2.13 Quality care indicators Numerator Number of key attributes that are met (overall and by domain) Denominator Total number of patients interviewed Preferred data source Population-based survey or patient survey (as part of an exit-interview during a facility survey or a separate visit- follow-up patient questionnaire) Rationale Patient-reported experiences provide critical insight into the quality of care received. The experience of the patient is an important quality outcome in its own right that can complement other, more commonly used clinical measures in building a picture of whether quality care was received. Such data, especially when disaggregated into specific aspects such as those outlined in the indicator definition, can be used to inform health workers and health service leadership on key quality challenges within the service and to support design and monitoring of quality improvement efforts. A comprehensive understanding of the patient perspective on care received requires insight into the three inter-related areas listed within the definition. Patient experience data informs descriptively from the patient perspective on the care received, with those same aspects explored from a patient satisfaction angle to understand the degree to which patients believe their expectations were met during their experience. Similarly, the focus on health system responsiveness assesses the ability of the health system to meet the legitimate expectations of the population regarding the non-medical and non- financial aspects of care, a factor which has been found to improve other measures of health, for example through increasing compliance and care seeking behaviour. This indicator aims to broadly reflect perceptions of health care from the patient perspective, described across three categories: patient experience, patient satisfaction and health system responsiveness. For the purposes of this composite indicator, a limited number of subcomponents have been included under each category. They reflect key primary care components relevant across all settings. However, when collecting data on these subcomponents it may be helpful to select additional subcomponents for each of these three categories to provide further detail on patient perceptions that can support monitoring, evaluation and decision-making, relevant to the local setting. Reference(s) Health at a Glance 2019: OECD Indicators. Paris: OECD Publishing; 2019. https://doi.org/10.1787/4dd50c09-en (https://www.oecd-ilibrary.org/social-issues-migration-health/health-at-a-glance-2019_4dd50c09-en, accessed 20 April 2021). Operational framework for primary health care: transforming vision into action. Geneva: World Health Organization and the United Nations Children’s Fund (UNICEF), 2020 (https://www.who.int/publications/i/ item/9789240017832, accessed 17 August 2021). Johns Hopkins Primary Care Policy Center Primary Care Assessment Tools (https://www.jhsph.edu/research/ centers-and-institutes/johns-hopkins-primary-care-policy-center/pca_tools.html, accessed 19 August 2021). Existing data collection tool Patient-reported indicator survey (PaRIS) from OECD measure these domains. OECD. Patient-reported indicator survey (PaRIS). Patient and Provider Questionnaires. Technical Materials 2021 (https://www.oecd.org/health/paris/, accessed 18 September 2021). To note: WHO is working with partners on adapting these measures for broader applicability. 122 123 Indicator75 Quality care People’s perceptions of health system and services Indicator short name People’s perceptions of health system and services Indicator long name People’s perceptions of health system and services Domain Quality care Sub-domain Core primary care functions (first-contact accessibility, continuity, comprehensiveness, coordination, people-centredness) M/E domain Outputs Definition Percentage of people that have positive perception of health system and services that include the following domains: • Perception of the public health system • Perceptions of the overall health systems • Expectations of health systems quality • Use and non-use of care A score is generated per domain based on the number of domain elements present, then an overall general community perceptions of health systems score is calculated based on the mean of the domains. Disaggregation(s) Provider type (where care was sought) – public, private, other Wealth quintile Education Gender Age Numerator Number of people that have positive perception of health system and services Denominator Total number of people interviewed for the survey Preferred data source Population-based survey Rationale Patient experiences are important to assess and improve the quality of care provided. Patient experiences can influence care-seeking behaviour. However, beyond the actual experiences that drive care-seeking, there is also the population’s expectation for the quality of care as well as their overall perspectives on the health system, which can also be drivers for care-seeking. Reference(s) Voice, agency, empowerment-handbook on social participation for universal health coverage. Geneva: World Health Organization; 2021 (https://www.who.int/publications/i/item/9789240027794, accessed 27 September 2021). Community Engagement: A health promotion guide for universal health coverage in the hands of the people. Geneva: World Health Organization; 2020 (https://www.who.int/publications/i/item/9789240010529, accessed 27 September 2021). Primary Health Care Performance Initiative. Primary Health Care Progression Model Assessment Tool. 2019 (https://improvingphc.org/sites/default/files/PHC-Progression%20Model%202019-04-04_FINAL.pdf; accessed 20 April 2021). Margaret E Kruk, Anna D Gage, Catherine Arsenault, Keely Jordan, Hannah H Leslie, Sanam Roder-DeWan, et al. High-quality health systems in the Sustainable Development Goals era: time for a revolution. The Lancet Global Health Commission| Volume 6, Issue 11, E1196-E1252, November 01, 2018 (DOI:https://doi. org/10.1016/S2214-109X(18)30386-3, accessed 26 September 2021). Existing data collection tool There is a measure of community needs, perceptions and demand through a community assessment tool developed by WHO to measure health service capacity assessment. Community needs, perceptions and demand: community assessment tool. Geneva: World Health Organization; 2021 (https://apps.who.int/iris/handle/10665/339388, accessed 19 August 2021). To note: WHO is currently revising its measurement and methodology to incorporate additional elements of PHC measurement. Indicator76 Quality care Diagnostic accuracy (provider knowledge) Indicator short name Diagnostic accuracy (provider knowledge) Indicator long name Diagnostic accuracy (provider knowledge) Domain Quality care Sub-domain Effectiveness M/E domain Outputs Definition Percentage of cases correctly diagnosed out of the number of patients examined, as observed through clinical vignettes on multiple common conditions, including patients with multimorbidity Disaggregation(s) Facility type (as relevant to context): including primary care facilities (e.g., GP practices, health centres, community health posts), first-level hospitals, second-level hospitals, specialty hospitals, long-term care facilities, continuing care facilities, etc.) Managing authority: public, private Subnational Urban/rural Cadre (e.g., doctor, clinical officer, nurse, CHW, etc.) Tracer condition Numerator Sum of the total number of correct diagnoses identified Denominator Number of patients examined Preferred data source Patient-provider observations or record reviews during facility surveys Rationale PHC providers face high patient volumes and have to make decisions under considerable uncertainty. Patients present with common conditions that are often difficult to differentiate. A diagnostic error happens when a provider misdiagnoses a patient or misses diagnosing a patient. Diagnostic error can lead to patient harm and is a key component of patient safety. Accurate diagnosis is fundamental in providing quality and appropriate care. Reference(s) World Health Organization. UHC Compendium Bank. Service Delivery Indicators (https://www.who.int/ universal-health-coverage/compendium,https://www.sdindicators.org/, accessed 17 August 2021). Operational framework for primary health care: transforming vision into action. Geneva: World Health Organization and the United Nations Children’s Fund (UNICEF), 2020 (https://www.who.int/publications/i/ item/9789240017832, accessed 17 August 2021). Existing data collection tool Currently the World Bank’s Service Delivery Indicator survey measures diagnostic accuracy for the following five clinical presentations: (i) acute diarrhoea; (ii) pneumonia; (iii) diabetes mellitus; (iv) pulmonary tuberculosis; (v) malaria with anaemia. World Bank. Service Delivery Indicators (https://www.sdindicators.org/, accessed 19 August 2021). To note: WHO is currently revising its facility survey modules to incorporate additional elements of PHC measurement and will provide recommended scoring methodology. 124 125 Indicator77 Quality care Adherence to clinical standards for tracer services Indicator short name Adherence to clinical standards for tracer services Indicator long name Adherence to clinical standards/ guidelines for primary care tracer services (family planning, antenatal care, sick child care, hypertension, diabetes) based on observed visits (percentage of tracer services adhering to standards) Domain Quality care Sub-domain Effectiveness M/E domain Outputs Definition Adherence to clinical guidelines measures the number of relevant history and physical examination questions asked and documented by a provider during a clinical encounter compared to the total number of relevant history and examination questions that should have been asked, examined through clinical vignettes. Alternatively, could be examined through exit interviews or record reviews Disaggregation(s) Facility type (as relevant to context): including primary care facilities (e.g., GP practices, health centres, community health posts), first-level hospitals, second-level hospitals, specialty hospitals, long-term care facilities, continuing care facilities, etc.) Managing authority: public, private Subnational Urban/rural Cadre (e.g., doctor, clinical officer, nurse, CHW etc.) Numerator Total number of relevant history and examination questions asked by the provider Denominator Total number of relevant history and examination questions that should have been asked by the provider Preferred data source Facility survey (patient-provider observations or record review) Rationale Measuring adherence to practice guidelines is a measure of quality of care. Adherence to clinical guidelines improves patient outcomes. However, there is often a gap between clinical standards and actual provider practice. By examining adherence to clinical guidelines for a tracer set of commonly occurring diseases and conditions (services involving women and children and noncommunicable diseases) demonstrates if providers are providing health services according to standards. The selection of these tracer services/diseases also shows that if providers have difficulty in meeting the clinical standards for commonly presenting diseases and conditions, they will also have problems with other, less-common diseases. Reference(s) World Health Organization. UHC Compendium (https://www.who.int/universal-health-coverage/compendium, https://www.sdindicators.org/, accessed 17 August 2021). Existing data collection tool This information is partially collected through existing health facility survey tools such as World Health Organization’s SARA and HHFA, World Bank’s SDI, and DHS program’s SPA. World Health Organization. Service Availability and Readiness Assessment (https://www.who.int/data/data- collection-tools/service-availability-and-readiness-assessment-(sara)?ua=1, accessed 16 August 2021). The DHS Program. Service Provision Assessment. September 2020 (https://dhsprogram.com/publications/ publication-spaq1-spa-questionnaires-and-manuals.cfm, accessed 18 August 2021). World Bank. Service Delivery Indicators (https://datatopics.worldbank.org/sdi/, accessed 19 August 2021). World Health Organization. Harmonized Health Facility Assessment. March 2021 (https://www.who.int/data/ data-collection-tools/harmonized-health-facility-assessment/introduction, accessed 16 August 2021). To note: WHO is currently revising its facility survey modules to incorporate additional elements of PHC measurement and will provide recommended scoring methodology. Indicator78 Quality care 30-day hospital case fatality rate (for acute myocardial infarction or stroke) Indicator short name 30-day hospital case fatality rate (for acute myocardial infarction or stroke) Indicator long name 30-day hospital case fatality rate (for acute myocardial infarction or stroke) Domain Quality care Sub-domain Effectiveness M/E domain Outputs Definition Percentage of hospital inpatients with primary diagnosis of acute myocardial infarction or stroke who died within 30 days after admission Disaggregation(s) Cause Facility type (as relevant to context): first-level hospitals, second-level hospitals, specialty hospitals, long-term care facilities, continuing care facilities, etc.) Managing authority: public, private Subnational Urban/rural Gender Age Numerator Number of deaths in any hospital and out of hospital that occurred within 30 days of the admission date of the denominator cases. Denominator Number of admissions to hospital for acute non-elective (urgent) care with a primary diagnosis of acute myocardial infarction or stroke in the specified year. Preferred data source Recommended to be collected through routine health information system (RHIS) but can also be collected through a record review during a facility survey Rationale Thirty-day hospital case fatality rate or morality following acute myocardial infarction or stroke is a measure of quality of acute care and measures and the provision of appropriate care in hospitals, but it also measures the process of travel/transport to the hospital in a timely manner, where a weakness in emergency transport systems can have an impact on mortality rates. Variations in rates can be due to the quality of care provided, access, or both. Reference(s) 2018 Global Reference List of 100 Core Health Indicators (plus health-related SDGs). Geneva: World Health Organization; 2018 (https://apps.who.int/iris/handle/10665/259951, accessed 20 April 2021). Health at a Glance 2019: OECD Indicators. Paris: OECD Publishing; 2019. https://doi.org/10.1787/4dd50c09-en (https://www.oecd-ilibrary.org/social-issues-migration-health/health-at-a-glance-2019_4dd50c09-en, accessed 20 April 2021). Existing data collection tool Country health information system 126 127 Indicator79 Quality care Avoidable complications (lower limb amputation in diabetes) Indicator short name Avoidable complications (lower limb amputation in diabetes) Indicator long name Avoidable complications (Lower limb amputation in diabetes) Domain Quality care Sub-domain Effectiveness M/E domain Outputs Definition Admissions who had a major lower extremity amputation as a percentage of population age 15 and older with diabetes Disaggregation(s) Age Gender Subnational Numerator Number of admissions with a procedure code of major lower extremity amputation and a diagnosis code of diabetes in any field in the specified year Denominator Per 100 000 population Preferred data source Recommended to be collected through RHIS but can also be collected through a record review during a facility survey Rationale Poor control of the level of glucose in the blood over the short term can lead to vomiting, dehydration and even cause coma, whereas sustained high levels of blood glucose over several years can result in serious diseases with ongoing consequences for a person’s health and well-being. For example, diabetes can cause nerve damage and poor blood circulation over time. This indicator measures the inability of the primary care system to manage patients with diabetes in primary care and avoid amputation. Reference(s) Health at a Glance 2019: OECD Indicators. Paris: OECD Publishing; 2019 (https://www.oecd-ilibrary.org/social- issues-migration-health/health-at-a-glance-2019_4dd50c09-en, accessed 20 April 2021). Existing data collection tool Country health information system Indicator80 Quality care Hospital readmission rates for tracer conditions Indicator short name Hospital readmission rates for tracer conditions Indicator long name Hospital readmission rates for tracer conditions Domain Quality care Sub-domain Effectiveness M/E domain Outputs Definition Percentage of unplanned and unexpected hospital readmissions for tracer conditions (acute myocardial infarction, pneumonia, asthma, diabetes, surgical site infections) Disaggregation(s) Tracer condition Facility type (as relevant to context): first-level hospitals, second-level hospitals, specialty hospitals Managing authority (public/private) Subnational Urban/rural Age Gender Numerator Number of admissions for acute myocardial infarction, pneumonia, asthma, diabetes, surgical site infections with an unexpected and unplanned admission within 30 days of discharge Denominator Total number of admissions for acute myocardial infarction, pneumonia, asthma, diabetes, surgical site infections Preferred data source Recommended to be collected through RHIS but can also be collected through a record review during a facility survey Rationale Hospital readmission is a key measure of quality of care. Reducing preventable hospital readmission is important both as a measure of quality of care given (improving effectiveness of care) as well as a measure of managing health care costs. While some readmissions are unavoidable or necessary, hospital readmission demonstrates a lack of linkage with PHC service providers for continuity of care for discharged patients. Reference(s) 2018 Global Reference List of 100 Core Health Indicators (plus health-related SDGs). Geneva: World Health Organization; 2018 (https://apps.who.int/iris/handle/10665/259951, accessed 20 April 2021). Agency for Health care Research and Quality (https://www.ahrq.gov/topics/hospital-readmissions.html, accessed 30 August 2021). Existing data collection tool Country health information system 128 129 Indicator81 Quality care Admissions for ambulatory care sensitive conditions Indicator short name Admissions for ambulatory care sensitive conditions Indicator long name Admissions for ambulatory care sensitive conditions (asthma, chronic obstructive pulmonary disease, diabetes, congestive heart failure, hypertension) Domain Quality care Sub-domain Effectiveness M/E domain Outputs Definition Rate of admission with ambulatory care sensitive conditions, including asthma, or chronic obstructive pulmonary diseases, diabetes, congestive heart failure, and hypertension per 100 000 population in a specified year and as percentage of all hospitalizations. Disaggregation(s) Tracer condition Sub-national Gender Age Numerator All non-maternal/non-neonatal hospital admissions with a principal diagnosis of asthma, or chronic obstructive pulmonary diseases, congestive heart failure, hypertension, or diabetes in a specified year. Denominator Population count and total number of inpatient admissions Preferred data source RHIS (inpatient) Rationale A high rate of admissions for avoidable hospital admissions could identify problems related to access to health services and the quality of primary care. Additionally, it can be used for comparative analysis between health models with different degrees of development of primary care and for monitoring the evolution and functioning of the health system. Reference(s) 2018 Global Reference List of 100 Core Health Indicators (plus health-related SDGs). Geneva: World Health Organization; 2018 (https://apps.who.int/iris/handle/10665/259951, accessed 20 April 2021). Health at a Glance 2019: OECD Indicators. Paris: OECD Publishing; 2019. https://doi.org/10.1787/4dd50c09-en (https://www.oecd-ilibrary.org/social-issues-migration-health/health-at-a-glance-2019_4dd50c09-en, accessed 20 April 2021). Existing data collection tool Country health information system Indicator82 Quality care Prescribing practices for antibiotics Indicator short name Prescribing practices for antibiotics Indicator long name Overall volume of antibiotics for systemic use prescribed Domain Quality care Sub-domain Safety M/E domain Outputs Definition Overall volume of antibiotics for systemic use prescribed Disaggregation(s) Subnational Numerator Sum of defined daily dose of all antibiotic prescriptions for systemic use (ATC code J01) Denominator Total population captured in prescription database in the specified year Preferred data source Prescription database Rationale Prescribing practices can be used to assess both health care quality (safety) as well as efficiency as the over-, under- or misuse of antibiotics can cause negative health consequences at both individual and population levels (e.g., antibiotic resistance) and also lead to waste. Reference(s) Health at a Glance 2019: OECD Indicators. Paris: OECD Publishing; 2019 (https://www.oecd-ilibrary.org/social- issues-migration-health/health-at-a-glance-2019_4dd50c09-en, accessed 20 April 2021). World Health Organization. Anatomical Therapeutic Chemical (ATC) Classification System (https://www.who. int/tools/atc-ddd-toolkit/atc-classification, accessed 26 August 2021). Existing data collection tool Country health information system 130 131 Indicator83 Quality care Proportion of people 65 years and over prescribed antipsychotics Indicator short name Proportion of people 65 years and over prescribed antipsychotics Indicator long name Proportion of people 65 years and over prescribed antipsychotics in the reference year Domain Quality care Sub-domain Safety M/E domain Outputs Definition All persons 65 years and over (on the first day of the reference year) in the prescribing database (5 year age groups) that show at least one prescription for antipsychotics in the reference year Disaggregation(s) Subnational Numerator Number of individuals ≥65 years on first day of reference year with ≥1 prescription for any antipsychotic medication (ATC codes N05A) prescribed during the reference year, excluding prescriptions for antipsychotic medications registered through in-patient hospital prescription registries Denominator Number of individuals ≥65 years of age on first day of reference year in the national prescription database in the reference year Preferred data source Prescription database Rationale Despite widespread clinical agreement that antipsychotic medications should not be used to manage most difficult behaviour in dementia, rates of antipsychotic prescribing vary by a factor of more than two across the OECD. On average, one in twenty people aged 65 and over receives a prescription of antipsychotics across OECD countries. Medication review by a trained health care professional, especially to reduce psychotropic medication, has been shown to reduce falls. Reference(s) Health at a Glance 2019: OECD Indicators. Paris: OECD Publishing; 2019 (https://www.oecd-ilibrary.org/social- issues-migration-health/health-at-a-glance-2019_4dd50c09-en, accessed 20 April 2021). Health Care Quality and Outcomes (HCQO). 2020-21 Indicator Definitions (https://www.oecd.org/els/health- systems/Definitions-of-Health-Care-Quality-Outcomes.pdf, accessed 4 October 2021). World Health Organization. Anatomical Therapeutic Chemical (ATC) Classification System (https://www.who.int/ tools/atc-ddd-toolkit/atc-classification, accessed 26 August 2021). Integrated care for older people: guidelines on community-level interventions to manage declines in intrinsic capacity. Geneva: World Health Organization; 2017 (https://www.who.int/publications/i/item/9789241550109, accessed 11 February 2022). Existing data collection tool Country health information system Indicator84 Quality care Provider caseload Indicator short name Provider caseload Indicator long name Provider caseload (including primary care) Domain Quality care Sub-domain Efficiency M/E domain Processes Definition Average number of outpatient service units provided by a given health worker in a specified period (e.g., working day, year) Service units are defined according to the health service model, e.g., outpatient consultations by physicians; ANC consultations by midwives; immunization consultations by nurses Disaggregation(s) Facility type (as relevant to context): including primary care facilities (e.g., GP practices, health centres, community health posts), first-level hospitals, second-level hospitals, specialty hospitals, long-term care facilities, continuing care facilities, etc.) Managing authority: public, private Subnational Urban/rural Cadre (e.g., nurse, midwife, physician, community health worker, etc.) Numerator Number of service units provided in a specified period (e.g., working day, year) Denominator Number of workers providing the service X number. of available working days in the same period Preferred data source Facility survey - Record review Rationale Provider caseload can affect quality of care. Health worker shortages may result in increased caseloads per provider, potentially compromising service quality. Conversely, low caseloads can also contribute to decreased quality of care (e.g., through decreased provider motivation, increased absenteeism, and fewer opportunities to practice skills) or serve as a sign of poor availability of care or services. Reference(s) Toolkit for analysis and use of routine health facility data. Integrated health services analysis: national level. Geneva: World Health Organization; 2021 (https://cdn.who.int/media/docs/default-source/world-health-data- platform/rhis-modules/national-guidance_2021_01_21_final.pdf?sfvrsn=28365283_5, accessed 19 August 2021). Primary health care performance initiative Indicator Library (https://improvingphc.org/content/indicator-library, accessed 26 August 2021). WISN – Workload indicators of staffing need. User’s manual. Geneva: World Health Organization; 2010 (https://www.who.int/workforcealliance/knowledge/toolkit/17/en/, accessed 4 October 2021). Existing data collection tool Country health information systems or from existing health facility survey tools such as World Health Organization’s HHFA and World Bank’s SDI. World Health Organization. Harmonized Health Facility Assessment. March 2021 (https://www.who.int/data/ data-collection-tools/harmonized-health-facility-assessment/introduction, accessed 16 August 2021). World Bank. Service Delivery Indicators (https://www.sdindicators.org/, accessed 19 August 2021). To note: WHO is currently revising its facility survey modules to incorporate additional elements of PHC measurement and will provide recommended scoring methodology. 132 133 Indicator85 Quality care Bed occupancy Indicator short name Bed occupancy Indicator long name Bed occupancy Domain Quality care Sub-domain Efficiency M/E domain Processes Definition Percentage of available beds that have been occupied over a given period Disaggregation(s) Facility type (as relevant to context): first-level hospitals, second-level hospitals, specialty hospitals Managing authority (public/private) Subnational Urban/rural Numerator Number of occupied bed-days Denominator Number of available bed-days Preferred data source RHIS Rationale Bed occupancy rate is a measure of resource utilization rate and resources available for delivering services to inpatients. Bed occupancy is affected by different factors such as hospital size and types of services offered at the hospital. There are also demand factors that can affect occupancy rates. The aim is not to achieve 100 percent occupancy rates. Bed occupancy levels above 85% can lead to bed shortages and also higher levels of infections. For OECD countries, the average bed occupancy rate in 2017 was 75%. Beds represent major capital investments that should be optimized. Hence, a low occupancy rate indicates a poor utilization of scarce resources and hence an efficiency issue. It can also indicate poor confidence in services or concerns over affordability of hospital services. Conversely, an average occupancy rate above a threshold (i.e., 85% to 90%) signals issues with access to hospital services and risk of volume congestion. It means some hospitals or departments are in full occupancy or above and hence not able to cope with any surge in demand and deteriorating quality. When occupancy rates are high, interventions to increase patient turnover - reducing length of stay and avoiding inappropriate admissions - have an impact on caseload and requires adaptation of staffing norms per bed. Reference(s) 2018 Global Reference List of 100 Core Health Indicators (plus health-related SDGs). Geneva: World Health Organization; 2018 (https://apps.who.int/iris/handle/10665/259951, accessed 20 April 2021). Toolkit for analysis and use of routine health facility data. Integrated health services analysis: national level. Geneva: World Health Organization; 2021 (https://cdn.who.int/media/docs/default-source/world-health-data- platform/rhis-modules/national-guidance_2021_01_21_final.pdf?sfvrsn=28365283_5, accessed 19 August 2021). Existing data collection tool Country health information systems Indicator86 Quality care Cancer stage at diagnosis (by cancer) Indicator short name Cancer stage at diagnosis (by cancer) Indicator long name Cancer stage at diagnosis (by cancer) Domain Quality care Sub-domain Timely access M/E domain Outputs Definition Percentage of all stageable cancers diagnosed that are recorded as presenting as a Stage 1 or Stage 2 in a given year Disaggregation(s) Gender Cancer type Numerator Number of cancers presenting as a Stage 1 and Stage 2 Denominator All stageable cancer cases in a year Preferred data source Cancer registry Rationale Cancer diagnosis at a higher stage is associated with increased morbidity and mortality. A higher average stage at diagnosis may reflect problems with prevention and screening and/or timely access to testing, which are key parts of primary care service delivery. Reference(s) National Cancer Registration and Analysis Service. http://www.ncin.org.uk/cancer_type_and_topic_specific_ work/topic_specific_work/cancer_outcome_metrics, accessed 23 August 2021). Existing data collection tool Country health information systems 134 135 Indicator87 Quality care Waiting time to elective surgery Indicator short name Waiting time to elective surgery Indicator long name Waiting time to elective surgery (for tracers) Domain Quality care Sub-domain Timely access M/E domain Processes Definition Average number of days that patients have been waiting for elective procedures (i.e., non-urgent) surgeries – cataract, coronary angioplasty, hip replacement, knee replacement in a given period This measure refers to the time between when the provider adds the patient to a waiting list for the procedure and the actual date of the procedure Disaggregation(s) Type of procedure Facility type (as relevant to context): first-level hospitals, second-level hospitals Managing authority: public, private Urban/rural Gender Numerator Average number of days that patients have been waiting for elective procedure (i.e., non-urgent) surgeries – cataract, coronary angioplasty, hip replacement, knee replacement, skin biopsies Denominator Not applicable Preferred data source RHIS (Waiting time management systems) Rationale According to Sanmartin (2003) as cited by OECD (Health at a Glance 2011: OECD Indicators), “Excessive waiting times to see a doctor or for non-emergency surgery can sometimes lead to adverse health effects such as stress, anxiety or pain.” This measures a health system’s performance in terms of providing timely access to essential health services to individuals in need. Reference(s) 2018 Global Reference List of 100 Core Health Indicators (plus health-related SDGs). Geneva: World Health Organization; 2018 (https://apps.who.int/iris/handle/10665/259951, accessed 20 April 2021). Health at a Glance 2011: OECD Indicators. Paris: OECD Publishing; 2011 (https://www.oecd-ilibrary.org/social- issues-migration-health/health-at-a-glance-2011_health_glance-2011-en, accessed 20 April 2021). Existing data collection tool Country health information systems 136 IndicatorA Additional hospital-oriented indicators Bed density (inpatient only) Indicator short name Bed density (inpatient only) Indicator long name Bed density (by facility type, ward, managing authority) Domain Physical infrastructure Sub-domain Physical infrastructure M/E domain Inputs Definition Total number of hospitals beds per 1 000 population Disaggregation(s) Facility type (as relevant to context): first-level hospitals, second-level hospitals, long-term care, etc. Managing authority: public, private Subnational Urban/rural Type of bed: observation, inpatient, type/ward including ICU Numerator Total number of hospitals beds (excluding labour and delivery beds) Denominator Total population Preferred data source RHIS, facility census, other routine information data sources Rationale Hospital beds are used to indicate the availability of inpatient services. It is important to note that it is not sufficient to just increase the number of hospital beds to meet inpatient service needs. In OECD countries, the average bed density is 4.7 hospital beds per 1 000 population. However, a greater supply of beds has also been shown to lead to higher admission rates. The right number of beds will be dependent on different contexts considering occupancy levels. Reference(s) 2018 Global reference list of 100 core health indicators (plus health-related SDGs). Geneva: World Health Organization; 2018 (https://apps.who.int/iris/bitstream/handle/10665/259951/WHO-HIS-IER-GPM-2018.1-eng. pdf?sequence=1&isAllowed=y, accessed 16 August 2021). National Institute of Healthcare Excellence. Chapter 39 Bed occupancy. Nice; 2018 (https://www.nice.org.uk/ guidance/ng94/evidence/39.bed-occupancy-pdf-172397464704, accessed 4 October 2021). Health at a Glance 2019: OECD Indicators. Paris: OECD Publishing; 2019 (https://www.oecd-ilibrary.org/social- issues-migration-health/health-at-a-glance-2019_4dd50c09-en, accessed 3 September 2021). Existing data collection tool While the preferred data source is RHIS, existing global facility survey tools such as World Health Organization’s SARA and HHFA and DHS program’s SPA also measure this indicator fully or partially. World Health Organization’s Service Availability and Readiness Assessment (https://www.who.int/data/data- collection-tools/service-availability-and-readiness-assessment-(sara)?ua=1, accessed 16 August 2021). The DHS Program. Service Provision Assessment. September 2020 (https://dhsprogram.com/publications/ publication-spaq1-spa-questionnaires-and-manuals.cfm, accessed 18 August 2021). World Health Organization. Harmonized Health Facility Assessment. March 2021 (https://www.who.int/data/ data-collection-tools/harmonized-health-facility-assessment/introduction, accessed 16 August 2021). To note: WHO is currently revising its facility survey modules to incorporate additional elements of PHC measurement. 2.14 Additional hospital-oriented indicators 137 IndicatorB Additional hospital-oriented indicators Institutional mortality Indicator short name Institutional mortality Indicator long name Institutional mortality rates all causes Domain Quality care Sub-domain Effectiveness M/E domain Outputs Definition Inpatient deaths in health facilities (all causes) per 100 discharges Disaggregation(s) Cause -of- death Age (minimum 0-4 and 5+ years) Facility type (as relevant to context): first-level hospitals, second-level hospitals, specialty hospitals, etc. Managing authority: public, private Subnational Urban/rural Numerator Number of inpatient deaths X 100 Denominator Number of discharges (discharges also include deaths) Preferred data source RHIS, death surveillance and response systems Rationale This indicator is an important outcome measure of quality and safety of care. However, it should also be interpreted with care, as institutional mortality is influenced by a number of factors such as hospital level (higher level referral hospitals received more complicated cases) and transport time to reach the facility. Reference(s) 2018 Global Reference List of 100 Core Health Indicators (plus health-related SDGs). Geneva: World Health Organization; 2018 (https://apps.who.int/iris/handle/10665/259951, accessed 20 April 2021). Toolkit for analysis and use of routine health facility data. Integrated health services analysis: national level. Geneva: World Health Organization; 2021 (https://cdn.who.int/media/docs/default-source/world-health-data- platform/rhis-modules/national-guidance_2021_01_21_final.pdf?sfvrsn=28365283_5, accessed 19 August 2021). Existing data collection tool Country routine information systems 138 IndicatorC Additional hospital-oriented indicators Caesarean section rate Indicator short name Caesarean section rate Indicator long name Caesarean section rate Domain Quality Sub-domain Safety M/E domain Outputs Definition Number of caesarean deliveries performed per 100 live births Disaggregation(s) Facility type (as relevant to context): first-level hospitals, second-level hospitals, etc. Managing authority: public, private Subnational Urban/rural Age Education (in population-based surveys) Numerator Number of live births delivered by caesarean section in a given time period Denominator Total number of live births in the same time period X 100 Preferred data source Routine health information system (RHIS) but can also be collected through a population-based survey or through a record review during a facility survey. Rationale The percentage of births by caesarean section is an indicator of access to and use of emergency health care during childbirth. However, it has also being been more frequently selected as the mode of delivery due to the convenience it offers. There is evidence that there is increased risk for complications for subsequent deliveries. While it is critical to have this life-saving procedure available for reducing maternal and newborn mortality, there is diminishing returns on mortality reduction when c-section rates are higher than 10% at the population level, according to WHO. Reference(s) 2018 Global Reference List of 100 Core Health Indicators (plus health-related SDGs). Geneva: World Health Organization; 2018 (https://apps.who.int/iris/handle/10665/259951, accessed 20 April 2021). Health at a Glance 2019: OECD Indicators. Paris: OECD Publishing; 2019. https://doi.org/10.1787/4dd50c09-en (https://www.oecd-ilibrary.org/social-issues-migration-health/health-at-a-glance-2019_4dd50c09-en, accessed 20 April 2021). Existing data collection tool Country health information systems This indicator is also collected through population-based surveys such as the Demographic Health Survey and UNICEF’s Multiple indicator cluster survey (MICS). The Demographic and Health Surveys Program. Demographic and Health Surveys (https://dhsprogram.com/ Methodology/Survey-Types/DHS.cfm, accessed 19 August 2021). UNICEF. Multiple Indicator Cluster Survey. 2021 (https://mics.unicef.org/, accessed 19 August 2021). 139 IndicatorD Additional hospital-oriented indicators Postoperative sepsis Indicator short name Postoperative sepsis Indicator long name Postoperative sepsis Domain Quality care Sub-domain Safety M/E domain Outputs Definition Percentage of discharges with postoperative sepsis among abdominopelvic discharges only Disaggregation(s) Facility type (as relevant to context): first-level hospitals, second-level hospitals, specialty hospitals, etc. Managing authority: public, private Subnational Numerator Discharges among cases defined in the denominator with ICD code for sepsis in a secondary diagnosis filed during the surgical admission Denominator Total number of abdominopelvic surgical discharges only. Preferred data source Recommended to be collected through RHIS but can also be collected through a special study Rationale Patient safety remains one of the most pressing health issues for public education and further policy action. Reference(s) 2018 Global Reference List of 100 Core Health Indicators (plus health-related SDGs). Geneva: World Health Organization; 2018 (https://apps.who.int/iris/handle/10665/259951, accessed 20 April 2021). Health at a Glance 2019: OECD Indicators. Paris: OECD Publishing; 2019. https://doi.org/10.1787/4dd50c09-en (https://www.oecd-ilibrary.org/social-issues-migration-health/health-at-a-glance-2019_4dd50c09-en, accessed 20 April 2021). Existing data collection tool Country health information systems. World Health Organization’s HHFA has questions that ask if a facility collects this information routinely. If this information is not collected routinely, it can be collected as a special study from a sampling of hospitals. World Health Organization. Harmonized Health Facility Assessment. March 2021 (https://cdn.who.int/media/ docs/default-source/world-health-data-platform/hhfa/hhfa_-questionnaire_combined_core_2021.03.07. pdf?sfvrsn=698754fa_5&download=true, accessed 16 August 2021). 140 IndicatorE Additional hospital-oriented indicators Postoperative pulmonary embolism Indicator short name Postoperative pulmonary embolism Indicator long name Postoperative pulmonary embolism Domain Quality care Sub-domain Safety M/E domain Outputs Definition Percentage of discharges with pulmonary embolism among all hip and knee replacement discharges Disaggregation(s) Facility type (as relevant to context): first-level hospitals, second-level hospitals, specialty hospitals, etc. Managing authority: public, private Subnational Numerator Discharges among cases defined in the denominator with ICD code for pulmonary embolism in a secondary diagnosis field during the surgical admission Denominator Hip- and knee-replacement discharges Preferred data source Recommended to be collected through RHIS but can also be collected through a special study Rationale Patient safety remains one of the most pressing health issues for public education and further policy action. Reference(s) 2018 Global Reference List of 100 Core Health Indicators (plus health-related SDGs). Geneva: World Health Organization; 2018. (https://apps.who.int/iris/handle/10665/259951, accessed 20 April 2021). Health at a Glance 2019: OECD Indicators. Paris: OECD Publishing; 2019. https://doi.org/10.1787/4dd50c09-en (https://www.oecd-ilibrary.org/social-issues-migration-health/health-at-a-glance-2019_4dd50c09-en, accessed 20 April 2021). Existing data collection tool Country health information systems. World Health Organization’s HHFA has questions that ask if a facility collects this information routinely. If this information is not collected routinely, it can be collected as a special study from a sampling of hospitals. World Health Organization. Harmonized Health Facility Assessment. March 2021 (https://cdn.who.int/media/ docs/default-source/world-health-data-platform/hhfa/hhfa_-questionnaire_combined_core_2021.03.07. pdf?sfvrsn=698754fa_5&download=true, accessed 16 August 2021). 141 IndicatorF Additional hospital-oriented indicators Postoperative deep vein thrombosis Indicator short name Postoperative deep vein thrombosis Indicator long name Postoperative deep vein thrombosis Domain Quality care Sub-domain Safety M/E domain Outputs Definition Percentage of discharges with deep vein thrombosis among all hip and knee replacement discharges Disaggregation(s) Facility type (as relevant to context): first-level hospitals, second-level hospitals, specialty hospitals, etc. Managing authority: public, private Subnational Numerator Discharges among cases defined in the denominator with ICD code for deep vein thrombosis in a secondary diagnosis field during the surgical admission Denominator Hip- and knee-replacement discharges Preferred data source Recommended to be collected through RHIS but can also be collected through a special study Rationale Patient safety remains one of the most pressing health issues for public education and further policy action. Reference(s) 2018 Global Reference List of 100 Core Health Indicators (plus health-related SDGs). Geneva: World Health Organization; 2018 (https://apps.who.int/iris/handle/10665/259951, accessed 20 April 2021). Health at a Glance 2019: OECD Indicators. Paris: OECD Publishing; 2019. https://doi.org/10.1787/4dd50c09-en (https://www.oecd-ilibrary.org/social-issues-migration-health/health-at-a-glance-2019_4dd50c09-en, accessed 20 April 2021). Existing data collection tool Country health information systems. World Health Organization’s HHFA has questions that ask if a facility collects this information routinely. If this information is not collected routinely, it can be collected as a special study from a sampling of hospitals. World Health Organization. Harmonized Health Facility Assessment. March 2021 (https://cdn.who.int/media/ docs/default-source/world-health-data-platform/hhfa/hhfa_-questionnaire_combined_core_2021.03.07. pdf?sfvrsn=698754fa_5&download=true, accessed 16 August 2021). 142 IndicatorG Additional hospital-oriented indicators Perioperative mortality rate Indicator short name Perioperative mortality rate Indicator long name Perioperative mortality rate Domain Quality care Sub-domain Safety M/E domain Outputs Definition All-cause death rate prior to discharge or within 30 days of procedure among patients having one or more procedures in an operating theatre during the relevant admission. Disaggregation(s) Emergency versus elective surgery Tracer condition Facility type (as relevant to context): first-level hospitals, second-level hospitals, specialty hospitals, etc. Managing authority: public, private Subnational Numerator Number of deaths among patients having one or more procedures in an operating theatre during the relevant admission Denominator Total number of surgical procedures in an operating theatre Preferred data source Recommended to be collected through RHIS but can also be collected through a special study Rationale This indicator is an important outcome measure of access to safe surgery and anaesthesia. It also provides information on the volume of surgeries being conducted. Having the flexibility of measuring deaths before discharge or within 30 days of procedure allows lower-income countries to collect this information. Reference(s) 2018 Global Reference List of 100 Core Health Indicators (plus health-related SDGs). Geneva: World Health Organization; 2018 (https://apps.who.int/iris/handle/10665/259951, accessed 20 April 2021). Existing data collection tool Country health information systems Country health information systems. World Health Organization’s HHFA has questions that ask if a facility collects this information routinely. If this information is not collected routinely, it can be collected as a special study from a sampling of hospitals. World Health Organization. Harmonized Health Facility Assessment. March 2021 (https://cdn.who.int/media/ docs/default-source/world-health-data-platform/hhfa/hhfa_-questionnaire_combined_core_2021.03.07. pdf?sfvrsn=698754fa_5&download=true, accessed 16 August 2021). 143 IndicatorH Additional hospital-oriented indicators Hospital-acquired infections Indicator short name Hospital-acquired infections Indicator long name Hospital-acquired infections Domain Quality care Sub-domain Safety M/E domain Outputs Definition Percentage of inpatient discharges with at least one health care-associated infection (which is relevant to country context) Disaggregation(s) Tracer condition Facility type (as relevant to context): first-level hospitals, second-level hospitals, specialty hospitals, etc. Managing authority: public, private Numerator Number of hospitalised patients with at least one health care-associated infection Denominator Total number of inpatient discharges Preferred data source RHIS Rationale Patient safety remains one of the most pressing health issues for public education and further policy action. Hospital -acquired infections are very costly and can put considerable strain on hospital budgets. In OECD countries, it was found that 6% of public hospital budgets went toward hospital-acquired infections. Reference(s) Health at a Glance 2019: OECD Indicators. Paris: OECD Publishing; 2019. https://doi.org/10.1787/4dd50c09-en (https://www.oecd-ilibrary.org/social-issues-migration-health/health-at-a-glance-2019_4dd50c09-en, accessed 20 April 2021). Existing data collection tool Country health information systems or existing health facility survey tools such as European Centre for Disease Prevention and control point prevalence survey. European centre for Disease Prevention and Control. Health care-associated infections and antimicrobial use point prevalence survey database (https://www.ecdc.europa.eu/en/healthcare-associated-infections-acute-care- hospitals/surveillance-disease-data/database, accessed 26 August 2021). 144 Indicator I Additional hospital-oriented indicators Coverage of timely emergency resuscitation at first-level hospitals Indicator short name Coverage of timely emergency resuscitation at first-level hospitals Indicator long name Coverage of timely emergency resuscitation at first-level hospitals Domain Quality care Sub-domain Safety M/E domain Outputs Definition Proportion of adults and children [at first-level hospitals] admitted or transferred with shock from any cause who received oxygen and/or intravenous volume in the emergency unit prior to admission or transfer Disaggregation(s) Facility type (as relevant to context): first-level hospitals, second-level hospitals, specialty hospitals, etc. Managing authority: public, private Subnational Numerator Number of patients [at first-level hospitals] admitted or transferred with shock who receive any oxygen or intravenous volume (fluids or blood) in the emergency unit prior to admission or transfer Denominator All patients [at first-level hospitals] admitted/transferred with shock from any cause Preferred data source RHIS or through special study Rationale Coverage of timely emergency resuscitation helps to assess access to emergency care services as first-contact care. Reference(s) World Health Organization. WHO Emergency Care System Framework (https://www.who.int/publications/i/ item/who-emergency-care-system-framework, accessed 17 August 2021). Existing data collection tool Country health information system 145 146 3. Cross-cutting indicators for quality, equity and resilience Table 3.1 Monitoring quality across PHC measurement framework Domain/subdomain Indicators Quality consideration Governance Governance and policy frameworks Existence of national health policy oriented to PHC and UHC Embeds quality as a key part of PHC delivery Existence of policy, strategy or plan for improvement of quality and safety Sets forth the national plan for quality and safety Physical infrastructure Availability of basic WASH amenities With attention to infection prevention --- a necessary prerequisite for the delivery of quality services Availability of power Necessary for life-saving equipment and life-saving processes - a prerequisite for quality Availability of communications Life-saving process - a prerequisite for quality Access to emergency transport for interfacility transfer Allows access to necessary care when care is not available at site Health workforce Health worker density and distribution Necessary for delivery of health care services Accreditation mechanism for education and training institutions With attention to medical education meeting standards to deliver quality care National systems for continuing professional development Emphasizes knowledge building and relevance in order to meet changing health care standards Medicines and other health products Regulatory mechanisms for medicines Monitors quality standards for medicines Availability of essential medicines Availability of medicines is a necessary prerequisite for delivery of quality services Availability of essential in vitro diagnostics Availability of diagnostics is a necessary prerequisite for delivery of quality services Availability of priority medical equipment and other medical devices Availability of devices/essential technologies is a necessary prerequisite for delivery of quality services Health information Percentage of facilities using comprehensive patient records Necessary for monitoring continuity of care -– a prerequisite for quality Digital technologies for health Capacity for data linkages Necessary for monitoring continuity of care -– a prerequisite for quality Models of care Selection and planning of services Service package meeting criteria Standards-based service packages are necessary to deliver and maintain quality services Service design Protocols for patient transfer, referral and counter-referral Systems to aid people in getting appropriate care are a prerequisite for quality Organization and facil- ity management Existence of supportive supervision system Ongoing supervision is a key part of quality improvement Systems for improving quality of care Percentage of facilities with systems to support quality improvement Examines in-facility prerequisites for quality 147 3.1 Quality indicators Domain/subdomain Indicators Quality consideration Access and availability Service availability and readiness Percentage of facilities offering services according to nationally defined service package Service availability is a prerequisite for quality Provider availability (absence rate) Presence of trained provider to deliver services is a prerequisite of quality Percentage of facilities meeting minimum standards to deliver tracer services Readiness of facility to deliver services is a prerequisite for quality Quality care Core primary care func- tions (first-contact accessibility, continuity, comprehensiveness, coordination, people- centredness) Patient- reported experience Patient experiences and satisfaction with health system responsiveness are critical to quality of care Community perceptions of health system and services Perceptions and knowledge are key factors in determining care-seeking behaviours Effectiveness Diagnostic accuracy (provider knowledge) Provider knowledge to accurately diagnose is an intrinsic part of quality of care Adherence to clinical standards for tracer conditions Measures provider ability to deliver quality services against established standards 30-day hospital case fatality rate (for acute myocardial infarction or stroke)** Reflects the processes of care, including timely transport of patients and effective medical intervention Avoidable complications (lower -limb amputation in diabetes) Measures the inability of the primary care system to manage patients with diabetes in primary care and avoid amputation Hospital readmission rate for tracer conditions** Improper/ineffective care can the first time can lead to increased readmissions Admissions for ambulatory care sensitive conditions Identifies problems related to access to- and quality of primary care services Safety Prescribing practices for antibiotics Over- or under-prescribing can lead to negative health consequences Proportion of people 65 years and over prescribed antipsychotics Polypharmacy can have negative impact on health outcomes Caesarean section rate It is a life-saving measure but over-use can also have a negative effect Efficiency Provider caseload Can lead both to compromised quality of service and workflow management issues Bed occupancy** Too high or too low can indicate poor planning and can result in gap in service provision or wasted resources Timely access Cancer stage at diagnosis (by cancer) A higher stage at diagnosis can reflect problems with prevention and screening and/or timely access to testing. Waiting time for elective surgery Longer wait time can have adverse health effects. Timely access is a critical component of quality of care. ** Hospital-oriented indicators considered important for broader PHC monitoring and relevant in terms of inter-relations with primary care 148 Table 3.2 Monitoring equity across PHC measurement framework Domain/Subdomain Indicators Equity consideration Governance Political commitment and leadership Existence of right- to -health legislation Legally recognized access to rights for all individuals Governance and policy frameworks Existence of national health policy oriented to PHC and UHC Criteria for policy includes and highlights equity- oriented, gender-responsive and human rights- based health services Engagement with communities and other multisectoral stakeholders Coordination mechanisms with multistakeholder participation and community engagement With due attention to gender issues and involvement of populations experiencing vulnerability Adjustment to population needs Monitoring and evaluation Priority setting is informed by data and evidence With attention to improving health equity, gender responsiveness, and ensuring the right to health Financing Funding and allocation of resources Per capita total health expenditure (and PHC -specific) With attention to populations experiencing vulnerability Sources of expenditure on health (and PHC -specific) With attention to populations experiencing vulnerability and prevention of affordability- related barriers Purchasing and payment systems Services included in HBP (including primary care) Emphasis on promoting equity and gender responsiveness Purchasing and provider payment methods are in place (including primary care) Emphasises promotion of equity, and prevention of financial hardship Health workforce Health worker density and distribution With attention to availability of health workforce in rural and sparsely populated areas Models of care Selection and planning of services Service package meeting criteria With attention to populations experiencing vulnerability Roles and functions of service delivery platforms and settings defined With attention to populations experiencing vulnerability Community linkages and engagement Collaboration between facility-based and community-based service providers With attention to adequate resourcing of community-based services Community engagement in service planning and organization Supports decision-making power of communities. Proactive population outreach Emphasis on access to prevention and promotion activities to vulnerable populations Access and availability Accessibility, affordability, acceptability Geographical access to services Measures geographical access to services, especially in rural and remote areas Perceived barriers to access (geographical, financial, sociocultural) Determines barriers to access for vulnerable populations Access to emergency surgery Measures geographical access to services, especially in rural and remote areas Existence of system of post-crash care With attention to rural and remote areas 149 3.2 Equity indicators Domain/Subdomain Indicators Equity consideration Quality care Core primary care functions (first-contact accessibility, continuity, comprehensiveness, coordination, people-centredness) Community perceptions of health system and services With emphasis on populations experiencing vulnerability 150 Table 3.3 Monitoring resilience across PHC measurement framework Domain/subdomain Indicators Resilience consideration Governance Political commitment and leadership Health in All Policies with multisectoral coordination Coordination ensures better preparedness Governance and policy frameworks Existence of health emergency and disaster risk management strategies A plan is a prerequisite for successful implementation Institutional capacity to meet essential public health functions and operations Strong institutions are necessary for a resilient system Engagement with communities and other multisectoral stakeholders Coordination mechanisms with multistakeholder participation and community engagement Support of communities and other sectors are key factors of resilient systems Engagement with private sector providers Evidence of effective stewardship of mixed health systems Involvement of private sector, especially in crisis management, strengthens resilience Finance Funding and allocation of resources Government PHC spending as percentage of government health expenditure Strong PHC system bolsters health during crisis Contingency funds available for emergencies Funds available during times of crisis Purchasing and payment systems Purchasing and provider payment methods are in place (including primary care) Ensures health needs of the population are met Physical infrastructure Availability of basic WASH amenities With attention to IPC Availability of power Allows for use of necessary for life-saving equipment and life-saving processes Availability of communications Necessary for external contact, especially for life- saving communications Access to emergency transport for interfacility transfer Allows access to necessary care, especially during crisis Health workforce Health worker density and distribution Necessary for delivery of health care services Medicines and other health products Availability of essential medicines Availability of medicines is a necessary prerequisite for maintaining core public health functions Availability of essential in vitro diagnostics Availability of diagnostics is a necessary prerequisite for maintaining core public health functions Availability of priority medical equipment and other medical devices Availability of devices and essential technologies is a necessary prerequisite for resilient health care Health information Information systems Completeness of reporting by facilities Facilities able to report are also able to deliver some level of care. Lower levels of reporting can signal other underlying problems. Surveillance Existence of effective surveillance system An effective surveillance system provides early warning of emerging threats and is a necessary prerequisite for a resilient system 151 3.3 Resilience indicators Models of care Selection and planning of services Service package meeting criteria Standards-based service packages are necessary to deliver and maintain quality services Community linkages and en- gagement Community engagement in service planning and organization Active engagement of community in health ser- vice delivery ensures continuity, maintenance and use of services during crisis Resilient health facilities and services Percentage of facilities meeting criteria for resil- ient health facilities and services Measures readiness of facilities to withstand crisis Access and availability Service availability and read- iness Provider availability (absence rate) With attention to presence of trained provider to deliver services Percentage of facilities meeting minimum stan- dards to deliver tracer services With attention to ability/readiness of a facility to deliver quality care Utilization of services Outpatient visits Monitors utilization during crisis and provides a proxy measure of access and use during crisis Quality care Effectiveness Adherence to clinical standards for tracer condi- tions Standards-based practices are necessary for strong health care systems that can withstand crisis 152