Roadmap to monitoring health services delivery in the WHO European Region: WHO European Framework for Action on Integrated Health Services Delivery

Roadmap to monitoring health services delivery in the WHO European Region WHO European Framework for Action on Integrated Health Services Delivery Roadmap to monitoring health services delivery in the WHO European Region WHO European Centre for Primary Health Care Division of Health Systems and Public Health WHO European Framework for Action on Integrated Health Services Delivery Abstract At the 66th session of the Regional Committee for Europe in 2016, Member States endorsed the WHO European Framework for Action on Integrated Health Services Delivery. With its endorsement, Member States tasked the WHO Regional Office for Europe to monitor health services delivery by intensifying the measurement of existing and relevant indicators. To this end, this publication details a roadmap for transforming the WHO European Framework for Action on Integrated Health Services Delivery from an action-oriented policy framework to a framework for monitoring capacity and performance. The roadmap provides an overview of steps from the initial phases of designing, reviewing and preparing a monitoring tool to collecting and analysing data and reporting findings. The publication also describes the various partnerships and their envisaged functions throughout the process of developing this work. Keywords PRIMARY HEALTH CARE DELIVERY OF HEALTH CARE, INTEGRATED HEALTH SERVICES MONITORING EUROPE Address requests about publications of the WHO Regional Office for Europe to: Publications WHO Regional Office for Europe UN City, Marmorvej 51 DK-2100 Copenhagen Ø Denmark Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the Regional Office website (http://www.euro.who.int/pubrequest). Document number: WHO/EURO:2017-3048-42806-59735 © World Health Organization 2017 All rights reserved. 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Contents Acknowledgements vii Abbreviations viii Tables, boxes and figures viii Monitoring health services delivery in the WHO European Region: frequently asked questions ix Introduction 1 About this document 2 The case for monitoring health services delivery 3 A call for intensified monitoring of health services delivery 3 Scoping frameworks and tools for monitoring services delivery 4 Gaps in monitoring health services delivery in the European Region 5 Rationale and criteria for a specific monitoring framework for services delivery in the WHO European Region 8 Proposed monitoring framework 11 Developing a monitoring framework 11 Scope: primary health care 12 Conceptual framework 13 Capacity of primary care 14 Performance of primary care 15 Health outcomes 15 Aims and underlying policy question 16 Objective of the monitoring framework 16 Roadmap partnerships and processes 19 Partnerships and platforms for engagement 19 Secretariat 22 Advisory Group 22 Steering Committee 23 Wider network for consultations 23 Phases of development 24 Phase 1: defining a monitoring framework 26 Phase 2: reviewing indicators 27 Phase 3: preparing for data collection 28 Phase 4: collecting baseline data 29 Phase 5: analysing findings 29 Phase 6: collecting the second round of data 30 Phase 7: reporting back 30 References 33 Annex 1. Overview of the monitoring framework 35 Roadmap to monitoring health services delivery Acknowledgements This roadmap has been developed by Erica Barbazza, Ioana Kruse and Juan Tello, WHO European Centre for Primary Health Care of the WHO Regional Office for Europe. The Centre is the technical unit on health services delivery of the Division of Health Systems and Public Health of the Regional Office, directed by Hans Kluge. This work has benefited from the input of Niek Klazinga, Dionne Kringos and Michael van den Berg, WHO Collaborating Centre for Quality and Equity in Primary Health Care Systems, Academic Medical Center, University of Amsterdam in the initial design and development of the framework proposed. Tina Dannemann Purnat, Division of Information, Evidence, Research and Innovation, WHO Regional Office for Europe and Anna Kurmanova, Enrique Loyola and Ivo Rakova, WHO European Office for the Prevention and Control of Noncommunicable Diseases, WHO Regional Office for Europe provided input to the development of the phases and steps of the roadmap. The WHO Regional Office for Europe’s network of Integrated Health Services Delivery Focal Points provided important feedback and input to the framework and approach presented at an initial consultation during its 4th annual meeting in June 2017. David Breuer edited the text and Jakob Heichelmann designed the publication. vii Roadmap to monitoring health services delivery Abbreviations HCQI Health Care Quality Initiative HSPA Health Systems Performance Assessment NCD Office WHO European Office for the Prevention and Control of Noncommunicable Diseases OECD Organisation for Economic Co-operation and Development PC primary care PCET Primary Care Evaluation Tool PHAMEU Primary Healthcare Activity Monitor for Europe PHCPI Primary Health Care Performance Initiative PRIMASYS Primary Care Systems Profiles and Performance Tables, boxes and figures Tables Table 1 Examples of relevant frameworks and tools for monitoring services delivery 4 Table 2 Differentiating policy monitoring frameworks and tools 6 Table 3 Availability of reporting on hospital discharges 7 Table 4 Primary health care: services, practitioners and facilities 12 Table 5 Properties of the conceptual framework described 13 Table 6 Overview of steps for monitoring health services delivery 25 Boxes Box 1 Resolution calling for performance monitoring 3 Box 2 Functions of the Secretariat 22 Box 3 Functions of the Advisory Group 23 Box 4 Functions of the Steering Committee 23 Box 5 Functions of the wider network for consultations 24 Figures Fig. 1 Monitoring framework: conceptual framework 14 Fig. 2 Key milestones in monitoring health services delivery 20 Fig. 3 Partners and platforms for monitoring health services delivery 21 viii Roadmap to monitoring health services delivery Monitoring health services delivery in the WHO European Region: frequently asked questions 1 ______________________________ This statistical group includes Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Kyrgyzstan, the Republic of Moldova, the Russian Federation, Tajikistan, Turkmenistan, Ukraine and Uzbekistan. What is the WHO European Framework for Action on Integrated Health Services Delivery? The WHO European Framework for Action on Integrated Health Services Delivery takes forward the Region’s priority to transform health services delivery to meet the health challenges of the 21st century. It is intended as a resource for Member States by setting out a shortlist of essential areas for transforming services delivery that are results-oriented and adopts systems thinking to reason relevant interactions between the areas identified. In this way, the Framework serves as a checklist to ensure that key factors for transfor- mations are considered, appropriately sequenced and strategically managed. With the endorsement of the WHO European Framework for Action on Integrated Health Services Delivery and its resolution EUR/RC/R5 came a call for intensifying monitoring and regular reporting on services delivery in the European Region. A review of existing monitoring frameworks, assessment tools and evaluation initiatives related to health services delivery in Europe but also globally reveals several shortcomings of the existing initiatives and tools. These include: inadequate or irregular availability of data on health services delivery; limited ability of frameworks to unpack services delivery by both its model of care and performance; limitations in constructing measures to capture the specificity of systems across the Region, specifically the unique characteristics of countries of the Commonwealth of Independent States (until 2006)1; and a focus for frameworks to measure current health priority areas rather thanforecasting and anticipating the readiness of services delivery to respond to future health needs. In this context, a unique monitoring framework is needed. While drawing from existing resources, a monitoring framework for the WHO European Framework for Action on Integrated Health Services Delivery should respond to these perceived gaps to provide detailed information on services delivery across the 53 Member States in the Region. Why is a monitoring framework needed? ix Roadmap to monitoring health services delivery This roadmap to strengthening health services delivery monitoring in the Region is structured according to seven phases running from now until 2020 – the year of the first reporting back to the WHO Regional Committee for Europe on the status of services delivery in the Region. These phases include: defining the framework, reviewing indicators, preparing for data collection, collecting data, analysing findings, collecting a second round of data and reporting back. Throughout, a network of partners, engaged through varied platforms, will play a critical role. Expertise and input will be sought from technical experts, data specialists, experts from countries and key stakeholders. The Secretariat for this work is the WHO European Centre for Primary Health Care, as the Regional Office’s technical unit on health services delivery. The roadmap details biennual data collection for an initial baseline and second period of data collection before reporting back to Member States at the session of the Regional Committee in 2020. Country data will be consolidated in a regional analysis. Based on available data, country profiles will be generated electronically in agreement with Member States. All findings will be integrated with the Regional Office’s European Health Information Gateway. Many studies, tools, evaluations and initiatives for monitoring and measuring health services delivery are available both globally and regionally. This work has been designed to take stock of existing measures in the approach of the WHO European Framework for Action on Integrated Health Services Delivery and its novel breakdown of system and service structures and performance by care contact, service outputs and system outcomes. The envisaged database and country profiles should draw from existing databases and their current reporting for a consolidated health services delivery resource that houses data for all 53 Member States. In doing so, gaps in current reporting can be given priority as the focus of primary data collection processes. How will it be developed? How will the results be disseminated? How does this work link to ongoing monitoring of services delivery? x Roadmap to monitoring health services delivery 1 Introduction Across the WHO European Region, people are living longer than ever before. In the last 30 years, a gain of five years was recorded (1). The Region is also on track to achieve goals towards reducing premature mortality from the four major noncommunicable diseases, and the last European health report documented decreases in inequities (2). Despite this progress, population health trends signal increases in multimorbidity and chronicity. Risk factors, including alcohol consumption, tobacco use and obesity, remain major public health problems in the Region. These changes and persisting challenges place new demands on health services delivery. Health systems increasingly face demands for care that is: proactive rather than reactive, comprehensive and continuous rather than episodic; and disease-specific and founded on lasting patient– provider relationships rather than incidental provider-led care. In this context, health services delivery systems are required to adapt and respond to these changing needs but also to anticipate future demands. The global health and development priorities are clear on the importance of doing so. The link between population health and services delivery is made explicit in the 2030 Agenda for Sustainable Development in which health occupies a central place. The case for transforming services delivery is especially clear in Sustainable Development Goal 3, Target 3.8 on achieving universal health coverage, where making progress requires access to quality, essential health services that are safe and acceptable to all people and communities (3). In 2016, Member States globally affirmed their commitment to health services delivery with the adoption of a framework for strengthening people-centred health services in resolution WHA69.24 (4). Already in 2012, the European Member States adopted the European health policy, Health 2020, with the aim of improving health outcomes and reducing inequities. This commitment is in accordance with the health system strengthening priorities of the 2008 Tallinn Charter: Health Systems for Health and Wealth and extended to the 2015 priorities for strengthening people-centred health systems, in which transforming services delivery is one of two priority areas (5). The WHO European Member States take forward this priority with the WHO European Framework for Action on Integrated Health Services Delivery. The action- Roadmap to monitoring health services delivery 2 oriented framework identifies areas for action and articulates their interactions in a policy guide for thinking through services delivery reforms. It does so by reasoning transformations along three core domains. The domains include: understanding clearly areas for improving population and individual health; designing the provision of services that is conducive to improving outcomes; and ensuring that health system structures create the enabling conditions that support the envisaged model of care. Data are integral to the design, organization, management and improvement of health services delivery transformations, monitoring their performance implemen- tation and ensuring feedback on their performance. Intensifying reporting on health services delivery measures is a core component of the implementation of the WHO European Framework for Action on Integrated Health Services Delivery. This roadmap sets out a process for doing so. About this document The roadmap has three main sections. The first sets out to make the case for a unique framework for monitoring health services delivery in the WHO European Region, well recognizing past and present policy frameworks and tools but also persisting gaps and limitations to monitoring at present. To follow, a framework for monitoring health services delivery is described. The framework responds to these challenges and adapts the WHO European Framework for Action on Integrated Health Services Delivery from a policy to a performance framework. Finally, a process is detailed that maps out the phases and steps as well as partners envisaged to be engaged from the initial endorsement of the Framework to a first reporting back to Member States in 2020. Roadmap to monitoring health services delivery 3 The case for monitoring health services delivery A call for intensified monitoring of health services delivery At the 66th session of the WHO Regional Committee for Europe in 2016, European Member States endorsed the WHO European Framework for Action on Integrated Health Services Delivery (6). The Framework takes direction from the European health policy, Health 2020 (7), and the people-centred health systems strengthening priorities for the Region (5). It also aligns with the international health and development agenda for universal health coverage, where health services delivery plays an integral role in making progress towards global targets. The WHO European Framework for Action on Integrated Health Services Delivery is an action-oriented policy framework. It was developed for and with countries together with international experts and representatives from patient, provider and practitioner associations, development partners and other special interest groups (8). The Framework was developed over a three-year process of synthesizing research, generating evidence and facilitating consultations. It is meant to guide setting priorities for services delivery transformations by indicating policy options as areas for action and also their interactions by clustering them in relevant domains. With the endorsement of the WHO European Framework for Action on Integrated Health Services Delivery, Member States tasked the WHO Regional Office for Europe with the mandate to monitor the transformation of health services delivery (Box 1) specifically through intensified measurement of all relevant and existing indicators. The request is understood as a call to ensure due diligence on the reporting of existing measures in the framework and approach of the WHO European Framework for Action on Integrated Health Services Delivery in order to monitor and accelerate services delivery transformation in the Region. Box 1. Resolution calling for performance monitoring EUR/RC66/R5 requests the Regional Director: To monitor the implementation of the European framework for action on integrated health services delivery and report on progress to the Regional Committee every five years, commencing with its 70th session in 2020 (9). Roadmap to monitoring health services delivery 4 Scoping frameworks and tools for monitoring services delivery Until recently, the evidence base to measure health services delivery was not systematized. The evidence on the causes and consequences of strong health services delivery, in general, was also considered weak. Fortunately, the past two decades have seen a surge in efforts to conceptualize and measure health services delivery, an effect that can be largely credited to consensus on the importance of services delivery as a core function of health systems and link between health system performance and population health outcomes. Table 1 notes selected examples of relevant policy frameworks and tools for monitoring services delivery from project-based frameworks for monitoring health services delivery. In addition to these, it is recognized that numerous other databases, surveys and ad hoc research projects also contribute to capturing the performance of services delivery. These efforts are an important platform for measuring services delivery and complement an enriched understanding of services delivery. Scoping these tools and initiatives was considered a necessary starting-point for approaching a response to the call of Member States that evolves from earlier efforts and ensures alignment with those on- Name Organization Years active Countries Policy monitoring framework Tool Sustainable Development Goals (3) United Nations 2015-2030 194 WHO Framework on Integrated WHO 2016-present 194 People Centred Health Services (4) Health 2020 (6) WHO Regional 2012-present 53 Office for Europe Primary Health Care Performance Bill & Melinda Gates Foundation, the 2015-present 139 a (10) World Bank Group, WHO, Ariadne Labs and Results for Development Health Care Quality Initiative OECD 2002-present 35 (HCQI) (11) Primary Healthcare Activity Monitor NIVEL/European Commission 2007-2010 31 for Europe (PHAMEU) (8) Health Systems Performance European Commision 2014-present 29 Assessment (HSPA) (12) Primary Care Systems Profiles and Alliance for Health Policy and 2015-2018 20 Performance (PRIMASYS) (13) Systems Research Primary Care Evaluation Tool WHO Regional Office for 2008-2013 10 b (PCET) (9) Europe/NIVEL Table 1. Examples of relevant frameworks and tools for monitoring services delivery a The country sample size varies by specific indicators. b In addition, another tool was developed, the Primary Care Quality Management Tool, which has been implemented on a pilot basis in two Member States. Roadmap to monitoring health services delivery 5 going yet also addresses persisting gaps. These efforts have been considered by their guiding policy question, scope, focus countries and timing for reporting on data (Table 2). The table illustrates that, despite their shared health and development focus, each framework and tool applies to a specific group of countries, for varied time intervals and with a specified scope and question that directs their framing. For example, the Primary Health Care Performance Initiative and Primary Care Systems Profiles and Performance are linked and share a focus on low- and middle- income countries, evident in the scope of the countries monitored and measures tailored to the health needs of these contexts. In the European context, the Primary Healthcare Activity Monitor for Europe and Primary Care Evaluation Tool, as first efforts to report on services delivery in Europe, are now outdated in terms of results, conceptual developments and coverage. The Primary Care Evaluation Tool is unique in its view to all Member States of the WHO European Region, yet was applied to an initial 10 countries. Looking to policy monitoring frameworks (Table 2), these are guided by similar policy aims in the pursuit of access to essential health services. The scope of monitoring varies according to the strategic areas of each framework, and their scale of international comparability makes for a small, refined set of indicators of services delivery. Nevertheless, these measures reported on are an important source of data and a starting-point for aligning monitoring in the European Region. Gaps in monitoring health services delivery in the European Region The level of activity described signals the interest and importance of measuring health services as well as the progress in doing so. Nevertheless, recognizing the particu- larities of the monitoring frameworks and tools described and the unique approach of the WHO European Framework for Action on Integrated Health Services Delivery itself, the Region faces critical gaps in monitoring health services delivery. These include the following. 1. Gaps in the availability of data on services delivery indicators For nearly four decades, WHO European Member States have reported essential health-related statistics to the European Health for All family of databases. Among these, the European Hospital Morbidity Database collects aggregated data on hospital statistics from all 53 countries in the Region. The database can be used to calculate estimates of hospitalization for ambulatory care sensitive conditions by extracting hospital morbidity data with the corresponding disease codes of the ambulatory care sensitive conditions (14). However, on select measures of ambulatory care sensitive conditions, the availability of data is inconsistent over time and with considerable gaps in reporting across countries and across databases (Table 3). Although 52 countries report data to WHO to be included in the European Health for All database, data are outdated for all 32 countries that report also to Eurostat and OECD.Stat. Several factors contribute to Roadmap to monitoring health services delivery 6 Name Aim or primary policy question Scope International comparability Timing Policy monitoring framework Ensure healthy lives and promote well-being for all at all ages Ensure access to coordi- nated services that respect individual preferences, are safe, effective, timely, affor- dable and of high quality Ensure people-centred health systems What is the perfor- mance of primary health care? What is the gap between aspiration and achievement? What is the cause of the gap? What is the simplest system to close the gap? What is the quality of health service provision in OECD countries? How can the strength of primary care be measured and compared in Europe? What are good practices, methods and tools for health services performance assessment among participating countries? What is the performance of primary care systems? What is the state of primary health care according to system functions and key characteristics of primary care services? Goal 3, target 3.8 on access measures to quality essential health care services Five strategic areas of the IPCHS framework Priority area three on universal coverage and the right to health Domains on system, inputs services delivery (availability, access, quality and organization and management of services), outputs and outcomes Quality measures on effectiveness, safety and responsiveness and patient-centredness Primary care system structures and services processes (access, comprehensives, continuity, coordination) A platform for exchanging practices and harmonizing approaches for health services performance assessment across participating countries. Primary care as a subgroup area of focus System factors, processes and pathways that underpin and explain the outcomes of primary care services delivery System functions of governance, financing and resourcing and characteristics of primary care (access, continuity, comprehensiveness, coordination) Low- and middle- income countries OECD countries European Union countries, Iceland, Norway, Switzerland and Turkey European Union countries Low- and middle- income countries Central and eastern European and Central Asian countries Electronic database as a platform for consolidating reporting on core vital sign indicators Electronic database of health care quality indicator dataset Project-based spanning 2007– 2010, reporting 2012 Contributes to tools and methods; not active data collection Twenty-two country case studies between 2015-2018 Country reports based on appli- cation of tool; 10 country studies since 2008; not actively applied at present Global Global 53 Member States of the WHO European Region Ongoing to 2030 Since 2016; data collection forthcoming Ongoing to 2020 Sustainable Development Goals WHO Framework on IPCHS Health 2020 PHCPI HCQI PHAMEU HSPA PRIMASYS PCET Tool Table 2. Differentiating policy monitoring frameworks and tools Roadmap to monitoring health services delivery 7 this delay and gaps, especially the lack of reporting and the labour-intensive process to harmonize country data to match the coding of the database. Nevertheless, these existing indicators stand to benefit from further support to ensure their consistent and timely reporting based on data that are predominantly available in countries. 1 The data reported to Eurostat are harmonized with the data reported to OECD.stat, but Israel is the one country in the European Region that reports to OECD but not to Eurostat. 2 Bosnia and Herzegovina does not report data on hospital discharges to WHO. Sources: European Health for All database, Eurostat and OECD.stat. 2. Limited scope to monitoring services delivery Monitoring health services delivery presents methodological challenges without a defined framework or set of indicators (7). Most of the Region’s databases and tools for monitoring services delivery capture system inputs to services (such as human resources for health and health financing) and outcome measures (such as access and quality). Appreciation for the perspective of the individual and their experience with services is limited. These measures also often exclude more design elements of services delivery, such as how practitioners are organized, what types of facilities are in place and how services are managed. Nevertheless, in recent years, progress has been made in unpacking and specifying the unique processes of services delivery related to designing care across the life-course, organizing providers and settings, managing services and improving performance (15). The WHO European Framework for Action on Integrated Health Services Delivery is novel in its approach to distinguish these processes and propose strategic actions that correspond to each. The areas for action captured by the Framework mostly relate to already constructed indicators of the frameworks and tools described and reported on by countries. What is needed now is aligning measures in the approach of the Framework. Doing so will especially call attention to and disentangle aspects of Number of countries available in European Health for All database Subset of countries only available in European Health for All database Subset of countries available in Eurostat/ OECD.stat1 Number of countries available in Eurostat/ OECD.stat1 5227441 6 4 7 17 35 0 0 35 2 1 32 35 Table 3. Availability of reporting on hospital discharges Available data 2013 and earlier 2014 2015 and more recent Any year Roadmap to monitoring health services delivery 8 services delivery capacity from those related to other health system functions. 3. Lack of specificity to the European Region Health services delivery looks very different between countries, especially comparing countries from western, eastern and southern Europe, the Baltic countries, central Asia and the Caucasus, among other subregional geopolitical groups. This variability extends, for example, from the types of settings, such as polyclinics, to the classification of providers, such as therapeutists, feldshers and patronage nurses, and to specific services such as dispenserisation that are particular to certain countries. Progress has been made to define health services delivery to capture these specificities. However, work is still needed to capture the uniqueness in particular of the systems of the countries of the Commonwealth of Independent States. Addressing these differences with indicators that are constructed to apply to reflect these systems together with all other European Member States can help to address reporting gaps. Improving the construction of indicators to the realities of the Region also stands to improve the interpretation of results. 4. Timeliness to evolve with changing needs The WHO European Framework for Action on Integrated Health Services Delivery recognizes the need for services delivery to continually adapt and evolve according to changing needs (6). At the first meeting of the Primary Health Care Advisory Group in June 2017 – an expert group to support the continued advancement of primary health care – members conceded that what has changed recently is the pace of these changes (16). In the WHO European Region, the emerging health needs include but are not limited to the growing challenges of chronic illness, as well as acute stroke and heart disease, rising prevalence of Alzheimer’s disease and dementia and rising rates of comorbidity and polypharmacy, adding to social needs. This places an increasing strain on the services and systems to continually evolve and adapt. Policy foresight is needed for a monitoring framework to generate evidence that enables adapting to changing demands and anticipating future health and social needs. What is needed now is to further tighten the link between performance and outcomes, with measurement that is guided by pertinent health needs and conceptual advancements. Rationale and criteria for a specific monitoring framework for services delivery in the WHO European Region Given the policy mandate of Member States to ensure diligence in reporting, the lack of a tool that captures the specificities of the Region and the current shortcomings of data collection in the Region, a specific monitoring framework Roadmap to monitoring health services delivery 9 for health services delivery in the WHO European Region is needed. In this context, a monitoring framework should set out to address and incorporate the following. • Drawing from existing indicators and data sources. The various frameworks and tools described offer a valuable pool of indicators for monitoring health services delivery. These indicators and data, where available, should be drawn from as far as possible in constructing a monitoring framework for the Region. • Adopting an integrated services delivery lens. The WHO European Framework for Action on Integrated Health Services Delivery calls for focusing on monitoring services delivery processes but also the importance of the perspective of individuals. It also means making services delivery measures distinct from other health system functions. • Ensuring specificity to the Region. The development of indicators should capture the specificities of the European Region in terms of countries with services delivery systems that have transitioned from public to private, from centralized to decentralized, planned to liberal, single to multi-profile, single to group or multidisciplinary practices, inpatient to outpatient services, specialist to generalist practice, single to distributed accountability and management, among many other aspects inherent to health services delivery in the Region. • Taking a forward-looking approach. The selection and use of tracer conditions that reflect an evidence-based understanding of future health needs specific to the European Region should guide the development of a monitoring framework that enables services delivery to anticipate and accelerate transformation rather than to react to it. With these aims, the WHO European Framework for Action on Integrated Health Services Delivery can be adapted from a policy framework to a monitoring framework for measuring health services delivery. As a policy, the Framework reasons from health improvement areas to the design of services delivery processes and alignment of enabling system conditions. To measure performance, the Framework’s approach can be realigned to assess the link between the capacity of system and services to contribute to outcomes and overall performance. A monitoring tool is proposed to carry out this task. Roadmap to monitoring health services delivery 10 Roadmap to monitoring health services delivery 11 Proposed monitoring framework Developing a monitoring framework In the context described, in late 2016, the WHO Regional Office for Europe began to develop a monitoring framework for health services delivery as part of the implementation of the WHO European Framework for Action on Integrated Health Services Delivery. Taking the Framework as the starting platform for this work has meant translating it from a policy, action-oriented approach to a monitoring framework. Specifically, this required adapting the Framework’s core domains of population and individuals, services delivery processes and system enablers to reason in the logic of a causal chain for inputs, processes, outputs and outcomes; whereby inputs refer to system structures, processes to constructing the model of care, outputs as delivering services, outcomes as the performance of the broader health system and, ultimately, final effects on health. As a policy framework, attention is put to the integration of services and people- centredness as the guiding principles for transforming services. In practice, this means focusing on primary health care as the cornerstone of services delivery and the foundation for the integration of health services. In this way, primary health care can be found at the centre of all transformation of health services delivery towards improved integration and therefore common to the various avenues for carrying out transformations. In the European Region, these avenues for transforming services delivery include the integration of primary health care and public health services, primary health care and hospitals and health services delivery and social care. As such, for the purposes of the monitoring framework, the focus is on primary health care as a gateway to transforming integrated health services delivery. Specifying the properties for the monitoring framework draws from the approach of the WHO European Framework for Action on Integrated Health Services Delivery. The monitoring framework has been enriched with the framework and tools described (Tables 2 and 3) while also referring to these to ensure alignment in the measures captured. The criteria for a monitoring framework has also been guided by the need to draw from existing data and indicators, to ensure specificity to the Region, to adopt a services delivery lens and to take a forward-looking approach. Roadmap to monitoring health services delivery 12 Based on this exercise, the framework for monitoring the WHO European Framework for Action on Integrated Health Services Delivery, its scope, concepts, aims, policy questions and objectives are described. Scope: primary health care A working definition for the parameters of primary health care has been constructed to guide the design and scope of measures for the monitoring framework. The scope for monitoring purposes is based on an understanding of primary health care services, practitioners and facilities (Table 4). The definition of services extends the full continuum from prevention to clinical diagnosis, treatment, management of disease, palliative care and other parallel services. The definition also captures a large range and the diversity of practitioners and facilities care that are unique to the countries in the Region. As described, primary health care is used to anchor the scope of the monitoring framework from which the properties of integration and people-centredness Services Practitioners Facilities Prevention Population-based screening Counselling services Individual risk assessment Immunization Diagnostic procedure Diagnostic exam Confirmation of diagnosis Treatment Prescription Therapeutic appliance Referral Management of disease (Multi)-drug therapy Secondary prevention Follow-up Psychological services Palliative care (Multi)-drug therapy Home care Pain management Psychological services Cognitive therapy Parallel service Laboratory testing Imaging Rehabilitation Stabilization Physiotherapy Patient engagement Health literacy Self-management Doctor Physician Family physician Paediatriciana Therapeutist without specialization Narrow specialista Doctor in outpatient clinic Nurse Nurse Family nurse Feldsher Midwife Feldsher-midwife Patronage, paediatric nursea Public health worker Public health specialist Health promoter Healthy lifestyle counsellor Dietician Nutritionist Allied health professional Psychologist Physiotherapist Rehabilitation specialist Social worker Ambulatory care Primary care centre Office of general practitioners Ambulatory health care centre Family planning centre All other ambulatory centre Home health care centre Nursing home Polyclinic Other settings Walk-in treatment centre Outpatient department District hospital General hospital Ambulance Mobile clinic Laboratory Pharmacy Palliative care establishment Rural-specific Rural physician ambulatory Feldsher assistance point Midwifery post Rural health house Table 4. Primary health care: services, practitioners and facilities aspecific to countries of the Commonwealth of Independent States. Sources: adapted from Tello & Barbazza (15); and OECD et al. (17). Roadmap to monitoring health services delivery 13 can be assessed. Primary health care is therefore an entry point for monitoring transformations towards the integration services. Conceptual framework The monitoring framework features the logic of inputs, processes, outputs and outcomes, provides a novel focus to capture processes of services delivery, offers a unique perspective on outcomes from the perspective of patients, captured as care contact, and distinguishes the performance of services from the performance of the system. Specifically, the framework’s main components consider the capacity and performance of primary care and the contribution of both to health outcomes. For each component, specific domains are identified. These include: primary care structures, model of primary care, care contact, primary care outputs, health system outcomes and impact. Subdomains are associated with each, drawing from the areas for action of the WHO European Framework for Action on Integrated Health Services Delivery. These subdomains are measured according to select features, each with corresponding indicators. These properties of the framework are described in Table 5 and visualized in Fig. 1. Annex 1 provides an overview of the framework by main components, domains, subdomains and features. Adapted from: Glossary of terms: English-Russian version – the European Framework for Action on Integrated Health Services Delivery (18) Property Description Component The framework is organized in two main components: capacity and performance. It focuses on unpacking both and their interactions to ultimately reason the links between each and health outcomes. Subdomain The subdomains draw from the areas for action of the WHO European Framework for Action on Integrated Health Services Delivery as the essential areas for targeting strategic efforts to transform services. The subdomains serve to highlight the specific properties of each domain to be measured. The subdomains of the model of primary care, for example, include: selection of primary care services; primary care design; organization of the primary care workforce; managing primary care services; and improving the quality of primary care. Features Features characterize the relevant property of each subdomain for measurement. These features are not exhaustive and instead focus on the properties highlighted as key strategies in the WHO European Framework for Action on Integrated Health Services Delivery and as measurable outcomes of the performance component. Domain The domains cluster and sequence the breakdown of the framework’s components. This breakdown distinguishes the following domains: primary care structures; model of primary care; care contact; primary care outputs; health system outcomes; and impact. Table 5. Properties of the conceptual framework described Roadmap to monitoring health services delivery 14 Fig. 1. Monitoring framework: conceptual framework Source: WHO European Centre for Primary Health Care, 2017. Capacity of primary care • Primary care structures Primary care structures correspond to the WHO European Framework for Action on Integrated Health Services Delivery domain of system enablers and the core health system functions of governing, financing and resourcing. These structural aspects serve as an input to services delivery and taken together with the model of care, account for the capacity of primary care. The component of system structures is broken down to consider: primary care governance, financing and resources, further delineated to include the primary care workforce, information systems, medicines, diagnostics, technology and facility infrastructure. This detailed breakdown of resources is considered especially relevant for primary care and its often-overlooked capacity needs. • Model of primary care The model of primary care is the second core domain of the framework and point of departure compared with other similar approaches that measure services delivery. The model of care is defined to reflect the processes of delivering primary care. These are captured as: the selection of primary care services, the design of primary care, the organization of the primary care workforce, the management of primary care services and quality improvement processes. The specific features and their associated indicators for each subdomain distinguish between indicators that are descriptive, design elements (such as practice skill mix, gatekeeping system and opening hours) and those that are outcomes of these decisions (such as unmet needs, treatment continuity and patient experience). Outcomes are instead associated with the performance component of the framework. The structure Primary care governance Primary care medicines Primary care financing Primary care diagnostics Primary care workforce Primary care technology Primary care information systems Primary care facility infrastructure Model of primary care Organization of primary care workforce Primary care services management Primary care quality improvement Health status and well-being Quality Access to primary care services Repsonsiveness of primary care Safety of primary care Effectiveness of primary care services Equity Efficiency Impact Health system outcomes Primary care outputs Continuity of primary care Coordination across settings Comprehensiveness of primary care services People-centredness of primary care Care contact Social determinants and context (political, social, demographic, socioeconomic) Primary care structures Performance of primary care Capacity of primary careHealth outcomes Utilization Selection of primary care services Primary care design Roadmap to monitoring health services delivery 15 of the framework is novel in this distinction between design and outcomes and is felt to offer meaningful insight into the strategic decisions that can be taken to construct the model of care. Performance of primary care • Care contact Care contact bridges between what makes up the health system and the actual experience of the provision of services. It focuses on the relationship between health professionals and the patient. This interface at the junction of services and their delivery is an often-missed yet important component for measuring the performance of services from the perspective of the individual and, overall, people-centredness. • Primary care outputs Output measures specifically consider aspects resulting from services provision. They result from the interaction of the system structure, the model of primary care and the care contact. They evaluate the accessibility of primary care services, the responsiveness of services to the health needs of the population, safety in service provision and the effectiveness of health services. • Health system outcomes The aspects of quality, equity and efficiency are captured as health system outcomes, measuring the value and impact of the health system as a whole. They bridge between outputs and population outcomes. These measures capture the performance attributable to the whole- of-system interactions. Equity refers not only to inequalities in health outcomes but evaluates the capacity of the system to delivery comprehensive, quality services to everyone who needs them without financial or other barriers to receiving care. Efficiency refers to technical efficiency, the ability to improve the level and distribution of health outcomes with the available resources, while not compromising other system goals, such as equity, quality and responsiveness. From this perspective, these measures are cross-cutting across the framework. Health outcomes • Impact As an outcome-oriented framework, the impact component aims to focus on specific health improvements (morbidity and mortality) to measure the effect of primary health care systems on population health outcomes. Outcomes should be measured by select tracer conditions, identified based on the best available evidence and forecasting of future health and social needs. Outcome measures draw from existing regional and global commitments, including Health 2020, to reflect priority areas for improving health and well-being. Roadmap to monitoring health services delivery 16 The broader social, economic and political context in each country, including the level of education and the employment and economic status of citizens, influences health outcomes. However, this context is considered an exogenous variable and thus not captured in the measures of the framework itself. Aims and underlying policy question The monitoring framework aims to establish a Region-wide baseline on the status of primary health care to inform the monitoring of the WHO European Framework for Action on Integrated Health Services Delivery. Its design gives priority to the following consideration: how ready is primary health care for the future? On the capacity side, the monitoring framework is designed to challenge the current expectations of primary health care and to consider such variables as the diagnostic capacity of primary care and its ability to respond to acute care needs or to strategically manage the population’s health through such techniques as individual risk stratification. The expectations related to primary health care need to be challenged to anticipate changes from recent trends such as population ageing. On the performance side, the tool breaks down performance to capture measures from the perspective of patients through care contact, services delivery as outputs and health system outcomes. Considering these perspectives is aligned with the approach of the WHO European Framework for Action on Integrated Health Services Delivery and its consideration across populations and individuals, services delivery processes and system outcomes. Using tracer conditions, the tool is tailored to follow the capacity and performance of primary health care for identified priority health areas. These areas adopt a forward-looking perspective and are to be selected based on pertinent trends in the Region. Objective of the monitoring framework This work will analyse the relative status of primary health care systems across the Region in terms of capacity and performance. All data consolidated will be made available through a common database, linking to the existing and ongoing reporting of the Regional Office. Specifically, the objectives of this work are: • to report on indicators for primary health care performance and capacity in the framework described constructed from primary and secondary data sources; • to disseminate data through the existing reporting databases of the European Health Information Gateway hosted by the WHO Regional Office for Europe; and • to generate country briefs in agreement with Member States to display core findings using common visuals through graphs and tables with analysis of results. Roadmap to monitoring health services delivery 17 End-users of the data include primary health care decision-makers, as a resource for identifying areas for improving capacity and performance. The results are envisaged to apply more broadly to include patients, practitioners, managers, governments, insurers and citizens. Roadmap to monitoring health services delivery 18 Roadmap to monitoring health services delivery 19 Roadmap partnerships and processes This section describes the phases and steps for intensifying health services delivery monitoring in the Region as a roadmap for the continued development and roll-out of a monitoring framework. The phases are timed according to the commitment to report to Member States on transformation of services delivery every five years, commencing with the 70th session of the WHO Regional Committee for Europe in 2020 (9). Fig. 2 summarizes the milestones leading up to this as the main events in developing this work. Partnerships and platforms for engagement In detailing the process for intensifying the monitoring of health services delivery, describing opportunities for engaging a range of partners has been emphasized, including primary care experts, data specialists, country representatives, provider representatives, patient associations and other stakeholders. To ensure a participatory approach, the roadmap signals possible contributions and opportunities for collaborations across the phases of this work. The partnerships identified extend a range of actors to include the following (Fig. 3): • representatives from Member States, linking to the existing network of integrated health services delivery focal points and national experts for advice on the practicalities of reporting structures in countries; • technical experts on health services delivery in general and with relevant specializations, including the primary health care workforce, financial incentives, quality of care and the integration of services, among other technical areas; • data specialists with expertise on constructing indicators, information systems and data collection processes; and • stakeholders, including provider associations, professional associations, special interest groups such as organizations for caregivers or consumer interests and other international organizations, specifically, partners of the PHCPI, European Commission and OECD. Roadmap to monitoring health services delivery 20 September 2016 WHO European Framework for Action on Integrated Health Services Delivery endorsed at the 66th session of the WHO Regional Committee for Europe June 2019 Third-country and partners consul- tation meeting on baseline data and preparation for the second round of data collection September 2020 First reporting back to Member States at the 70th session of the Regional Committee for Europe June 2017 First country and partners consultation meeting on monitoring framework and approach June 2018 Second country and partners consultation meeting on baseline study October 2018 40th anniversary conference of the Declaration of Alma-Ata Early 2020 Meetings of the Standing Committee of the Regional Committee July 2018 Launch of first-round data collection – baseline study December 2017 Preliminary test of questionnaire April 2018 Piloting of monitoring framework July 2019 Launch of the second round of data collection March 2019 Second meeting of the Steering Committee March 2018 First meeting of the Steering Committee Fig. 2. Key milestones in monitoring health services delivery Roadmap to monitoring health services delivery 21 Fig. 3. Partners and platforms for monitoring health services delivery Source: WHO European Centre for Primary Health Care. Four platforms have been identified to organize and engage these different actors. The platforms include a Secretariat, an Advisory Group, a Steering Committee and a wider network for consultations that includes countries and other partners. The functions of each are described in the following sections. Ministry of Health Integrated Health Services Delivery Focal Points Selected Integrated Health Services Delivery Focal Points National experts Countries Technical experts Primary Health Care Advisory Group WHO Regional Office for Europe WHO Primary health care experts Technical representatives Collaboration Centre NCD Office Division of Information, Evidence, Research and Innovation Division of Information, Evidence, Research and Innovation Data experts NCD Office Data specialist representatives Data specialists Patient associations Provider associations Special interest groups International partners Stakeholder representatives Stakeholders Consultations Steering Committee Advisory Group Secretariat Platforms WHO European Centre for Primary Health Care Partners Roadmap to monitoring health services delivery 22 Secretariat The WHO European Centre for Primary Health Care will function as the Secretariat for this work (Box 2). Based in Almaty, Kazakhstan, the Centre is the technical unit on health services delivery of the Division of Health Systems and Public Health. The Centre supports and oversees the implementation of the WHO European Framework for Action on Integrated Health Services Delivery as well as the phases for its monitoring. Advisory Group An Advisory Group (Box 3) is envisaged as a key partner throughout the phases of the roadmap. This group includes at least three key partners: the WHO Collaborating Centre for Quality and Equity in Primary Health Care Systems, Academic Medical Center, University of Amsterdam, together with the Division of Information, Evidence, Research and Innovation and WHO European Office for the Prevention and Control of Noncommunicable Diseases (NCD Office), both of the WHO Regional Office for Europe. These partners specialize in technical areas related to services delivery and data collection. They will serve as strategic advisers, flagging key considerations for the alignment and uptake of relevant research and development as well as with other efforts and databases of the Regional Office. This platform is envisaged to work closely with the WHO European Centre for Primary Health Care, building on existing working modalities with each. Box 2. Functions of the Secretariat • To coordinate the development of the monitoring tool of the WHO European Framework for Action on Integrated Health Services Delivery to maximize opportunities for engaging partners. • To facilitate links with relevant partners and projects for the continued alignment of monitoring with these initiatives. • To consolidate the input received from the various platforms of partners to draw from this input for continuously improving and refining the monitoring tool. • To inform about the development of the monitoring framework and its application through regular reporting in the form of briefs, news items, reports and other relevant means of dissemination. Roadmap to monitoring health services delivery 23 Steering Committee A Steering Committee, as a subset of a wider consultation network, is envisaged to be closely engaged in review processes (Box 4). The Steering Committee includes representation from content experts, data specialists, countries and other stakeholders. Country representatives will be drawn from the existing network of integrated health services delivery focal points. The Steering Committee will review in depth the framework, tool and indicators before the data collection. The expertise of the Steering Committee will be called on remotely and through consultation meetings at the WHO European Centre for Primary Health Care in Almaty, Kazakhstan together with the Advisory Group. Wider network for consultations A wider network of partners spans across the profiles identified and includes everyone expected to be engaged in this process: countries, technical experts, data specialists and health services stakeholders (Box 5). • Countries. Representatives from countries will play an important role at each stage of the roadmap from the initial development of the framework to its validation and eventual data collection. The existing network of integrated health services delivery focal points is intended to serve as country coordinators, Box 4. Functions of the Steering Committee • To represent varied areas of expertise across partners and advocate for key considerations in the initial phases of development. • To provide a critical review of indicators aligned to the framework, considering the criteria for selecting indicators and other relevant variables such as tracer conditions and data availability and quality. • To recommend considerations for the Secretariat’s review and action in consolidating feedback. Box 3. Functions of the Advisory Group • To provide technical expertise throughout the phases of the roadmap on the technical specificities of services delivery in general and primary health care in particular and from the perspective of data specialists. • To regularly review the development of the monitoring framework, its measures and tool, providing expertise on the methods and advising on relevant steps. • To validate findings along the various phases for developing an initial baseline and biennual reporting. Roadmap to monitoring health services delivery 24 providing access to relevant in-country information and validating findings. Representatives from each country’s ministry of health will be engaged in the phases of data collection and analysis and in reporting back through their participation at the sessions of the Regional Committee. Country experts will be invited to participate in reviews and as informants in data collection. • Technical experts. Wider reviews and consultations aim to engage members of the Primary Health Care Advisory Group – the Region’s network of primary health care experts representing various organizations and areas of expertise for the continued development of primary health care. Reviews and consultations will also be extended to other technical units of the Regional Office, in particular of the Division of Health Systems and Public Health but also other technical divisions and WHO headquarters, for input and alignment. Opportunities for input will also be extended to other experts working in primary health care. • Data specialists. Input from data specialists includes a wider network of colleagues of the Division of Information, Evidence, Research and Innovation, NCD Office and external data experts. Feedback will be sought on aspects related to the definition of indicators, considering especially English-Russian translation and construction of topics. • Health services stakeholders. Key stakeholders to be engaged in consultations include patient associations (general and disease-specific), professional associations and other special interest groups. Wider consultations will also solicit alignment with international organizations working in relevant areas of delivering health services and measuring performance to facilitate the coordination and exchange of good practices. Phases of development This roadmap for intensifying health services delivery monitoring in the Region is organized in seven phases (Table 6): (1) defining the framework; (2) reviewing indicators; (3) preparing for data collection; (4) collecting baseline data; (5) analysing findings; (6) collecting the second round of data; and (7) reporting back. Box 5. Functions of a wider network for consultations • To represent the interests, experiences and needs of different groups throughout the development and implementation of the monitoring framework. • To provide feedback on measures to ensure their accuracy and specificities to relevant areas. • To facilitate opportunities for strengthening alignment in approaches and measurement with ongoing projects and initiatives. Roadmap to monitoring health services delivery 25 Table 6. Overview of steps for monitoring health services delivery Adapted from: Process of arriving at a joint monitoring framework (19). Phases Steps Defining the framework Define the purpose and objectives of a monitoring framework Define the scope of the monitoring framework (such as primary health care, tracer conditions) Convene an initial consultation with countries and other partners Reviewing indicators Agree on maximum number of indicators Consider a core list and additional list of indicators Scan the availability of data Agree on critieria for including indicators Agree on the proportion of indicators covering the framework’s areas Convene a consultation on proposed indicators Pretest indicators in Russian language Design an analysis plan Preparing for data collection Prepare a final list of indicators Disseminate indicators to partners Develop an electronic tool for data collection Populate indicators based on the existing data for countries Consult with country focal points Develop an electronic data repository Collecting baseline data Collect data for the identified indicators Convene a workshop with country focal points Provide at-distance and in-country support Validate findings Collecting the second round of data Collect secondary data to address gaps Consult Steering Committee on the findings Analysing findings Collect secondary data to address gaps Consult Steering Committee on the findings Reporting back Report on findings of baseline and second round of data collection Update the country profiles Disseminate data through an online platform Roadmap to monitoring health services delivery 26 Phase 1: defining a monitoring framework October 2016–August 2017 Since late 2016, the Secretariat, together with its WHO Collaborating Centre at the Academic Medical Center, University of Amsterdam, began preparations to develop a framework for monitoring the WHO European Framework for Action on Integrated Health Services Delivery. This work required rearticulating the approach and areas for action from an action-oriented policy framework to a performance-oriented frame- work that would facilitate measurement. In this phase, a critical review of services delivery initiatives and tools was launched to align with existing frameworks and indicators. The review considered new, relevant emerging topics in health services delivery such as measures of patient-reported experience. Consideration was also given to ensuring alignment with the priority areas of other European and global policies and strategies relevant to primary care. Through regular meetings of the Secretariat and members of the Advisory Group, a comprehensive list of core components and features was identified. A detailed description of this review process will be published elsewhere2. This phase to define the framework also included an evidence-based process to identify tracer conditions. This initial phase has included a first consultation of the monitoring framework and approach presented at the 4th Annual Meeting of Integrated Health Services Delivery Focal Points in June 2017. The framework was also presented at the first meeting of the Primary Health Care Advisory Group in June 2017, where the tool was discussed together with other regional and global performance initiatives. The discussions and input from these initial consultations has informed the further refinement of the framework detailed in this roadmap document. Steps • Define the purpose and objectives of a monitoring framework • Define the scope of the monitoring framework (such as primary health care, tracer conditions) • Convene an initial consultation with countries and other partners 2 ______________________________ See the WHO Regional Office for Europe health services delivery website for up-to-date access to published material developed as part of this work: http://www.euro. who.int/en/health-topics/Health- systems/health-services-delivery/ publications. Roadmap to monitoring health services delivery 27 Phase 2: reviewing indicators September 2017–March 2018 A second phase in the development of this work aims to solicit the feedback of the Steering Committee and wider network of partners in consultation on selecting indicators. Key considerations include agreement on the criteria for including indicators, a core list and additional list of indicators, specifying the distribution of indicators spanning the framework’s domains and the design of the analysis plan. As part of this phase, a scanning exercise to assess the availability of data will be organized. This effort aims to ensure that existing information and data sources directly inform the selection of indicators3. A consultation on the identified indicators will take place remotely in collaboration with the various partners. It will also include an in-person consultation with the Steering Committee held at the WHO European Centre for Primary Health Care in Almaty, Kazakhstan in early 2018. This phase is also envisaged to include pretesting of the identified indicators in the Russian language to ensure the alignment of terms and measures. This will allow the Secretariat to gain insight into the tool’s feasibility and validity at the country level and to revise the indicators as needed. This phase will conclude with refining the indicator list and using it for data collection. An analysis plan will also be presented during the consultation with the Steering Committee for agreement on the approach for reporting findings in country profiles and overall trends. Steps • Agree on maximum number of indicators • Consider a core list and additional list of indicators • Scan the availability of data • Agree on criteria for including indicators • Agree on proportion of indicators covering the framework’s areas • Convene a consultation on proposed indicators • Pretest indicators in Russian language • Design an analysis plan 3 _______________________________ The results of this scanning exercise will be made available through the WHO Regional Office for Europe webpage: http://www.euro. who.int/en/health-topics/Health- systems/health-services-delivery/ publications. Roadmap to monitoring health services delivery 28 Phase 3: preparing for data collection April 2018–June 2018 This phase of preparing for data collection includes several activity lines. Initially, similar to the pretest of indicators, the reviewed list will be applied to a select few piloting countries. Based on this, the indicators and data collection tool will be revised. A final list of indicators will be developed to consolidate the input of reviewers, the Steering Committee and piloting. This final list will be disseminated to partners. Then the indicators will transferred into an electronic tool for data collection using DataForm – a LimeSurvey online data collection instrument. The data collection tool and indicator passports will be available in English and Russian. Before data collection, the tool will be populated with available data from secondary sources: WHO, OECD, Eurostat and other international databases. This also includes relevant data in existing country-specific reports and surveys. The intention is ultimately to tailor the data collection process in countries to exclusively address information gaps. The process of preparing for data collection will include engaging an integrated health services delivery focal point or an identified country coordinator at the discretion of each ministry of health. The country focal points will be fully engaged in the data collection process and need to be well versed in the tool itself and the identified sources of data in this preparatory phase. This phase will include the annual meeting of the integrated health services delivery focal points in Almaty, Kazakhstan as an opportunity to prepare for launching the baseline study. In preparation for data collection, a database will be established to host data retrieved from secondary data sources, WHO surveys and primary data collected directly from countries. This database is envisaged to update data from secondary sources yearly and with each round of data collection in countries. This phase will conclude with the electronic version of the tool finalized in English and Russian and with data prepopulated with available data across the 53 Member States. Steps • Pilot indicators and data collection tool • Prepare the final list of indicators • Disseminate the indicators to partners • Develop an electronic tool for data collection • Populate the indicators based on existing data for countries • Consult with country focal points • Develop an electronic data repository Roadmap to monitoring health services delivery 29 Phase 4: collecting baseline data July 2018–December 2018 In phase 4, the Secretariat will work with integrated health services delivery focal points or country coordinators to identify relevant data sources and validate previously inputted data. Workshops with country focal points in-person and remotely will be convened to facilitate this process. The first round of data collection will aim to generate a baseline on the status of health services delivery based on 2015 data – the year before the WHO European Framework for Action on Integrated Health Services Delivery was adopted. The Secretariat will provide regular support throughout this phase. In-country support will also be made available to assist with the data collection process as needed. At the 40th anniversary conference of the Declaration of Alma-Ata in October 2018, one aim is to share the approach to monitoring and the preliminary results of the baseline study, signalling a significant milestone of strengthening the measurement of the capacity and performance of health services delivery. This phase will conclude with the validation of data for inputting into the data collection tool for a fully populated database to begin the analysis. Phase 5: analysing findings January 2019–June 2019 Preliminary analysis will be carried out to identify any gaps in the availability of data that could hinder analytical work. The results will be presented in regular discussions with the Advisory Group. The second meeting of the Steering Committee will discuss the preliminary results and consider issues of data availability and validity together with an initial analysis of trends. Steps • Collect data for identified indicators • Convene workshops with country focal points • Provide remote and in-country support • Validate the findings Steps • Collect secondary data to address gaps • Consult the Steering Committee on findings • Review the data • Consult with partners on baseline data and second round data collection • Generate country profiles Roadmap to monitoring health services delivery 30 At the annual meeting of integrated health services delivery focal points traditionally held in the spring, together with technical experts, data specialists and other stakeholders, baseline data will be jointly reviewed. This meeting will also serve as preparation for the second round of data collection and focused data collection to address pertinent information gaps. The analysis of results aims to report trends that reflect the design of the monitoring framework to measure and report on the readiness of services delivery in the Region. An analysis by country will be generated to inform country-specific improvement of capacity and performance. The database of measures and country-specific profiles is intended to be available publicly. Phase 6: collecting the second round of data July 2019–December 2019 This second round of data collection sets out to generate a second data point, collecting data from 2017 together with the year of most recent reporting by country. The electronic tool will be disseminated to countries in a similar approach to prepopulate the available data and focus data collection specific to the data gaps. The data from secondary sources will be consolidated in the electronic database. Regular in-country and at-distance support will be provided to support this process. This phase will close with the year-end to prepare for reporting back to Member States. Phase 7: reporting back January 2020–September 2020 In a final phase of reporting back, the findings of the analysis will be summarized in a report on the status of primary health care across the 53 Member States. Each ministry of health will be requested to validate the findings before reporting. This period of preparing for reporting back includes regular meetings Steps • Disseminate the data collection tool • Update the data from secondary sources • Provide regular support to countries for data collection Steps • Report on findings of baseline and second round of data collection • Update the country profiles • Disseminate data through an online platform Roadmap to monitoring health services delivery 31 of the Standing Committee of the Regional Committee. The report to the Regional Committee at its 70th session in 2020 will serve as the first reporting back to Member States. Further reporting is expected to continue on a five-year cycle, with regular updating to the database of measures identified throughout. Electronic country profiles will be updated based on the second round of data collection. Roadmap to monitoring health services delivery 32 Roadmap to monitoring health services delivery 33 1. European health for all database [online database]. Copenhagen: WHO Regional Office for Europe; 2017 (http://data.euro.who.int/hfadb, accessed 10 October 2017). 2. The European health report 2015. Copenhagen: WHO Regional Office for Europe; 2015 (http://www.euro.who.int/__data/assets/pdf_file/0006/288645/ European-health-report-2015-full-book-en.pdf, accessed 10 October 2017). 3. Transforming our world – the 2030 agenda for sustainable development. New York: United Nations; 2015 (https://sustainabledevelopment.un.org/?menu=1300, accessed 10 October 2017). 4. Framework on integrated, people-centred health services. 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Copenhagen: WHO Regional Office for Europe; 2013 (http://www.euro.who.int/__data/assets/pdf_file/0006/199536/ Health2020-Short.pdf?ua=1, accessed 10 October 2017). 8. Strengthening people-centred health systems in the WHO European Region: a roadmap. Copenhagen: WHO European Regional Office for Europe; 2013 (http://www.euro.who.int/__data/assets/pdf_file/0005/231692/e96929- replacement-CIHSD-Roadmap-171014b.pdf, accessed 10 October 2017). 9. Regional Committee for Europe. Resolution: Strengthening people-centred health systems in the WHO European Region: framework for action on integrated health services delivery. Copenhagen: WHO Regional Office for Europe; 2016 (http:// www.euro.who.int/__data/assets/pdf_file/0016/319111/66rs05e_IHSD_160764. pdf?ua=1, accessed 10 October 2017). References Roadmap to monitoring health services delivery 34 10. Primary Health Care Performance Initiative. Methodology note. Washington (DC): Primary Health Care Performance Initiative; 2015 (http:// phcperformanceinitiative.org/sites/default/files/PHCPI%20Methodology%20 Note_0.pdf, accessed 10 October 2017). 11. Kelley E, Hurst J. Health care quality indicators project conceptual framework paper. Paris: OECD; 2006 (https://www.oecd.org/els/health-systems/36262363. pdf, accessed 10 October 2017). 12. Expert Group on Health Systems Performance Assessment. Brussels: European Commission; 2015 (https://ec.europa.eu/health/systems_performance_ assessment/policy/expert_group_en, accessed 10 October 2017). 13. Alliance for Health Policy and Systems Research. Report of the expert consultation on primary care systems profiles and performance (PRIMASYS). Geneva: World Health Organization; 2015 (http://www.who.int/alliance-hpsr/projects/PRIMASYS_Expert_ Consultation_Final_Report.pdf?ua=1, accessed 10 October 2017). 14. Assessing health services delivery performance with hospitalizations for ambulatory care sensitive conditions. Copenhagen: WHO Regional Office for Europe; 2016 (http://www.euro.who.int/__data/assets/pdf_file/0010/305875/ Assessing-HSD-performance-with-ACSH.pdf?ua=1, accessed 10 October 2017). 15. Tello J, Barbazza E. Health services delivery: a concept note. Copenhagen: WHO Regional Office for Europe; 2015 (http://www.euro.who.int/en/health- topics/Health-systems/health-service-delivery/publications/2015/health-services- delivery-a-concept-note-2015, accessed 10 October 2017). 16. First meeting report of the Primary Health Care Advisory Group. Copenhagen: WHO Regional Office for Europe; 2017. 17. OECD, European Union, WHO. A system of health accounts. Paris: OECD; 2011. 18. Glossary of terms: English-Russian version – the European Framework for Action on Integrated Health Services Delivery. Copenhagen: WHO Regional Office for Europe (http://www.euro.who.int/_data/assets/pdf_file/0020/318152/ Glossary-of-terms-AIHSD-E-R-versions.pdf?ua=1, accessed 10 October 2017). 19. Process of arriving at a joint monitoring framework. Copenhagen: WHO Regional Office for Europe; 2017. Roadmap to monitoring health services delivery 35 Annex 1 Overview of the monitoring framework Note that this work is in its initial phase. The menu of features is therefore still being reviewed. Moreover, priorities for the list of associated indicators will ultimately be set by applying a feasibility lens to restrict the list to a priority set for all 53 countries, and a supplementary list where data availability allows for additional secondary or optional indicators. Primary care capacity Primary care governance (GOV) Primary care financing (FIN) Primary care workforce (WRK) Primary care information systems (INF) Primary care medicines (MED) Primary care diagnostics (DGN) Primary care technologies (TCH) Primary care facility infrastructure (STR) GOV1. Primary care priorities FIN1. Primary care expenditure WRK1. Primary care workforce planning WRK3. Primary care workforce availability INF1. Data capture MED1. Essential medicines list DGN1. Laboratory TCH1. Basic Technology STR1. Basic amenities MED2. Generic prescribing DGN2. Imaging TCH2. Technology for self-care INF2. Aggregation of data INF3. Patient platforms WRK4. Academic status of primary care WRK2. Financial status of general practitioners and family medicine providers GOV2. Accountability arrangements FIN2. Payment methods in primary care FIN3. Financial protection in primary care FIN4. Comprehensiveness of financial protection for primary care services GOV4. Quality assurance mechanisms GOV3. Stakeholder participation and engagement Domain Subdomain Feature Primary care structures Roadmap to monitoring health services delivery 36 Primary care capacity Model of primary care Primary care selection of services (SEL) Primary care design (DES) Primary care workforce organization (ORG) Primary care services management (MAN) Primary care quality improvement (IMP) SEL1. Preventive care SEL5. Parallel services DES3. Flexible access modes DES4. Shared care plans SEL2. Diagnostic procedures SEL6. Patient engagement DES1. Referral system ORG1. Practice population MAN1. Primary care staffing IMP1. National or regional primary care performance assessment MAN2. Primary care facility budgets MAN3. Strategic planning IMP2. Practice-level quality improvement mechanisms IMP3. External accountability for quality of care IMP4. Continuous professional development IMP5. Job satisfaction ORG2. 24/7 access to primary care ORG4. Scope of practice of primary care practitioners ORG5. Collaboration of primary care with other professionals ORG3. Primary care teams DES2. Care pathways SEL4. Management of disease SEL3. Treatment Domain Subdomain Feature Roadmap to monitoring health services delivery 37 Primary care capacity Care contact Outputs Health system outcomes Utilization (UTL) Coordination of care across settings (COR) Continuity of primary care (CON) People-centredness of primary care (PCC) Access to primary care services (ACC) Responsiveness (RES) Safety of primary care (SAF) Effectiveness of primary care services (EFF) Quality (QLY) Equity (EQT) Efficiency (EFC) Comprehensiveness of primary care (COP) EQT1. Equity in utilization of services EFC1. Unnecessary procedures EFC2. Prescriptions UTL1. Utilization CON3. Longitudinal continuity of care COP1. Comprehensiveness of service UTL2. Preventive care CON4. Informational continuity of care COR1. Discharge management DES1. Referral system PCC1. Patient experience ACC1. Accessibility RES1. To be determined SAF1. Medical errors SAF2. Poly-pharmacy patients EFF1. Management and control of disease QLY1. Quality of care of chronic conditions QLY2. Quality of care of acute conditions QLY3. Prescribing in primary care EFF2. Prescribing behaviour of practitioners SAF3. Medicine review and reconciliation ACC2. Financial affordability ACC3. Acceptability PCC2. Shared decision-making PCC3. Patient engagement COR2. Transition management CON2. Follow-up care CON1. Treatment Primary care performance Health outcomes Domain Domain Subdomain Subdomain Feature Feature Impact Health status and well-being (HSW) HSW1. Burden of disease and risk factors HSW2. Mortality Document number: WHO/EURO:2017-3048-42806-59735 World Health Organization Regional Office for Europe UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark Tel.: +45 45 33 70 00 Fax: +45 45 33 70 01 E-mail: contact@euro.who.int The WHO Regional Office for Europe The World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for international health matters and public health. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health conditions of the countries it serves. 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