Primary Healthcare Frameworks Primary Healthcare Improvement Global Stakeholder

Primary Healthcare Frameworks Primary Healthcare Improvement Global Stakeholder Meeting WHO 6 -8 April, 2016 Anbrasi Edward

Evidence of Strategies to Strengthen Performance of Health Organizations

Evolution of Afghanistan’s BSC 2004 BSC for BPHS NHSPA 04 NHSPA 05 2002…. MOPH, Donor and NGO investments: policy, health infrastructure, workforce, drugs, protocols, guidelines 2007 BSC for EPHS NHSPA 06 NHSPA 07 BPHS+EPHS 2009 BSC for HMIS NHSPA 08 BPHS+EPHS NHSPA 09 -13 BPHS+EPHS

Afghanistan Balanced Score Card – Health Service Delivery

Performance by BSC Domains: National Median Score ↑ 19*** ↑ 13. 7* ↑ 11* ↑ 29*** ↑ 27*** * p<0. 05 *** p<0. 0001 Edward A, Kumar B, Kakar F, Salehi AS, Burnham G, et al. (2011) Configuring Balanced Scorecards for Measuring Health System Performance: Evidence from 5 Years’ Evaluation in Afghanistan. PLo. S Med 8(7): e 1001066. doi: 10. 1371/journal. pmed. 1001066

Hospital BSC Trends - 2007 to 2009/10 8. 6* 11. 1* 4. 8 5. 8 * p<0. 05 3 7. 6* 6*

Evidence of the Scorecard Strategy § 1 st pioneers to integrate BSC for National Health Systems § Benchmarking successfully employed for service delivery through contracting mechanisms for provincial comparisons § Significant progress in all domains § Facilitated a culture of measurement and accountability to inform policy analysis and planning § Scorecard innovations for hospital performance and health information systems

Limitations § Skewed SC: input/process not outcome measures § Linked facility HH surveys § Non-users § Lacked measures for community oriented health services § Facility teams not equipped with problem solving/QI tools § Bias (observer, courtesy, not risk adjusted) § Inadequate documentation of strategic inflection points § § removal of user fees increased service utilization? investment of resources, policy changes etc?

BSC and Performance Improvement July Y 00 Assessment Jan Y 01 BSC National dissemination Mar/Apr Y 01 BSC Provincial/NGO dissemination Ap to Jun Y 01 July Y 01 Performance improvement strategies Assessment Strategic Inflection Points -Policy /Strategy change - Resources -QI /PS methods Iterative Process

Further innovations § Rapid developments in the heath system landscape § New policies, standards, strategies, tools § HS reconfiguration; sub-centers, health posts, mobile clinics § Epidemiological transitions § Security Constraints § Reconciling indicators from other measurement systems – HMIS

Cascading the Scorecard A. Patients & Community 1 Overall Patient Satisfaction National SC Organizational SC with all domains and indices for policy and planning at the national level Lower Upper National Median 2004 2005 2006 2007 2008 66. 4 90. 9 83. 1 86. 3 86. 0 77. 7 81. 0 66. 2 83. 9 76. 0 76. 2 80. 3 77. 6 77. 5 18. 1 66. 5 34. 2 54. 5 66. 4 86. 0 94. 3 56. 1 67. 9 63. 5 64. 1 68. 1 69. 0 69. 1 52. 4 92. 0 76. 7 90. 0 81. 3 90. 7 82. 7 61. 3 90. 0 65. 7 67. 0 78. 7 83. 8 88. 4 53. 3 81. 8 71. 1 83. 7 85. 7 81. 0 86. 3 43. 4 80. 3 61. 4 70. 0 82. 9 93. 7 94. 9 5. 6 31. 7 18. 3 36. 3 43. 3 58. 5 64. 5 10. 1 54. 0 39. 3 58. 0 66. 9 63. 9 72. 1 44. 8 62. 3 53. 5 69. 0 68. 7 30. 1 56. 3 39. 0 74. 3 68. 9 68. 5 71. 1 49. 6 80. 7 67. 7 65. 8 74. 9 91. 5 92. 4 22. 5 51. 0 34. 8 48. 9 61. 6 78. 3 83. 9 49. 3 63. 2 55. 0 44. 6 48. 7 54. 6 54. 1 56. 1 92. 5 65. 6 63. 2 69. 4 70. 0 69. 9 8. 3 26. 6 15. 8 20. 6 37. 4 53. 7 62. 9 2 Patient Perception of Quality Index Written Shura-e-sehie activities in 3 community B. Staff 4 Health Worker Satisfaction Index 5 Salary payments current Two-Way Influence BSC NGO/Provincial SC for managers and NGOs at the provincial level to benchmark and improve performance C. Capacity for Service Provision 6 Equipment Functionality Index 7 Drug Availability Index 8 Family Planning Availability Index Two-Way Influence Laboratory Functionality Index 9 (Hospitals & CHCs) CSC Facility/Team SC Facility and QI Team SC Select Indicators 1 Staffing Index -- Meeting minimum 0 staff guidelines 1 1 Provider Knowledge Score 1 2 Staff received training in last year Two-Way Influence 1 3 HMIS Index Community SC will include indicators of CHW/Shura activities, referral and feedback on quality of services 1 4 Clinical Guidelines Index 1 5 Infrastructure Index 1 6 Patient Record Index 1 7 Facilities having TB register D. Service Provision Edward, A. , K. Osei-Bonsu, et al. (2015). "Enhancing governance and health system accountability for people centered healthcare: an exploratory study of community scorecards in Afghanistan. " BMC Health Serv Res 15: 299.

Community SC Process

Siadara Community Scorecard Indicators Provider SC Water (dysfunctional water pump) Lack and non-use of IEC materials Damaged clinic roof due to snow avalanche Inadequate medical equipment Clinic cleanliness Round 1 Round 2 Round 3 Reasons (3 m) (6 m) 5 10 10 Water pump is repaired 8 10 9. 5 Additional IEC materials and old copies replaced with new 9 8 10 Metal roof of clinic was repaired 7 7 6 9 7 9. 5 Waiting time Clinic management 9 9 10 9. 5 10 10 Accurate clinical examination 7 9 9. 5 Good behavior among the personnel Community SC No Water in the clinic Electricity in clinic 10 10 10 5 3 10 6 10 10 Medicines 7 10 10 Clinic staff adequacy Waiting room seating 10 5 10 10 Staff Punctuality Staff behavior with patients Patient Counseling 10 10 10 Patients Waiting Time 10 10 10 The medical equipment requires replacement, very old Right now even the clinic guard is aware of preparing 0. 5 % chlorine solution. But incinerator is not available patient load is low, separate OPD for male and females We work as a team, interpersonal relationship is good, clinic is managed responsibly When patient volume is high, the examination time is not satisfactory especially for ANC, PNC and IMCI No problem, we work as a team Water pump is repaired and safe water is available for all Initially no electricity, the Provincial Rehabilitation Team (PRT) promised to install solar power and eventually did install it. Quality is good, but inadequate quantity. They prescribe ‘white tablets’ (Paracetamol) for all conditions. Now clinic has all medicines required for each patient for the condition Adequate staff and always present on the job Patients stand due to insufficient chairs. More chairs were provided. They are always present Good behavior of staff, all are satisfied with them When we receive treatment, they give good counseling on how to use the medicines, when to return comeback etc. We do not wait for long time we are satisfied

Siadara Action Plan Indicator Action Proposed Who? Timeline Implementation Research Observations Water supply Request sent to AADA by Shura following the monthly meeting with the facility staff. The clinic in charge coordinated it through the Yakawlang district governor, Bamyan PPHD and NGO Clinic in 3 m after the Multiple negotiation meetings and follow up. charge, AADA, shura Staff paid for water pump from salary and PPHD, Shura meeting eventually reimbursed IEC materials Clinic in charge requests staff to prepare a list of IEC materials and forward the request to NGO Clinic in charge address the issue with NGO and PPHD Clinic in charge, NGO 1 m Follow up requests for 2 m. but materials were not received. Condition of clinic Clinic in Building (damaged charge, NGO, roof) PPHD Clinic equipment Clinic in charge requests all departments for Clinic in and infrastructure equipment needs, and submits requests to charge, NGO (waiting room chair) NGO 1 -6 m The DHO and District Governor were also engaged in processing the request 3 m Discovered chairs in storage and transferred to waiting area. Though shura were not indicated in action plan there were involved in all decisions. Clinic hygiene Clinic in charge to train staff on infection prevention (IP), create a plan for the clinic, and follow up Clinic in charge and staff Ongoing URC NGO working on QA, set standards for IP, trained the staff and helped with action plan for different sections of the clinic. The staff followed up daily. The staff engaged in a self-audit, till they achieved 100% compliance, and were awaiting an external evaluation by URC Accuracy of exam , pt education and time spent with pt Pt triaging to avoid ‘noise’ , time spent with pt must be considered staff Ongoing According t BPHS, spend at least 9 min with pts The guard was involved in determining the reason for clinic visit and guides the pts to the specific area

Health Facility Teams and Communities jointly engage for PHC Improvement

PAHO Renewing PHC in the Americas

Designing Health System Performance Assessment Framework - Multiphase Strategy Phase • JHU: Selected Review of HSPA Models, June 2010 1 Phase • PAHO HSPA Experts Meeting , June 8 -9: 2010 2 Phase • JHU/PAHO TAG Review of Expert Recommendations, Prioritize HSPA domains and indicators, July 27 -29, 2010 3 Phase • JHU Design of PAHO HSPA Conceptual Model and BSC Tool 4 Phase • JHU and PAHO TAG Review and Development of HSPA Model and 51 Indicator score Card 5 Phase • PAHO Country Stakeholder Meeting - Cuba, December, 2010 6 Phase • JHU/PAHO TAG Review of Cuba Meeting Recommendations and Proposed Changes to BSC 7 Phase • JHU Redesign of Conceptual Model and 118 Indicator BSC 8 Phase 9 • JHU and PAHO TAG Meeting: Review of Revised HSPA and BSC Levels for Country Implementation, December 14, 2011 – 3 -Tier 110 Multi-indicator framework Phase • Country Consultation and Contextualization using Delphi tool and Pilot of PAHO BSC, April 2013

PAHO Multidimensional HSPA No Domain D 1 Participatory and intersectoral governance D 2 Financing towards universal coverage Description Defined as one in which all the relevant stakeholders take part in governance and decision-making processes and are ensured that their opinions and expectations were given due consideration even if they were not always included in the final decisions for healthcare delivery. Defined as ensuring access for all, to appropriate promotive, preventive, curative and rehabilitative services at an affordable cost. Thus, universal coverage incorporates two complementary dimensions in addition to financial risk protection: the extent of population coverage (e. g. who is covered) and the extent of health service coverage (e. g. what is covered). D 3 Adequate resources and capacity D 4 People-centered service delivery Defined as the specific capacity of a healthcare entity (or organization), measured in quantity and level of quality, over an extended period which is satisfactory or acceptable in quality or quantity D 5 Equitable, effective and efficient outputs D 6 Improved health and well-being (outcomes) D 7 Context and other determinants of health Refers to maximizing healthcare outputs (the products of healthcare) produced from a set of healthcare inputs, holding healthcare output quality constant (efficiency) in a manner that is equitable (fair) and effective (produces the expected result Defined as health care delivery that is respectful of, and responsive to, the preferences, needs and values of patients and consumers. The widely accepted dimensions are respect, emotional support, physical comfort, information and communication, continuity and transition, care coordination, involvement of family and careers, and access to care Defined as changes to the health status of the individual patient and target population that are brought about or produced by healthcare delivery Refers to the background, environment, framework, setting, or situation which influence health-related outcomes

PAHO HSP Progressive 110 Indicator Framework Level A- 30 -50 core performance indicators for each domain for countries in early stage of institution Level B- 50+ expanded, to include additional indicators, for countries with advanced information systems Level C- Comprehensive for progressive health systems to accommodate changes in technology and other healthcare environment factors

PAHO PHC Oriented BSC

Design QI Frameworks for Child Health Evidence of QI Strategies -A Selected Review & Compendium of QI Models 37 26 Evidence of short term small scale improvements, but failed to create learning organizations and empowered teams to sustain QI interventions for routine performance in the absence of external financing. Very few illustrate successful national integration of these models. ra to en ss m as se ity cil Fa F 3 PB ud it ) (B rd Ca re la n Ba 3 SC s am Sc o ce d t( en tm es nv yi cit pa 3 Te ad m rs de in em de rr ov i Pr 4 in or pr o m uc at io ed nt tie Pa 4 e) n ) ffi (s ta en t m st in ity pa c Ca 4 pt s 4 ng th al He ve ai ch ly Su pp 5 m tio n ta 5 m Fa cil i t em ag an 5 n s) o Jo b ai d( ov i en ba ck ed he c rc de rg Fe (s ) kl el ui d rv Pr Su pe ist in on isi ng ni ai Tr es 6 tiv 12 ist ra 22 Ca 23

Performance Metrics Lord Kelvin “You cannot manage what you cannot measure” Albert Einstein “Not everything that can be counted counts and not everything that counts can be counted”

Essential Public Health Functions David Bishai

Primary Care Assessment Tool – Leiyu Shi PCAT – Consumer/client PCAT – Facility Survey