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Well-structured and dynamic processes for adjusting to population health needs strengthen the resilience and responsiveness of a health system.

They also underpin a country’s ability to develop a transparent, participatory, and evidence-informed national health strategy that meets the complex needs of its population.

Adjustment to population health needs includes regular collection and analysis of data and evidence about population health status and needs, appropriate use of this information to set and implement priorities, and continuous assessment and monitoring of changing population health needs and contexts. Adjustment to population health needs also involves the process of stimulating the development and making use of new and existing evidence, research, and data to continually learn and adapt to changing population health needs. It should take into account health determinants, trends and risks as well as a country’s epidemiological, political, socioeconomic, and organizational context with a focus on equity.

A few key  processes/mechanisms for adjusting to population health needs include:

  • Priority setting: the process of making decisions about how best to allocate limited resources to improve population health.
  • M&E: processes by which stakeholders collect, measure, and use data to assess and maximize the impact of projects, programs, or social initiatives over time. 
  • Innovation & learning: a characteristic of a health system that enables flexibility and iteration in order to continuously improve services and ultimately drive improved health outcomes.
  • Surveillance: a core public health function which involves the “continuous, systematic collection, analysis, and interpretation of health-related data”. 31
  • The National Health Strategy (NHS) sets the medium- to long-term vision for the health sector, including what activities and investments are needed to achieve health sector objectives in the most efficient way possible. It is the “blueprint” for policies, plans, and strategies in the health sector. 1 When done effectively, priority setting, M&E, surveillance, and innovation and learning processes help to ensure that the NHS is evidence-based and well-implemented across the health system. Below, we describe how each of these processes fits into the development, implementation, and evaluation of the NHS:

    Priority setting

    Priority setting directly feeds into the content of the NHS. It generally follows the situation analysis and precedes costing and budgeting exercises. A participatory, transparent, and evidence-based priority setting exercise is fundamental to designing and updating the NHS in line with population health needs. 2

    Monitoring & evaluation

    M&E is a critical component of the NHS. When done effectively, it helps to ensure that the NHS meets strategic goals and objectives. M&E mechanisms are typically specified during the strategic planning phase, whereby M&E activities across all major disease programs are linked to NHS milestones and targets. The M&E plan is typically prepared as a separate strategy document. The evidence from M&E processes can be used to inform future priority-setting and planning exercises. For example, the final evaluation of a national health strategy could serve as the initial situation analysis and evidence-base for subsequent priority-setting and planning exercises. (3,4)

    Surveillance

    Surveillance is a primary source of data for M&E and priority-setting efforts. It provides up-to-date information on population health needs. As such, surveillance data helps to ensure that the content of the NHS reflects current population health needs. 4

    Innovation & learning

    While not an essential component of / input for the NHS, mechanisms for innovation and learning can help key stakeholders to make better, more sustainable decisions in the long term. For example, countries that invest in increasing the learning capabilities of their health system (i.e. establishing local institutions for innovation &/or research) can accelerate the generation, adaptation, &/use of knowledge that is reflective of local priorities. This can help decision-makers to devise more impactful, relevant strategies. 5 6 7

PHCPI is a partnership dedicated to transforming the global state of primary health care, beginning with better measurement. While the content in this report represents the position of the partnership as a whole, it does not necessarily reflect the official policy or position of any individual partner organization.

Every country should improve their ability to adjust to population health needs. Before taking action, countries should first determine where to target improvement efforts. Read on to learn how to use country data to:

  • Make informed decisions about where to spend time and resources 
  • Track progress and communicate these updates to constituents or funders 
  • Gain new insights into long-standing trends or surprising gaps

Countries can measure their performance using the Vital Signs Profile (VSP). The VSP is a first-of-its-kind tool that helps stakeholders quickly diagnose the main strengths and weaknesses of primary health care in their country in a rigorous, standardized way. The second-generation Vital Signs Profile measures the essential elements of PHC across three main pillars: Capacity, Performance, and Impact. Adjustment to population health needs is measured in the Governance domain of the VSP (Capacity Pillar).

If a country does not have a VSP, it can begin to focus improvement efforts using the subsections below, which address:

Key indications

If your country does not have a VSP, the indications below may help you to start to identify whether adjustment to population health needs is a relevant area for improvement:

  • Poor data collection, analysis, use, & dissemination practices: If data are not consistently collected, analyzed, and used to set health priorities at the national and sub-national level for the burden of disease, user needs and preferences, service delivery evaluations, and cost-effectiveness, it may indicate that priority setting approaches and/or mechanisms for data collection, analysis, use, and dissemination needs reform. It may also indicate that existing M&E processes are fragmented or underutilized. 
  • Narrow &/or inconsistent stakeholder engagement: If diverse stakeholders are not systematically engaged and consulted during decision-making processes (i.e. no community representatives are presented during the priority setting exercise), it may indicate that strategic planning and decision-making processes require reform. 
  • Inefficient or ineffective allocation of resources: If the allocation of resources is not based on data and evidence (including evaluations/assessments of current and past national health strategies, the situation analysis, and the results of the priority setting exercise) it will likely compromise the cost-effectiveness and efficiency of reforms. 
  • Insufficient or non-existent mechanisms for innovation and learning: If mechanisms for innovation and learning are not in place (ie, the existence of national knowledge management or evidence review process), it can prevent new or emerging data, evidence, and/or technologies from being introduced. A weak culture around learning, innovation, and quality improvement can also stifle innovation and knowledge-sharing between stakeholders. 
  • Weak or delayed surveillance, response, and management measures: If critical surveillance, response, and management measures are poorly functioning or not in place (i.e. risks are not communicated to stakeholders in a timely manner and/or the local network of providers is ill-equipped to meet the needs of the population) it may indicate that priorities in your our health system are not reflective of population health needs and/or poor allocation of resources. It may also point to a breakdown in information sharing and use across levels of care. 
Key outcomes and impact

Countries that strengthen their ability to adjust to population health needs may achieve the following benefits or outcomes:

  • Efficient and effective allocation of resources for PHC: Evidence-informed priority setting and M&E exercises help decision-makers to get an accurate picture of population health needs. When they use these data to set priorities and improve on previous strategic planning exercises, it enables them to make the best use of resources over time. 1 8
  • Responsiveness: Health systems and the environments in which they operate are constantly in flux, due to contextual changes such as population composition and political economies. At the same time, the fields of medicine and public health are dynamic, with new information, guidelines, and best practices emerging frequently. The aforementioned mechanisms can strengthen a country’s ability to adapt to and learn from these external forces to ensure that the health system is evolving to effectively and equitably meet population health needs with high-quality care. 8 9 10 11 12
  • Resilience: In addition, routine and non-routine surveillance, M&E, and research activities strengthen a country’s ability to identify and respond to public health problems. For example, countries can use the data generated from surveillance activities to better prevent, prepare for, and respond to health emergencies. 8 13 14 15
  • Quality: Well-coordinated M&E and research activities enable countries to monitor the effectiveness of policies and programmes over time. In turn, they can use this data to improve the design and implementation of future programmes in line with country targets for PHC. For example, they can use the data generated from M&E and health research activities to get a better understanding of what is and is not working in the health system, as well as potential solutions to these problems. 8 13 14 15
  • Equity in health: Priority setting, M&E, and innovation and learning mechanisms that are built on transparent, participatory processes help to ensure that all stakeholders’ voices are heard, thus promoting equity in health. In addition, M&E activities help to hold decision-makers accountable to these interests, as well as PHC-related targets that promote their health and well-being, such as equity in the delivery of health services. 14 16 17

PHCPI is a partnership dedicated to transforming the global state of primary health care, beginning with better measurement. While the content in this report represents the position of the partnership as a whole, it does not necessarily reflect the official policy or position of any individual partner organization.

Explore this page for a curated list of actions to improve policy & leadership, which embark on:

  • An explanation of why the action is important for a country’s ability to adjust to population health needs
  • Descriptions of activities or interventions countries can implement to improve a country’s ability to adjust to population health needs
  • Descriptions of the key drivers in the health system that should be improved to maximise the success or impact of actions
  • Relevant tools & resources

Key actions:

PHCPI is a partnership dedicated to transforming the global state of primary health care, beginning with better measurement. While the content in this report represents the position of the partnership as a whole, it does not necessarily reflect the official policy or position of any individual partner organization.

Understanding and identifying the drivers of health systems performance--referred to here as “related elements”--is an integral part of improvement efforts. We define related elements as the factors in a health system that have the potential to impact, whether positive or negative, a country's ability to adjust to population health needs. Explore this section to learn about the different elements in a health system that should be improved or prioritized to maximize the success of actions described in the “take action” section. 

While there are many complex factors in a health system that can impact adjustment to population health needs, some of the major drivers are listed below:

Policies, leadership, & financing

Strong governance structures, such as PHC policies, leadership commitment, and dedicated budgets, help to establish and enforce participatory priority setting, M&E, and innovation and learning mechanisms necessary for adjustment to population health needs. Regulatory structures, such as internal audits or reviews also help to ensure that these mechanisms consistently generate high-quality, reliable information that is being used as intended. From a financing perspective, understanding the financial capacity for PHC funding and cost-effectiveness measures helps to inform priority setting including resource distribution.

Learn more in the policy & leadership and financing modules.

Multi-sectoral approach

Priority-setting, M&E, and innovation and learning are dynamic processes that rely on shared learning and input from stakeholders across all levels of the system. Encouraging broader social participation in the decision-making process (including community-based representation and a multisectoral approach) helps to strengthen accountability across sectors and forge collaborative partnerships for equitable and sustainable initiatives.

Learn more.
 

Information & technology

Priority setting and M&E rely on the use of diverse sources of data (including health and burden of disease information, service delivery evaluations, and cost-effectiveness assessments and surveillance data) as well as stakeholder input to prioritize the most appropriate programs and interventions to improve population health for all. Up-to-date health information also helps to guide innovation and learning efforts and is essential for monitoring, evaluating, and scaling innovations.

Learn more.

Management of services & population health

Several facility- and community- level mechanisms can help to reinforce national-level priority setting, M&E, and innovation and learning efforts:

  • Community engagement: Priority setting exercises at the national level should both inform and be informed by local priorities. Additionally, stakeholder engagement from the local level is an important tool for making innovations (and the evaluations of health strategies and innovations) responsive to existing and emerging social concerns and priorities relevant to the sub-national level.
  • Facility leadership and performance management: Effective management supports the adoption and adaptation of novel and ongoing quality improvement initiatives for innovation and learning activities at the facility level. Performance measurement and management also enable the monitoring and evaluation of innovations at the facility level. 
  • Systems for improving quality improvement: Quality management infrastructure, a component of organisation of services, creates and enables a systems environment for improvement, which is part and parcel of building a culture of innovation and learning. 

Learn more in the population health management and management of services modules. 

Person-centredness

Understanding health sector priorities and performance from the perspective of the patient are critical to designing national health strategies and innovations that meet patient needs and ultimately enable the design of person-centred health systems.

Learn more.

PHCPI is a partnership dedicated to transforming the global state of primary health care, beginning with better measurement. While the content in this report represents the position of the partnership as a whole, it does not necessarily reflect the official policy or position of any individual partner organization.

Countries seeking to improve their ability to adjust to population health needs can pursue a wide array of potential improvement pathways. The short case studies below highlight promising and innovative approaches that countries around the world have taken to improve. 

PHCPI-authored cases were developed via an examination of the existing literature. Some also feature key learnings from in-country experts. 

East Asia & the Pacific   
Europe & Central Asia
Latin America & the Caribbean
Middle East & North Africa
North America
South Asia
Sub-Saharan Africa
Multiple regions

PHCPI is a partnership dedicated to transforming the global state of primary health care, beginning with better measurement. While the content in this report represents the position of the partnership as a whole, it does not necessarily reflect the official policy or position of any individual partner organization.

Building consensus on what adjustment to population health needs is and key strategies to fix gaps is an important step in the improvement process.

Below, we define some of the core characteristics of adjustment to population health needs in greater detail, with the exception of public health surveillance, which is covered in the Information and Technology module. 

  • Priority setting is the process of making decisions about how best to allocate limited resources to improve population health. It involves the use of information collected from surveillance systems and other health information systems to set, implement, and adjust priorities over time. For this reason, a well-functioning health information system is also a critical input to the priority setting process. If data generated from these systems is incomplete or unreliable, it may lead decision-makers to make false conclusions about the extent of health problems and the effectiveness of strategies. 40 57 58 59

    Effective priority setting also involves the use of an evidence-informed deliberative process (EDP). EDPs provide a structured process by which diverse stakeholders identify explicit criteria for priority setting, interpret evidence, and deliberate on recommendations and decisions based on their opinions, needs, and interests. When rooted in a strong multisectoral approach (whereby diverse stakeholders are involved and held accountable to citizen interests), EDPs add both scientific and social credibility to the decision-making process. 40 57 58 59 60 61

    Priority setting may occur at all levels of the health system. However, the information here is specific to national and sub-national priority setting. More information on priority setting at the community level can be found in the population health management module. 

    Priorities are evidence-based

    Priority setting relies on the use of diverse sources of data (including health and burden of disease information, service delivery evaluations, and cost-effectiveness assessments) as well as stakeholder input to prioritize the most appropriate programs and interventions and inform resource allocation. 57 58 59 

    Priority setting exercises should therefore start with an in-depth situation analysis of the health sector to determine existing and emerging needs. 2 A situation analysis identifies the strengths and weaknesses of the health system and is a key initial step in the development of different elements of the national health plan, including the strategic directions and identification of priority diseases and interventions. 62 The situation analysis must generate a sufficient evidence base to ensure that stakeholders have access to quality and diverse information needed to make informed decisions consistent with the needs and values of the population. 58 While the situation analysis can happen at any level of the health system and on varying themes and scopes, such as health financing or workforce, 2 62 this module focuses on an overall health sector situation analysis for system-wide priority setting. 

    According to the World Health Organization, a well-facilitated situation analysis should be participatory and inclusive, analytical, relevant, comprehensive, and evidence-based and is separated into three distinct streams of analysis: 62

    • Health data - Analyses of health data from all levels of the health system - national, regional, and local - including trends and developments over time, provide information on both the health needs of the population and the current performance of the health system in meeting those needs. Analysts involved in examining health data should include technical experts trained to analyze and interpret data and non-technical experts familiar with health sector activities. Examples of data sources include population health surveys, HMIS, CRVS, facility assessments, patient-reported outcomes, and surveillance system reports.
    • Activity and budget - An analysis of the health sector budget and the implementation of health sector activities should assess whether the budgets allocated in the health sector and the policies, strategies, or plans adopted into the national health plan reflect the broader national health plan objectives, including whether activities are sufficiently funded and able to be implemented as per the planned activities and budget. Examples of data sources include Ministry of Health and Ministry of Finance routine financial reports, national health accounts, public expenditure data, performance reports, and facility assessments.
    • Effectiveness of national health plan activities - This analysis should assess the strengths and weaknesses of different elements in the health system, including programs, sub-policies, and strategies, focusing on whether those elements have achieved the expected results and what changes may need to occur in order to reach higher levels of effectiveness. While the first two streams of analysis rely heavily on technical expertise, this analysis is grounded in a participatory dialogue that considers both the opinions of experts as well as those using the health system on a daily basis - the service providers and the population themselves. 

    The situation analysis should be conducted by a core team of working groups comprised of relevant experts and stakeholders who have a sufficient understanding of the issue and are representative of all the categories of the population. 62 More information on establishing working groups, identifying the expertise required for situation analysis, and sequencing of work can be found in the WHO chapter on situation analysis of the health sector.

    Priorities are based on explicit criteria

    The national health planning process always includes priorities. These priorities may be explicitly set or ad hoc. Effective priority setting is explicit, meaning it involves a transparent discussion among diverse stakeholders who determine priorities based on a joint examination of the evidence and explicit criteria. Priority setting that is ad hoc does not encourage accountability and is prone to biases or special interests. The WHO recommends the following steps for an explicit priority setting process: 2 63

    1. Adopt a clear mandate for the priority setting exercise
    2. Define the scope of the priority setting exercise and who will play what role
    3. Establish a steering body and a process management group
    4. Decide on approach, methods, and tools
    5. Develop a work plan for priority setting and assure the availability of the necessary resources
    6. Develop an effective communication strategy
    7. Inform the public about priority setting and engage internal/external stakeholders
    8. Organize the data collection, analysis, and consultation/deliberation processes
    9. Identify or develop a scoring system
    10. Adopt a plan for monitoring and evaluating the priority-setting exercise
    11. Collate and analyze the scores
    12. Present the provisional results for discussion; adjust if necessary
    13. Distribute the priority list to stakeholders
    14. Assure the formal validation of recommendations of the priority setting outcome
    15. Plan and organize the follow-up of the priority setting, i.e. the decision-making steps
    16. Evaluate the priority setting exercise

    This process should result in a set of priorities, ranked by what is considered to be the most important based on the established criteria. Criteria are a set of measures that stakeholders use to weigh and determine which health problems, challenges, and solutions should be made a priority. These criteria should be defined before starting the priority setting process and be the basis for final priority setting decisions. In order to make high-quality PHC a priority, stakeholders need to define the principles that drive high-quality PHC (such as equity, efficiency, and sustainability) and set priorities for their health system based on these principles. 64

    These principles will inform how stakeholders evaluate criteria relative to each other when considering what is politically feasible, affordable, and technically possible. 57 65 The WHO suggests a non-comprehensive list of five criteria that can be used to set priorities in the health sector. These include:

    • The burden of disease: The burden of disease is a quantitative, time-based measure that combines years of life lost due to premature mortality and years of life lost due to time lived in states of sub-optimal health (i.e. injury, disease). 
    • The effectiveness of the intervention: This criterion evaluates how well the identified health issue can be addressed (clinically or practically) by the given intervention, including if the intervention is applicable and cost-effective for the local context. 
    • Cost of the intervention: This criterion considers the cost of an intervention in terms of affordability and efficiency. It is important to consider the absolute and relative costs to the health sector, target community, and individuals. The cost of an intervention must be both economically feasible and sustainable.
    • Acceptability of the intervention: This criterion refers to whether the target community or population accepts the chosen health intervention, taking into account the social and cultural norms as well as the willingness of providers or other health authorities to carry out the intervention (i.e. risk aversion, resistance to change, perceived value). This criterion strongly relates to the applicability and feasibility elements of the effectiveness criteria; both require contextual knowledge to evaluate the intervention.
    • Fairness: Fairness is a value judgment made collectively by governments and society based on the principles of equality and equity. The fairness criteria are essential to make well-informed judgements about tradeoffs on the importance of a health need and the effectiveness of an intervention. It also influences how much weight to give to the cost of a solution. For example, it might be important to prioritize the health problems of a specific at-risk or marginalized segment of the population, even if the intervention is not particularly cost-effective. An evaluation of fairness can help direct resources to marginalized populations, even when the intervention is not the most cost-effective solution.

    Often, stakeholders will have to make trade-offs between different criteria; for example, stakeholders may consider both equity and cost-effectiveness in the evaluation of a given health intervention and find that the intervention that is the most equitable might not be the most cost-effective. The weight given to different criteria is ultimately a political decision shaped by the country's context, including values, principles, and economic and political environment. 57

    While the above criteria are a strong starting point for priority-setting conversations, new criteria may need to be added or adapted based on contextual factors, such as the epidemiological and demographic profile of the country, the health system structure, and political and financial capital. 57 66 Accordingly, local needs and norms will influence the relative weight attached to these different criteria. The analyses of these criteria will depend on both the quality of the data and information available - including information on the implementation of interventions.

    Priorities are accountable to diverse stakeholder interests

    Effective priority setting addresses the differing interests and motivations of stakeholders through a clear process focused on the use of evidence, transparency, and participation to identify the most appropriate programs and interventions to address population health needs. 57

    Priority setting is a shared and multisectoral responsibility that relies on participatory and inclusive stakeholder engagement, including both people who will be affected by decision-making and people who can influence the implementation of the selected priorities during the priority-setting process. 57 67 Stakeholder engagement plays an important role in priority setting because it ensures that priorities reflect population needs and that the interventions and programs selected are acceptable, appropriate, and desired. 14 Stakeholder engagement should be systematic, meaning the processes for identifying, communicating with, and convening stakeholders are transparent and consistent, with engagements occurring at regular, predefined intervals as well as on an ad-hoc basis, as necessary. Opportunities should be made for citizens to play an active role in shaping the priority-setting agenda, including through citizen consultations and community leader involvement in decision-making processes. 

    The World Health Organization identifies three categories of stakeholders that should be involved in priority setting: 57 68

    • Government: The role of the government is to plan, initiate, coordinate, and oversee the priority-setting process within and across stakeholders and organizations. The way in which government stakeholders coordinate the priority setting process and who specifically will engage depends on the economic and political environment of the health system. For example, decentralized environments may need to collaborate more with local governments and providers whereas highly aid-dependent contexts may involve more collaboration with development partners. High-level actors may include policy-makers and planners in the Ministry of Health and other ministries as well as administrative and health authorities at decentralized levels.
    • Providers: Service delivery providers are important stakeholders because they can offer insights into the feasibility of prioritized service delivery decisions, including balancing patients’ needs and demands with cost-effectiveness. Provider-level actors may include health professionals in both the public and non-public sectors. 
    • Clients/citizens: To ensure stakeholders are accountable for their decisions, citizens should be involved in determining which priorities are set as a part of a democratic process. Citizens should be well-informed in advance about the advantages and disadvantages of various options. Citizen-level actors may include citizens themselves, community representatives, and/or groups of patients. Particular attention should be given to ensuring a diverse and representative group of citizen-level actors in this process. 

    Stakeholders must be willing to continue participating in the process and accept priority-setting decisions, even if they disagree with the outcomes. 59 Effective stakeholder engagement relies on robust institutional frameworks for multisectoral action and social accountability strategies. 57 More information on multi-sectoral engagement and social accountability can be found on the relevant tools and resources page for priority setting.

    Priorities are aligned with health sector policy, planning, & review processes

    While priority setting for PHC is an integral part of improving population health for all, it must be supported by strong governance, political, and financial commitment as well as regulation and implementation capacities to achieve priority setting goals. 64

    After the priority setting process, relevant stakeholders will need to translate priorities into the strategic and operational plans for the health sector, followed by costing and budgeting, implementation, and finally, monitoring and evaluation (covered in the Monitoring and Evaluation deep dive). 2 Multiple tools exist to assist with the planning and implementation of health interventions set as a part of the priority process, including Partners in Health’s UHC Monitoring and Planning tool. 69 70

    More information on resources allocation and planning can be found in the WHO’s chapters on estimating cost implications of a NHPSP, budgeting for health, monitoring, evaluation and review of NHPSP, and strategizing for health at sub-national level. 

  • Monitoring & evaluation (M&E) is a process by which stakeholders collect, measure, and use data to assess and maximize the impact of projects, programs, or social initiatives over time. It seeks to answer the question--is the project, program, &/or initiative going according to plan? If not, why? And what changes are needed to maximize impact? As opposed to surveillance, M&E is a more “passive” process, whereby the data collected on any disease or intervention is monitored on a weekly, monthly, quarterly, or even yearly basis depending on the project, program, or initiative. It involves two interrelated processes: 4 32 71 72 73

    • Monitoring, which is an ongoing process of collecting and analyzing data on specified indicators to track and measure how a change is happening. This data is used to plan, monitor, and improve projects, programs, &/or initiative activities. 
    • Evaluation, which is a process that builds on monitoring. It enables stakeholders to check whether a project, program, &/or initiative has met its objectives. It uses a systematic assessment to measure how successfully the change had the intended impact. An evaluation provides a more balanced interpretation of a project, program, or social initiative’s performance. It should produce evidence-based findings, recommendations, and/or lessons that are credible, reliable, and useful. This should inform future decisions regarding the project, program, or social initiative. 

    Below, we summarize the key attributes of a well-functioning system. For guidance on how to build one, see the following actions (take action section):

    • Use data to set priorities & tailor response efforts
    • Use M&E to track, measure, and improve priority actions and response efforts

    M&E is coordinated & harmonized

    Many countries already have mechanisms/systems for M&E in place, however, they are not necessarily coordinated across departments, programs, and sectors. Weak coordination of M&E processes (frameworks, indicators, and reporting systems) can lead to insufficient and/or poor quality data collection, analysis, use, and dissemination. This can subsequently limit the availability and use of reliable, accurate data for decision-making and performance improvement efforts. 3 74 75

    To better coordinate M&E processes countries should harmonize them under a single country-led platform. However, the transition to a single platform will be an ambitious goal for many countries. This will often be the case in countries that have many parallel government and development partner/donor M&E systems. It will also be a challenge in contexts that lack a central ministry or agency for M&E. Thus, improving coordination between M&E platforms will often be the first step. 19 20

    To learn more about the actions countries can take to improve the coordination of M&E processes, see the following action: use data to set priorities & tailor response efforts (institutionalize, coordinate, and harmonize HIS and M&E systems activity).

    M&E is aligned with the NHS

    A well-functioning M&E system can weather changes in administrative or governmental officials. This means that the M&E system is firmly institutionalized in core government processes, including budget cycles. A supportive institutional environment is characterized by:

    • Country-led mechanisms for M&E, such as a technical subcommittee for M&E within the MoH
    • Clearly defined roles and responsibilities for key institutions and stakeholders
    • Well-functioning data sources including civil registration and vital statistics systems, facility surveys, and logistics management systems, among others (key data sources are discussed in the information and technology module)
    • Capacity strengthening in the areas of data collection, management, analysis, use, and dissemination (also covered in the information and technology module)

    In addition, countries should include a detailed M&E plan in the NHS. Because the mid-and final-evaluation results of the NHS will likely inform future iterations of the NHS (i.e. the final evaluation results are used in the initial situation analysis for the next NHS), it is critical that the NHS and its M&E component are developed via a transparent, evidence-based, and participatory process. 3

    The M&E plan should outline the objectives of the NHS, what activities will be implemented to achieve these objectives, and what procedures will be used to evaluate whether or not these objectives have been met. It should also specify the resources required to evaluate and implement the plan. While an M&E plan should be developed at the beginning of health plan reform or design, it may need to be iterated on as country needs and priorities evolve. 17 32 76 77

    For additional guidance on planning for M&E, visit the following resources:

    M&E is built on a logical, evidence-based framework

    The M&E platform should be built on a comprehensive, logical framework. An M&E framework describes the indicators that will be used to measure the level of success of the NHS and related initiatives. This framework should address indicator selection, related data sources, and analysis and synthesis practices, including quality assurance, performance review, dissemination, and use. The M&E framework is clarified and operationalized through the country’s M&E plan (discussed above). 3 17 77 78 

    To achieve strong PHC systems, the framework should include a well-balanced and well-defined set of core indicators for PHC that can be tracked and measured at the national and sub-national levels. Countries are encouraged to use the WHO’s PHC monitoring framework and menu of indicators to develop an M&E framework and plan that is tailored to their local context. 17

    M&E includes mechanisms for review & action

    The M&E platform should also include mechanisms for regular data dissemination and communication. This implies the existence of a regular and transparent system for progress and performance reviews, by which diverse stakeholders assess the quality and independence of data against agreed-upon targets (i.e. via data auditing). This process should be equipped to cover the entire health system, including all major disease programs. Relevant quantitative and qualitative data would be synthesized and made publicly accessible through country health ‘observatories’ or intelligence portals to monitor country health progress and performance. Ideally, this data would also be incorporated into future decision-making processes in the health sector, including resource allocation and financial disbursement. 3 75

  • Innovation and learning (I&L) is a characteristic of a health system that enables flexibility and iteration in order to continuously improve services and ultimately drive improved health outcomes. 53 79 The goal of innovation and learning is to stimulate and make use of new and existing evidence, research, and data and to adapt and incorporate these learnings into changes at scale. 5 6 This requires routine incorporation of new evidence from research or data and routine reviews and discussions of progress and challenges so that lessons from past events are identified and can be used to predict and/or improve response to future threats or changing health needs. 79 While countries will develop their own ways of innovating and learning, it is measured by innovation capacity. 

    Innovation capacity refers to a country’s capabilities for adopting innovative solutions developed elsewhere and for creating innovations themselves and supporting these innovations from ideation to scale. Innovation capacity comprises two specific functions: knowledge creation and knowledge adaptation. 6 79

    • Knowledge creation is the process of generating new knowledge and technologies
    • Knowledge adaptation involves creating new value by accessing, anchoring, and spreading existing global and local knowledge 

    Developing innovation capacity at the national level relies on a commitment to innovation and learning as a priority investment through integration in national strategies, regulatory structures, dedicated budgets, and multisectoral stakeholder engagement. 6 55 80 The key components of strong in-country innovation capacity include:

    A system-wide culture of innovation and learning 

    The culture for innovation describes the specific values, behaviours, and processes that an organization or system takes to promote continual innovation. 54 81 The culture for innovation in an organization is a strong factor in determining whether a change (whether small, medium or large) can occur. It is closely linked with organizational readiness, or the organizational commitment to and efficacy in implementing innovations, and spread, which dictates the overall impact of an innovation. 50 82 Users can read more about creating a culture for innovation in healthcare here.

    Processes for recognizing, evaluating, and scaling innovations

    While the exact processes for innovation and learning will depend on the country's context, it is essential to ensure there is a systematic, structured, and reliable method in place for evaluating evidence and operationalizing these learnings into changes at scale. 6 This requires mechanisms to recognize and evaluate innovations as well as the operational capacity to scale identified interventions and programs:

    • Recognition: Mechanisms should enable key stakeholders to recognize where opportunities for innovation and learning exist. This includes the identification of information, practices, processes, structures, or other products that could serve as sources of inspiration for new ideas or tools. The relevance of different information or technologies depends on user needs, the policy and market environment, trends and future projections, and the strengths and competencies of an organization. 52
    • Evaluation: Evaluation mechanisms (i.e. M&E systems) should enable stakeholders to track and measure the progress and performance of innovations, including their relevance, feasibility, and utility for the local context. If the innovation was not developed locally, stakeholders should also review lessons from other contexts (i.e. barriers and facilitators to implementation). 
    • Scale: Scale refers to the process of spreading successful innovations within or among organizations to achieve a greater level of impact. 83 However, scale does not necessarily imply that the innovation should/will be implemented at all levels of the health system. The level of scale chosen will ultimately depend on what is most impactful/relevant to the local context. For example, innovators may decide between increasing surveillance functions of a particular disease using a novel technology nationwide or decide on district-by-district increases depending on what is most appropriate in their country's context. 

    Diverse stakeholder engagement and buy-in

    The broad involvement of stakeholders supports an overall culture for innovation, and clearly defined roles help ensure that mechanisms for recognizing success and subsequent scaling are not dependent on specific individuals or relationships between individuals, but formalized into a system. Taken together, broad stakeholder engagement paired with social accountability helps to ensure the benefits of innovations are realized and sustained throughout the broader system. 79 It is important that these decision-making processes are aligned with national strategic planning and budgetary cycles and take into consideration local norms, needs, and values in order to incorporate innovations in a sustainable and acceptable manner. 5

  • Surveillance is the “continuous, systematic collection, analysis, and interpretation of health-related data”. 31 Surveillance systems are dynamic and multimodal networks that combine monitoring and response activities to enable a country to identify and respond to emerging and existing threats and continuously assess and respond to communities’ needs over time. 11 84

    Surveillance is comprehensively addressed in the information and technology module. This module focuses its discussion on the use of surveillance data (and other information generated from health information systems) to support the aforementioned mechanisms/systems (priority-setting, M&E, and innovation and learning). 

    • Deliberative process: In the context of priority setting, a deliberative dialogue or process is a “process of collective and procedural discussion where an inclusive and representative set of stakeholders consider facts from multiple perspectives, converse with one another to think critically about options, and through reasoned argument refine and enlarge their perspectives, opinions and understandings.” 61
    • Explicit criteria: Criteria are a set of measures that stakeholders use to weigh and determine which health problems, challenges, and solutions should be made a priority. These criteria should be defined before starting the priority setting process and be the basis for final priority setting decisions. 
    • Innovation capacity: Innovation capacity refers to a country’s capabilities for adopting innovative solutions developed elsewhere and for creating innovations themselves, and supporting these innovations from ideation to scale. Innovation capacity comprises two specific functions: knowledge creation and knowledge adaptation.
    • Innovation & learning: a characteristic of a health system that enables flexibility and iteration in order to continuously improve services and ultimately drive improved health outcomes.
    • Health data: “In public health, “data” usually refers to statistics reported from health care facilities, survey data or data collected through observational studies. Distinctions can be made between routinely reported data and data that are collected at certain times or over a specific period of time as part of a special study or survey. Both routine and non-routine data, as well as data from research systems, are required and contribute to a  fuller picture of any given public health issue.” 15
    • Health research: “Health research has been broadly defined as the generation of new knowledge using the scientific method to identify and deal with health problems. It encompasses a wide variety of branches and methods of research, including: biomedical; clinical; public health; basic; applied; researcher driven; health system driven; quantitative; and qualitative.” 8
    • Information systems for health: “A health information system (HIS) is broadly defined as a system that integrates data collection, processing, reporting, and use of the information necessary for improving health service effectiveness and efficiency through better management at all levels of health services. It encompasses all health data sources including health facility and community data; electronic health records for patient care; population-based data; human resources information; financial information; supply chain information; and surveillance information, along with the use and communication of this information.” 85
    • M&E: processes by which stakeholders collect, measure, and use data to assess and maximize the impact of projects, programs, or social initiatives over time. 
    • M&E platform: “M&E platform” is used to describe various mechanisms used to support national and subnational monitoring, evaluation, and review efforts. The primary aim of the platform is to better align and reduce duplication of these efforts among key partners (i.e. governments, donors, and development organizations, among others). To simplify, we will use M&E system and M&E platform interchangeably in this module. 
    • Priority setting: the process of making decisions about how best to allocate limited resources to improve population health.
    • Surveillance: a core public health function which involves the “continuous, systematic collection, analysis, and interpretation of health-related data”. 

PHCPI is a partnership dedicated to transforming the global state of primary health care, beginning with better measurement. While the content in this report represents the position of the partnership as a whole, it does not necessarily reflect the official policy or position of any individual partner organization.

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