Last updated August 9, 2018

Note: The DRAFT Version 1.1 rubrics are now out of date and no longer being fielded as part of the Vital Signs Profile completion process. The current version of the PHC Progression Model rubrics, published in 2019, can be found here.


This page contains the Draft Progression Model V1.1 assessment rubrics used in the 2018 Trailblazer Country Vital Signs Profile assessments. The rubrics are used for measuring inputs across nine subdomains of the PHCPI Conceptual Framework:

The figure below provides more details about the structure of the rubrics contained in this page, and you can read more about the methodology of the Draft PHC Progression Model v1.1 rubrics here.

Governance and Leadership

“Ensuring strategic policy frameworks exist and are combined with effective oversight, coalition-building, regulation, attention to system-design and accountability.”  (1) 


Measure 1: Primary health care policies (1/2)

Primary health care policies are decisions and plans that are undertaken by governments with input from other stakeholders to achieve specific health care goals. PHC policies promote, support, and establish system orientation, financing, inputs, and service delivery mechanisms to ensure quality and improve and develop PHC functions and outcomes. They can also help integrate the functions above in higher performing systems. 

         1.    Is there a National Strategic Plan in the country?
         2.    Is there a PHC policy in the country?
         3.    Is PHC policy embedded in the Strategic Plan?
         4.    Is PHC policy evidence based?
         5.    Is PHC policy formulated through a participatory process?
         6.    Is PHC policy embedded in a legal framework?
         7.    Does the PHC include the fundamentals?
                         a.    Benefit package defined
                         b.    Financing mechanism
                         c.    M&E framework
         8.    Is there a joint review of the progress towards the PHC policy objectives?


Measure 2: Primary health care policies (2/2) 

Policies are decisions and plans that are undertaken by governments with input from other stakeholders to achieve specific health care goals. PHC policies promote, support, or establish system orientation, financing, inputs, and service delivery mechanisms to ensure quality and improve and develop PHC function and outcomes. They also can help integrate the functions above in higher performing systems.

This measure is about distinct primary health care institutional structures within the government. For PHC policies to be implemented, there must be identified and accountable people within the relevant ministries or other governmental organizational entities to carry them out. This person or governmental entity should coordinate, monitor, integrate, and implement national PHC policy with defined authority, clear accountability, adequate budget, and sufficiently competent staff. The mandate of this authority should include the public sector as well as interactions with the private sector.


Measure 3: Quality management infrastructure 

Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (2).   High-quality health services involve the right care, at the right time, responding to the service users’ needs and preferences, while minimizing harm and resource waste. Quality is a complex and multifaceted concept that requires the design and simultaneous deployment of combinations of discrete interventions. The development, refinement and execution of a national quality policy and strategy is a growing priority as countries strive to systematically improve health system performance. Most approaches to national quality strategy development involve one or more of the following processes:

a.    A quality policy and implementation strategy as part of the formal health sector national plan;
b.    A quality policy document developed as a stand-alone national document, usually within a multi-stakeholder process, led or supported by the ministry of health;
c.    A national quality implementation strategy – with a detailed action agenda – which also includes a section on essential policy areas;
d.    Enabling legislation and regulatory statutes to support the policy and strategy.

Seven categories of interventions stand out and are routinely considered by health system stakeholders, including providers, managers and policy-makers, when trying to improve the quality of the health care system:

  1. Changing clinical practice at the front line;
  2. Setting standards;
  3. Engaging and empowering patients, families and communities;
  4. Information and education for health care workers, managers and policy-makers;
  5. Use of continuous quality improvement programs and methods;
  6. Establishing performance-based incentives (financial and non-financial);
  7. Legislation and regulation.
  8. Any one of the four processes (a-d) listed above


Measure 4: Social accountability (1/2)

Social accountability is a measure of whether a country is held accountable to existing and emerging social concerns and priorities based on need relevant to PHC of internal and external stakeholders (for example, community, employees, governmental and nongovernmental organizations, management, and owners). Social accountability can be promoted through close involvement and collaboration among citizen groups, marginalized populations, private sector, civil society organizations, non-governmental organizations, and other stakeholders in health care planning, policy formation, monitoring and evaluation. Systems for social accountability should provide evidence of how inputs from non-governmental sectors are translated into changes reflective of the concerns of external stakeholders. In its best form, social accountability should be a bi-directional process in which government seeks and prioritizes external input, while non-governmental actors also seeks to amplify or improve government-led PHC efforts.


Measure 5: Social accountability (2/2)

Social accountability is a measure of a country's state of being responsive to existing and emerging social concerns and priorities relevant to PHC of internal and external stakeholders (for example, community, employees, governmental and nongovernmental organizations, management, and owners). Social accountability can be promoted through close involvement and collaboration among citizen groups, marginalized populations, private sector, civil society organizations, non-governmental organizations, and other stakeholders in health care planning and governance. Systems for social accountability should provide evidence of how inputs from non-governmental sectors are translated into changes reflective of the concerns of external stakeholders. Social accountability for primary health care can also be demonstrated within government through integration across government entities whose work intersects and interacts with Primary Health Care. Examples of such groups include cross-parliamentary groups on health, or other groups who coordinate PHC-related topics across relevant ministries.

Note: Pending discussion and approval from PHCPI partners and international experts, future iterations of the Progression Model may assess multisector coordination through examination of national multisectoral plans, the establishment of effective multisectoral coordination mechanisms and cross-cluster action teams, and engagement with private sector industries and civil society.

 

Adjustment to Population Health Needs

Adjustment to Population Health Needs includes routine collection of information about population health status and needs, appropriate analysis and use of this information to set and implement priorities, and continual learning and adaptation based on emerging evidence and data.


Measure 6: Surveillance 

Surveillance includes tracking the status of local and national health and burden of disease metrics (morbidity, mortality, incidence), including the submission of reports from local to higher levels of the health system and the detection, reporting, and investigation of notifiable diseases and of suspected outbreaks or extraordinary occurrences.

*Pending discussion and approval from PHCPI partners and international experts, future iterations of this measure may include assessments of the emergency preparedness of primary care facilities as well as the presence of national surveillance mechanisms and national lists of notifiable diseases, and inclusion the of private sector providers in surveillance systems.


 

Measure 7: Priority Setting

Priority setting involves making decisions about how best to allocate limited resources to improve population health. Effective priority setting involves assessing existing and emerging health needs (see above A3.a: Surveillance), stakeholder engagement and social accountability, use of an explicit process, consideration of values and context, funding programs, communicating decisions, and managing feedback and demands from stakeholders at national and sub-national levels. Note: This section refers to priority setting at a national and sub-national level. Local priority setting is addressed separately under C1.

Note: Pending discussion and approval from PHCPI partners and international experts, future iterations of this measure may include assessments of whether data and evidence-based policy briefs are used for policy making and planning, whether the national health sector strategic plan is based on data driven situation analyses, whether policy and legislative proposals are based on data and evidence, whether there is a central unit in the Ministry of Health responsible for data/evidence to policy translation, the strength of relationships between the Ministry of Health and expert nongovernmental organizations, and the annual conduct of inclusive health sector progress reviews.


Measure 8: Innovation and Learning

Health innovation contains most of the elements of change in healthcare and involves a combination of technological and organizational renewal within an environment featuring a diversity of stakeholders. It covers a wide range of changes in the design of services, products and production processes (technology element); new or altered ways in organizing or administering activities (organization element); new or improved ways of interacting with other organizations and knowledge bases (system interaction element); and new worldviews, rationalities, missions and strategies (conceptual element). Innovation involves interrelated changes in technological, organizational and institutional elements of healthcare. (3)

Drugs and Supplies

This subdomain focuses on the performance of supply chains and the availability of essential medicines, vaccines, products, and technologies at primary care facilities. 


Measure 9: Stock-out of essential medicines and consumable commodities

Note: Pending discussion and approval from PHCPI partners and international experts, future iterations of this measure may include assessments of the availability of vaccines, products, and technologies

 


Measure 10: Basic equipment

 


Measure 11: Diagnostic supplies

 

Facility Infrastructure

This sub-domain captures the physical availability of public facilities, including numbers of facilities, facility infrastructure, the distribution of facilities, and the appropriate mix of facility types to meet population health needs. Note: Geographic access from the patient’s perspective is addressed in the Performance Domain of the Vital Signs Profile. 


Measure 12: Facility Density

 


Measure 13: Facility amenities

Note: Pending discussion and approval from PHCPI partners and international experts, future iterations of this measure may include more quantitative assessments of the inequity of amenity availability.

  

 


Measure 14: Standard Safety Precautions and Equipment

Note: Pending discussion and approval from PHCPI partners and international experts, future iterations of this measure may be revised to more closely align with the World Health Organization Infection Prevention and Control Assessment Framework at the Facility Level.

 

Information Systems

Essential information systems include civil registration and vital statistics and routine Health Management Information Systems. This sub-domain focuses on the availability, coordination, and interoperability of these systems and the requisite infrastructure needed for their operation. Note: Information system use at the facility level is captured under a different subdomain (C2: Facility Organization and Management). 

 


Measure 15: Civil Registration and Vital Statistics (CRVS)

All countries should have a well-functioning CRVS system that registers all births and deaths, issues birth and death certificates, and compiles and disseminates vital statistics, including cause-of-death information. It may also record other events such as marriage, divorce, adoption and legitimation. CRVS systems generate administrative data, which serve as the basis for databases, or population registers, across multiple sectors and can be compiled to produce vital statistics.

 


Measure 16: Health Management Information Systems (HMIS) 

HMIS are routine facility reporting systems used to monitor service data. “Service data are generated at the facility level and include key outputs from routine reporting on the services and care offered and the treatments administered.” 

 


Measure 17: Personal Care Records 

Focused personal care records should include problem lists; care history and notes; medication lists and allergies; referrals and results of referrals; laboratory, radiology and other test results. 

 

Workforce

This subdomain reflects the need to have a sufficient number, skill mix, and distribution of appropriately trained health personnel to meet population health needs and promote equitable access to quality care.

Note: Specifics around measuring and improving provider competency and motivation is addressed in C4 (Service Delivery: Availability of Effective PHC Services).


Measure 18: Workforce Density and Distribution

 


Measure 19: Training

 


Measure 20: Community Health Workers

This measure is about a cadre of health worker whose primary responsibility is to conduct proactive outreach in the community to meet local population health needs. This cadre may be referred to as a Community Health Worker but may have other designations depending on the country. This cadre should be (7):

1.    Trained and accredited to provide a comprehensive suite of preventative, promotive, and curative health services, tailored to the local population health needs
2.    Formally employed and remunerated appropriately, in accordance with the local health worker salary scale  
3.    Supported at frequent, regular intervals by a designated supervisor 
4.    Integrated into local health facility service delivery system or teams
5.    Integrated into local health data reporting and feedback systems

Note: this cadre of health workers will also be involved in providing the services described in Measure 27, Proactive Population Outreach.

Note: Pending discussion and approval from PHCPI partners and international experts, this measure may be modified in the future to ensure alignment with forthcoming guidance from the World Health Organization on community health workers.

 

Funds

This sub-domain includes the availability, control, and appropriate management of funds at the facility level to address recurrent and fixed costs incurred at the facility, including payment of staff salaries. 

Note: Payment schemes including PBF are covered under another domain of the PHCPI Conceptual Framework (Health Financing) that is not assessed through the Progression Model.

 


Measure 21: Facility budgets

Facility budgets should include:

  1. Line item funds and/or global budgets as relevant
  2. Billing/insurance tracked use expenses
  3. Internally generated funds from user fees or other fees collected at the point of care. 

 


Measure 22: Financial Management Information System 

Financial Management Information Systems may be in a number of different paper-based or digitized forms and should manage and track expenditure, staff, line item budgets, internally generated funds, and reimbursed pooled payments.  

 


Measure 23: Salary Payment

Population Health Management

Population health management is defined as “an approach [that] focuses on interrelated conditions and factors that influence the health of populations over the life course, identifies systematic variations in their patterns of occurrence, and applies the resulting knowledge to develop and implement policies and actions to improve the health and well-being of those populations.” (8) 


Measure 24:  Local priority setting

Local priority setting entails the translation of national or regional policies into local strategic action plans that respond to the burden of disease and needs and preferences of the population. Note: Priority setting at the national and sub-national levels is covered under Governance and Leadership, Measure 7 (Priority Setting).

Note: Pending discussion and approval from PHCPI partners and international experts, future iterations of this measure may examine local priority setting at different levels of the health system than the sub-regional level.


Measure 25: Community engagement

Community engagement is a process of developing relationships that enable stakeholders to work together to address health-related issues and promote well-being to achieve positive health impact and outcomes (9). The definition is guided by these caveats:

  • Stakeholders comprise multiple communities that could include community members, patients, health professionals, policy-makers and other sectors.
  • Desired relationships are characterized by respect, trust and a sense of purpose.
  • Health-related issues include public health events such as emergencies.

Note: Pending discussion and approval from PHCPI partners and international experts, future iterations of this measure may separately assess whether sub-national units are collecting and using data from users of the health system and data regarding health worker interactions with patients, families, and communities.


Measure 26: Empanelment

Empanelment (also referred to as population registration or rostering in some areas), a necessary aspect of primary care delivery, is an ongoing and deliberate set of actions to identify, match, and actively review and update data describing a group of people for whom a healthcare organization, care team, or provider is responsible. Additionally, both patients and providers are aware of their relationship. The listing is actively reviewed and regularly updated to ensure accurate. 


Measure 27: Proactive population outreach

Proactive population outreach involves health systems actively reaching out to communities, particularly those that are underserved or marginalized, to provide necessary services aligned with local priorities and burden of disease, and link those in need to primary health care. Examples of proactive population outreach interventions include mobile health units, transport systems, home based care, telemedicine and proactive follow-up with patients with chronic illness.

Note: Pending discussion and approval from PHCPI partners and international experts, future iterations of this measure may examine local priority setting at different levels of the health system than the sub-regional level.

 

Facility Organization and Management

This subdomain includes: the effective organization of facility operations; deployment of human resources in multidisciplinary teams; routine collection and use of information systems to establish targets, monitor progress, and implement ongoing quality improvement initiatives; and the capability of managers to oversee, support, and enforce these processes. 


Measure 28: Team-based care organization

Team-based care is a strategic redistribution of work among members of a practice team. In the model, all members of the team play an integral role in providing patient care and share responsibilities for better patient care (10). Care teams are characterized by:
1.    A team identity.
2.    Regular meetings.
3.    Clearly defined roles and responsibilities.
4.    Shared goals of providing quality patient care that individual teammates cannot achieve on their own.
5.    Mutual accountability structures. 
 

Note: Pending discussion and approval from PHCPI partners and international experts, future iterations of this measure may assess the proportion of health workers who work in teams rather than proportion of primary care facilities that employ team-based care.


Measure 29: Facility management capability and leadership

Facility management capability includes the technical training and skills of facility managers to effectively:
1.    Organize facility operations
2.    Motivate staff
3.    Manage budgets and deploy resources, and 
4.    React to new challenges.


Measure 30: Information system use

Data use includes the routine collection and reporting of public health and facility data and the use of the data for priority setting, clinical purposes, risk stratification,  and performance measurement and management (Measures 31 and 32), across all levels of PHC. Effective data use is dependent on sufficient staff capacity to capture, report, and review data using available information system infrastructure. At higher levels of performance, it can drive quality improvement.

Note: Pending discussion and approval from PHCPI partners and international experts, future iterations of this measure may assess the proportion of facilities that have an identified staff member responsible for information system use.


Measure 31: Performance measurement and management (1/2)

Performance measurement and management includes both supportive and continuous supervision of staff as well as the routine establishment of performance targets, monitoring of progress towards these targets, and implementation of quality improvement initiatives to address identified gaps.


Measure 32:  Performance measurement and management (2/2)

Performance measurement and management includes both supportive and continuous supervision of staff as well as the routine establishment of performance targets, monitoring of progress towards these targets, and implementation of quality improvement initiatives to address identified gaps. This measure is specifically about supportive supervision, a component of performance measurement and management. Supportive supervision is characterized by collaborative problem solving and open dialogue. Supervision routinely includes addressing performance, knowledge and skill gaps, and setting individual goals and reviewing progress towards their achievement (11). 

References

[1] World Health Organization. The World Health Report 2008. Primary Health Care: Now More Than Ever. 2008 DOI:10.12927/hcpol.2013.22778.

[2] World Health Organization, Organisation for Economic Co-operation and Development, The World Bank. Delivering quality health services: A global imperative for universal health coverage. Geneva, 2018.

[3] World Health Organization. Framework on integrated, people-centred health services. 2016; : 1–12.

[4] WHO | Service Availability and Readiness Assessment (SARA). WHO 2015.

[5] World Health Organization. INFECTION PREVENTION AND CONTROL ASSESSMENT FRAMEWORK AT THE FACILITY LEVEL. 2018.

[6] World Health Organization. Guidelines on Core Components of Infection Prevention and Control Programmes at the National and Acute Health Care Facility Level. 2016; : 1–91.

[7] Ballard M, Schwarz R, Johnson A, et al. Practitioner Expertise to Optimize Community Health Systems. 2017 DOI:10.13140/RG.2.2.35507.94247.

[8] Kindig D, Stoddart G. What is population health? Am J Public Health 2003; 93: 380–3.

[9] WHO. WHO Community engagement framework for quality, people-centred and resilient health services. Geneva, Switzerland, 2017.

[10] Christine Sinsky, Ellie Rajcevich. Engage the entire team in caring for patients | Implementing Team-Based Care | STEPS Forward. https://www.stepsforward.org/modules/team-based-care (accessed Aug 9, 2018).

[11] Expanded Programme on Immunization of the Department of Immunization Vaccines and Biologicals. Training for mid-level managers (MLM) Module 4: Supportive supervision. Geneva, Switzerland, 2008 DOI:10.3402/gha.v7.24085.