Since 2004, PEPFAR has supported four partners to rapidly scale up ART services through the! Trac" 1#0 ART progra$s# 1 These partners currently support 2% &'( care and treat$ent services in 1) countries. This literature revie / supports the effort to strengthen analytical approaches to provincial and district health syste$ capacities.
Since 2004, PEPFAR has supported four partners to rapidly scale up ART services through the! Trac" 1#0 ART progra$s# 1 These partners currently support 2% &'( care and treat$ent services in 1) countries. This literature revie / supports the effort to strengthen analytical approaches to provincial and district health syste$ capacities.
Since 2004, PEPFAR has supported four partners to rapidly scale up ART services through the! Trac" 1#0 ART progra$s# 1 These partners currently support 2% &'( care and treat$ent services in 1) countries. This literature revie / supports the effort to strengthen analytical approaches to provincial and district health syste$ capacities.
Assessing Provincial and District Health System Capacity
to Sustain HIV/AIDS Care and Treatment ServicesA Literature evie! "or CDC/P#P$A Ilona Varallyay, Jennifer Yourkavitch, and Eric Sarriot. ICF Macro- May 28, 2! Introduction Since 2004, PEPFAR has supported four partners to rapidly scale up ART services through the ! Trac" 1#0 ART progra$# 1 These partners currently support 2% &'( care and treat$ent progra$s in 1) countries 2 , including $ore than 1,000 ART treat$ent sites# They are creating transition plans to facilitate the transfer of progra$ $anage$ent to *inistries of &ealth +*,&- and local organi.ations, /hich can provide sustaina0le support for &'( care and treat$ent progra$s over the long1ter$# !uring the scale up phase, the focus of progra$ activity /as at the health facility level# The transition no/ needs a co$prehensive approach to ensuring the capacity of *,& and local partners at the district and provincial levels to sustain &'( care and treat$ent services# To this end, Trac" 1#0 partners for$ed a provincial2district su01group and deter$ined core do$ains ) of health syste$ capacity to $anage &'( progra$ services# PEPFAR2!2&RSA see" to develop a rapid assess$ent tool to $onitor provincial and district *,& capacity in each do$ain, /hich /ill 0e used to assess the status of transition efforts# This literature revie/ supports the effort to strengthen analytical approaches to provincial and district health syste$ capacities to support &'( services 0y providing a rationale for the core do$ains of assess$ent, and 0y identifying certain $ethodologies and conte3tual factors to consider /hen designing the assess$ent tool# The authors revie/ed $ore than 40 sources on health syste$s strengthening, specifically for &'( services and related areas, and discussed related issues /ith health syste$s e3perts +Anne3 )-# This docu$ent su$$ari.es their findings and reco$$endations, and includes an annotated 0i0liography +Anne3 1- and a detailed ta0le that descri0es the $ain tools revie/ed +Anne3 2-# This literature revie/ lays a solid foundation for developing a rapid assess$ent tool for provincial and district health syste$ capacity to sustain &'( care and treat$ent services# %ethodology o" the revie! 'F perfor$ed a syste$atic revie/ of pu0lished and unpu0lished +grey- literature on the assess$ent of health syste$s capacity at various levels and also specifically relating to &'( service delivery# Search Strategy 'F identified sources fro$ a syste$atic search of co$puteri.ed data0ases +*edline, Popline, !ialog 4includes 5lo0al &ealth, Federal Research in Progress +FE!R'P-, E*are, The 6ancet-, 1 The four partners are &arvard 7niversity School of Pu0lic &ealth, 'AP at olu$0ia 7niversity *ail$an School of Pu0lic &ealth, the Eli.a0eth 5laser Pediatric A'!S Foundation, and A'!SRelief consortiu$ led 0y atholic Relief Services# 2
Trac" 1#0 countries include8 9ots/ana, ote d:'voire, Ethiopia, 5uyana, &aiti, ;enya, *o.a$0i<ue, =igeria, R/anda, South Africa, Tan.ania, 7ganda, >a$0ia 3 ore do$ains include8 strategic planning for integrated &'( services? hu$an resource $anage$ent for clinical services? supervision of clinical services? health facility renovation2$aintenance2e<uip$ent? la0oratory services support? phar$acy supply2logistics2&*'S, *@E syste$s? <uality $anage$ent2i$prove$ent syste$s? co$$unity lin"ages? sta"eholder $anage$ent and coordination? and financial $anage$ent of donor funding for &'( services a search of the electronic archives of relevant international organi.ations using the 5oogle search engine +A0t, &ealth Syste$s 20220, *EAS7RE Evaluation, A&,, the Aorld 9an", F&', etc#-, and 0y studying the 0i0liographies and reference lists of identified sources# Searches used co$0inations of the follo/ing "ey/ords8 Peripheral health syste$ capacity B !istrict health tea$ capacity B Provincial level capacity &'(2A'!S care and treat$ent B &'( integrationB &'( B &'( infections B &'( trans$ission &ealth Services Perfor$ance B health planning *anage$ent capacity B Essential functions B Supervision of Assess$ent ofC B Revie/ ofC B Assess$ent tool B *ethodology B capacity assess$ent Te$poral li$its /ere set to include sources fro$ the past 20 years? language restrictions /ere set to include references in Spanish, French, and English# Article Selection !ocu$ents /ere eligi0le for inclusion in the literature revie/ if they addressed either health syste$s strengthening at the su01national level? if they focused on health syste$s assess$ent at a 0roader level 0ut had lo/er level applications? if they addressed ART progra$s specifically? if they addressed capacity assess$ent along one of the !2Trac" 1#0 partner1proposed Dore !o$ainE areas? or if they addressed issues of sustaina0ility of health services# For &'(1related resources, a te$poral li$it /as set to all docu$ents dated post12001, as this /as the appro3i$ate ti$e that international organi.ations started scaling up the introduction of AR(s in developing countries# ,verall, 4) docu$ents /ere identified, including 1F assess$ent tools, F of /hich /ere &'(1 focused# &ey In"ormant Intervie!s 'n addition to the literature revie/ed, /e conducted se$i1structured "ey infor$ant intervie/s /ith several international health e3perts, /ho$ /e felt could contri0ute to the discussions around the selection of do$ain areas for the develop$ent of this tool# The selection of these contacts /as 0ased on initial reco$$endations fro$ colleagues involved in health syste$s strengthening and facility assess$ent /or", and then spanned out as each contact $ade references to others in a relevant field# 'ndividuals fro$ A0t Associates 'nc, A'!STAR1T/o, *&'P, *S&, 7SA'!, A&, provided infor$ation included in this literature revie/# All contacts /ith infor$ants too" place 0et/een April 2% th and *ay 11 th , 2010 +See Anne3 ) for list of infor$ants-# District Capacity !ithin a Health Systems Perspective The $ost do$inant fra$e/or" for assessing the capacity and perfor$ance of the health syste$ as a /hole is the A&, Si3 9uilding 9loc"s *odel +A&,, 200F-# This $odel 0rea"s the health syste$ functions into % 0road categories +Figure 0elo/-8 1# Service delivery: pac"ages? delivery $odels? infrastructure? $anage$ent? safety @ <uality? de$and for care 2# Health workforce: national /or"force policies and invest$ent plans? advocacy? nor$s, standards and data )# Information: facility and population 0ased infor$ation @ surveillance syste$s? glo0al standards, tools 4# Medical products, vaccines & technologies: nor$s, standards, policies? relia0le procure$ent? e<uita0le access? <uality G# Financing: national health financing policies? tools and data on health e3penditures? costing %# Leadership and governance: health sector policies? har$oni.ation and align$ent? oversight and regulation *ost of the $ore recent health syste$s literature and tools adhere to this co$prehensive conceptuali.ation# Ae focused our revie/ on the operational definition and $easure of capacity at provincial and district levels and did not find reason to challenge the H0uilding 0loc"s: as an overarching $odel for loo"ing at capacity and perfor$ance in the health section# 't is useful at this point to state i$portant pre$ises of our revie/# Capacity is not Per"ormance ,rgani.ational apacity is the a0ility of an organi.ation to $eet its $andate and achieve its o0Iectives# 4 Perfor$ance is ho/ effectively the sa$e organi.ation i$ple$ents its activities and delivers its services# Those t/o concepts are o0viously related, 0ut they are distinct# Perfor$ance can 0e assessed 0y the delivery of a good or service to clients# This can 0e translated into a relatively s$all nu$0er of si$ple $etrics# apacity, on the other hand, is far $ore $ultidi$ensional, and its develop$ent does not fit linear patterns# These t/o characteristics have provided nu$erous challenges to the $easure$ent of capacity over the years# G 4 6aFond, A#, 6# 9ro/n, ;# *acintyre# Mea"urin# Ca$acity in the %ealth Sector& a Conce$tual Fra'e(ork. 'nt J &ealth Plann *g$t 2002? 1F8 )122# Pu0lished online in Ailey 'nterScience +///#interscience#/iley#co$- !,'8 10#10022hp$#%4K 5 '0id# The District has a uni'ue and pivotal role in the health system 9ro/n and 6aFond again revie/ed the state of the art in assessing and $easuring capacity in the health sector# 'n the figure 0elo/, their $odel helps visuali.e ho/ assessing each level has to 0e analy.ed /ithin an overall syste$# 7nder this $odel, the !istrict fits at the level of the ,rgani.ation# !epending on si.e and political ad$inistrative structures of each country, districts report directly to a central level or through a regional ad$inistrative level# Provinces so$eti$es play the role of districts, other ti$es act as regional or <uasi1central structures# Ahere health districts as operational units are essential ele$ents of a health syste$, % the role of the province should 0e clearly defined and $ay include $onitoring the perfor$ance of district health syste$s, training district1level staff, and conveying central health policies, a$ong others# F ur focus here is on structures ! district or province ! directly overseeing and organi"ing the work of service delivery units and health workers# Assessment challenges The first challenge lies /ith the understanding and $easure$ent of capacity# The reader is referred again to 9ro/n and 6aFond for a thorough treat$ent of the concepts and $easure$ent challenges# 'n su$$ary8 capacity supports perfor$ance, 0ut the relationship 0et/een the t/o is $ultidi$ensional, non1linear, and co$ple3# 6 ;loss1Luiroga, 9# +Ed#-# In)Ent& *i"trict %ealth Mana#e'ent +ool"& Facilitator," Manual. 9erlin, 2004 7 hatora, Rufaro and Prosper Tu$usii$e# %ealth Sector -efor' and *i"trict %ealth Sy"te'". *i"trict %ealth Mana#e'ent +ea' +rainin# Module", Module !. 9ra..aville, A&,, 2004# Then, the uni<ue position of districts creates so$e challenges in the evaluation of its perfor$ance 0ut also its capacity# For e3a$ple, assessing ho/ a district organi.es and i$ple$ents supervision, or secures drugs and co$$odities to service providers, is certainly 0etter assessed at health facility level than in the district health office itself# Ahile this tension $ostly affects $easures of perfor$ance, it $ay on occasion 0e relevant to the assess$ent of district:s capacity as /ell# Si$ilarly so$e ele$ents of district capacity are deter$ined 0y central level policy or resource allocation decisions# 'n other /ords, a district capacity assess$ent $ay identify hu$an resources /ea"nesses, 0ut these $ay 0e e3pression of inade<uate policies or interventions of a higher level# The ta"e1ho$e $essage is that a Hdistrict capacity assess$ent:, 0y /hich an assess$ent is conducted at district level e3clusively, $ust 0e understood /ith a proper appreciation for the 0oundaries and li$itations it carries +i#e# so$e capa0ilities of the districts are 0etter analy.ed upstrea$ or do/nstrea$-# evie! o" e(isting assessment models )ature o" assessment methodologies and type o" indicators The tools revie/ed included <ualitative and <uantitative assess$ent $ethodologies? a fe/ incorporated 0oth ele$ents# Approaches included self1assess$ents, facilitated self1assess$ents, and traditional survey $ethodologies, al0eit $ainly at facility level# Assess$ents varied in the level of applica0ility fro$ national to provincial to district to facility levels? for purposes of this search, /e focused on relevant district and provincial level resources# =ational level tools that could serve as a guide for the develop$ent of relevant su01national assess$ent criteria /ere also included# The $ost co$$on data collection $ethodologies involved using secondary data, docu$ent revie/, and sta"eholder intervie/s# So$e are rapid assess$ents? others are intended for longer1ter$ i$ple$entation +See Anne3 2-# 'ndicators included 0oth <ualitative and <uantitative ele$ents# The different tools capture si$ilar do$ain areas /ith distinct indicators, /hich /ill 0e assessed for relevance to the ! rapid assess$ent tool# *any /ill have to 0e $odified to fit the conte3t of district2province, according to the roles of the health syste$ at this level# M Domains o" assessment at provincial / district levels Sa$0o presents a type of fra$e/or", /hich loo"s specifically at the !istrict level, assesses the functionality of the syste$ according to 0roader categories, /hich in su$ capture all of the A&, 0uilding 0loc"s8 1- the e3istence of functional district level management structures +village2to/n health co$$ittee, health facility $anage$ent co$$ittee, !&*T, etc- 2- the managerial process +planning, colla0oration, guidelines, supervision2 $onitoring, drug $anage$ent, referral $echanis$s, &*'S- )- the health activities2interventions delivered 4- the community health initiatives G- the availa0ility of locally $anaged health1related resources +facility 0udget, cost recovery, hu$an resources, infrastructure, e<uip$ent, supplies-# K This fra$e/or" does not loo" at health syste$ perfor$ance# ,ne health syste$ assess$ent tool /hich adheres to the A&, fra$e/or" /as adapted for use at provincial level, adIusting the fra$e/or" for applica0ility at su01national level# 10 A close 8 '0id# 9 Sa$0o et al# +ool" .""e""in# the /$erationality of *i"trict %ealth Sy"te'"# 9ra..aville, A&,, 200)# 10 Thi *ai ,anh, et al# .""e""in# 0rovincial %ealth Sy"te'" in Vietna'& 1e""on" fro' +(o 0rovince"# *arch 200K# 9ethesda, *!8 &ealth Syste$s 20220 proIect, A0t Associates 'nc# analysis of the specific indicators used at provincial level should infor$ the develop$ent of the ! assess$ent# The governance core do$ain is captured through indicators such as8 1- Responsiveness of govern$ent to pu0lic needs, 2- (oice of the people )- E3ercising local technical oversight of health service <uality 4- Production of services needed 0y the pu0lic G- 'nfor$ation and reporting %- !irection, oversight and resource allocation tas"s carried 0y govern$ent# The health financing core do$ain is captured through indicators such as8 1- revenue collection 2- pooling and allocation of financial resources )- purchasing and provider pay$ents# Service delivery is assessed /ith indicators such as8 1- availa0ility 2- general access, coverage and utili.ation )- service outco$es 4- service delivery access and utili.ation G- organi.ation of service delivery %- <uality assurance of care F- co$$unity participation in service delivery# Human resources infor$ation such as &R planning, &R policies, perfor$ance $anage$ent, and training and education are assessed# The pharmaceutical management system do$ain captures ele$ents including relevant 0udget, policies2la/s2regulations, procure$ent, storage @ distri0ution, appropriate use, access to <uality products, and financing# The HIS co$ponent includes infor$ation on resources2policies2regulation, data collection and <uality, data analysis, and use of infor$ation for $anage$ent# Another assess$ent fra$e/or" intended for use at the district level captured the ele$ents of the A&, si3 0uilding 0loc"s through F $odules, /hich loo"ed in turn at 1- !istrict health $anage$ent and support syste$s 2- pri$ary health care facility infor$ation )- rural2district hospital infor$ation 4- co$$unity participation and traditional health syste$s G- co$$unity and household infor$ation %- patterns of $ortality# 11 Such an approach co$0ines household level, facility level, and district level data collection# o$ponents /hich /ill 0e of particular relevance to the develop$ent of the ! tool include those on district health $anage$ent and support syste$s and on co$$unity participation2traditional health syste$s# The A&, !istrict &ealth *anage$ent Tea$s Training *odules used in !R 12 have 0een developed to assist each tea$ $e$0er to /or" as a leader and $anager in leading health develop$ent in the district# The $ethodology is of particular relevance for the develop$ent of the assess$ent tool as it provides a useful fra$e/or" for translating the functions of the health syste$ at national level into e<uivalent roles at district level, according to four 0road health syste$ function do$ains8 stewardship, resource generation, service delivery and financing# 't defines a nu$0er of "ey roles at province or regional level, particularly relevant in a conte3t of decentrali.ation# HIV*Speci+c esources A nu$0er of tools focused on assessing &'( progra$s or service delivery specifically, though pri$arily at either national or facility level# The do$ains of assess$ent are nonetheless pertinent to the proposed ! assess$ent and can 0e adapted to suit district2provincial level applica0ility# ,ne tool 1) translated the % A&, 0uilding 0loc"s into ART1specific do$ains and indicators in the follo/ing /ay8 1- Site 6eadership and *odel +6eadership? *odel of &'( are? ART1Specific protocols- 2- Services and linical are +o$prehensive &'( care services other than ART? ART delivery? Physical Space? o$$unity 'nvolve$ent- 11
*aier et al# .""e""'ent of the di"trict health "y"te' 2 u"in# 3ualitative 'ethod"# 5T>2A&,2'T&N5 &eidel0erg# +1KK4-# 12
hatora, Rufaro and Prosper Tu$usii$e# %ealth Sector -efor' and *i"trict %ealth Sy"te'". *i"trict %ealth Mana#e'ent +ea' +rainin# Module", Module !. 9ra..aville, A&,, 2004# 13 &irschhorn, 6# et al# +ool to .""e"" Site 0ro#ra' -eadine"" for Initiatin# .ntiretroviral +hera$y or Ca$acity for E4i"tin# .-+ "ite"# 9oston, *A8 John Sno/, 'nc# 200)# )- &ealth 'nfor$ation *anage$ent, *onitoring, Evaluation, and Luality +&*'S? Luality *anage$ent ART Progra$ *@E - 4- &u$an Resource apacity +Staffing needs? training and s"ills develop$ent? *anage$ent, supervision and staff retention- G- 6a0 apacity +6a0 procedures capa0ility? Luality standards- %- !rug *anage$ent and Procure$ent +!rug *anage$ent and Phar$acy *anage$ent- Ahile this assess$ent is intended for facility2site level i$ple$entation, these do$ain areas and indicators can 0e $odified for use at su01national level# Another relevant tool, &'(2A'!S Progra$ Sustaina0ility Analysis Tool 4&APSAT, focused on assessing the sustaina0ility of &'(2A'!S progra$s +including (T, P*TT, ART, care and support services, and prevention- through a co$puter10ased forecasting $odel# 14 This tool calculates resource needs for an &'(2A'!S progra$ /ith a user defined set of service level goals# &APSAT also co$pares proIected resource needs +focusing pri$arily on hu$an resources and financial resources- to e3pected resource availa0ility and can 0e used to identify and report e3pected gaps and resource i$0alances that $ade lead to inefficient or poor <uality service delivery# 't captures the follo/ing do$ains8 1-de$ographic data 2- epide$iological data )- financial data +trends in donor funding for &'(2A'!S progra$s and services and outline current and potential funding possi0ilities 4- 6a0or data G- service volu$e data %- $edical data F- cost data# E3a$ples of specific indicators include8 <uantity of health /or"ers? average salaries of health /or"ers? ART drug regi$ens cost? nu$0er of patients on each ART regi$en? a$ount of donor funding and internal revenue for &'(2A'!S currently and e3pected? cost of la0oratory tests? etc# This tool is very co$prehensive and very in depth? only a very $odified and lighter version of such a sustaina0ility assess$ent co$ponent could 0e pertinent for the ! rapid assess$ent tool# ,f nota0le interest /ere $odels addressing the chronic nature of &'(2A'!S and the i$portance of $aintaining the client at the center of any assess$ent fra$e/or"# Ahile such $odels /ere pri$arily designed for developed1country conte3ts, /e identified such fra$e/or"s as highly applica0le for the developing country conte3t as /ell# ,ne $odel 1G loo"s at three core co$ponents /ith respect to care for chronic conditions8 positive policy environment, the community, and the health care organi"ation? of particular interest are the H0uilding 0loc"s: for health care organi.ation /hich include promoting continuity and coordination? encouraging $uality care through leadership and incentives? organi"ing and e$uipping health care teams? supporting self%management and prevention? using information systems# Ahile the focus of the ! assess$ent is at district2provincial level, this $odel highlights the i$portance of 0earing in $ind the ulti$ate needs of the patient2client, /hich is relevant for district level $onitoring and supervision# !ifferences 0et/een developing and developed country assess$ent approaches lie in the assu$ption that certain capa0ilities are in place Has a given Hand that the assess$ent can $ove to/ard those capacity areas /hich support higher standards of <uality care# Domain*speci+c esources A nu$0er of do$ain1specific tools /ere also revie/ed# ,ne tool focuses on assessing the logistics system for HI&'(I)S programs, using <uantitative indicators to assess product availa0ility and inventory $anage$ent practices# 16 Specific indicators address8 inventory control syste$s +'Ss-? logistics $anage$ent infor$ation syste$s 14 &ealth Syste$s 20220 proIect# 5"in# %.0S.+ for %IV 0ro#ra' Su"taina6ility .naly"i"& .n Introductory 7uide# April 2010# 9ethesda, *!8 A0t Associates 'nc# 15 A&,# 'nnovative are for hronic onditions8 9uilding 9loc"s for Action# A&,, 2002# +6*'Ss-? and storage, logistics reporting, and ordering and institutional support# Another tool focuses on hu$an resources $anage$ent for &'(2A'!S progra$s 17 # 't contains 2% &R* co$ponents +su01do$ains- /hich are grouped /ithin five 0road areas of &R*8 &R* capacity +staffing, 0udget, and planning-? personnel policy and practice? perfor$ance $anage$ent? training? &R* data# 'F also revie/ed several articles and grey literature docu$ents addressing issues around scale up of (*+ progra$s /hich highlight a nu$0er of "ey issues for consideration in the develop$ent of this ! rapid assess$ent# ,ne report descri0es an assess$ent /hich focused on t/o areas8 logistical re<uire$ents for ensuring a relia0le and consistent supply of <uality antiretroviral drugs +AR(s- and related co$$odities, and infrastructure and personnel re<uire$ents necessary to ensure their safe and effective use 0y patients# 18 't outlines "ey criteria to assess site readiness for ART initiation /hich can 0e adapted into indicators for ART delivery capacity at a higher level# This docu$ent also stresses the i$portance of a ro0ust supply chain to $anage co$$oditiesOa "ey area for assess$ent at district2provincial syste$ic levelOand outlines the "ey ele$ents for effective 6*'S# Another report on the scale up of ART in 7ganda highlights a nu$0er of indicators according to the A&, fra$e/or", and also includes a do$ain for Hco$$unications: and 'E, e3ploring issues /hich influence the degree of co$$unity level a/areness of &'( services8 infor$ation on the availa0ility of treat$ent, care, and support services at co$$unity level? infor$ation ca$paigns? co$$unication $aterials such as 0oo"lets on AR( therapy? guides for service providers on dispensing AR( drugs? details of all AR( drugsOdosage, phar$aco"inetics2 phar$acodyna$ics, side effects, drug interactions, etc# 1K This ele$ent could 0e incorporated into the ! o$$unity 6in"ages do$ain# Another article sites progra$ planning guidance for the i$ple$entation of e3panded ART services and includes valua0le infor$ation on coordination /ith other progra$s that could 0e useful in developing indicators for the DSta"eholder *anage$ent and oordinationE core do$ain# 20 Analysis o" CDC/Trac, -./ Partners Proposed Core Domains The proposed 11 Dore !o$ainsE proposed 0y ! Trac" 1#0 partners can all 0e lin"ed to one of the A&, health syste$s 0uilding 0loc"s and, in their entirety, capture all of the ele$ents of the A&, $odel +see ta0le 0elo/-# 7nli"e the A&, $odel, these include a do$ain for assess$ent of co$$unity1related co$ponents# ,), proposed ,ore )omains *elevant -H Health System .uilding .locks Strategic Planning for 'ntegrated &'( Services 6eadership25overnance &u$an Resource *anage$ent for linical Services &ealth Aor"force Supervision of linical Services &ealth Aor"force @ Service !elivery 16 =yen/a, Ja0ulani, et al# >i$0a0/e &'( @ A'!S 6ogistics Syste$ Assess$ent# Arlington, (a#8 John Sno/, 'nc#2!E6'(ER, for the 7#S# Agency for 'nternational !evelop$ent, 200G# 17 *S&, 200)# &u$an Resource *anage$ent Rapid Assess$ent Tool for &'(2A'!S Environ$ents# a$0ridge, *A8 *S&# 18 =oguera, *#, et al# 8i'6a6(e& .ntiretroviral +hera$y 0ro#ra' 2 I""ue" and /$$ortunitie" for Initiation and E4$an"ion. Arlington, (A8 !E6'(ER2John Sno/, 'nc#, 200)# 19
Ta/fi", P#, et al# Introducin# .ntiretroviral +hera$y 9.-+: on a 1ar#e Scale& %o$e and Caution. 0ro#ra' 0lannin# 7uidance ;a"ed on Early E4$erience fro' -e"ource-1i'ited and Middle-Inco'e Countrie"# Aashington !, 7SA8 Acade$y for Educational !evelop$ent 5lo0al &ealth, Population and =utrition 5roup# =ove$0er 2002# &ealth Facility Renovation2*aintenance2E<uip$ent Service !elivery 6a0oratory Services Support *edical Products2vaccines2technologies @ Service !elivery Phar$acy Supply26ogistics *edical Products2vaccines2technologies &*'S, *@E Syste$s &ealth 'nfor$ation syste$ Luality *anage$ent2'$prove$ent Syste$s Service !elivery @ &ealth infor$ation syste$s o$$unity 6in"ages n2a Sta"eholder *anage$ent and oordination 6eadership25overnance Financial *anage$ent of !onor Funding for &'( services &ealth Financing $irst Leads "or the Development o" the CDC apid Assessment Tool A couple of do$ain areas identified in the literature revie/ /hich are not e3plicitly captured in the !1proposed do$ains, and /hich deserve consideration are co$ponents pertaining to district2provincial health tea$ role in8 1- positive policy environ$ent, and 2- co$$unications# Aith respect to policy environ$ent it $ay 0e useful to assess the district:s capacity in8 1- strengthening partnerships? 2- supporting legislative fra$e/or"s? )- integrating policies? 4- providing leadership and advocacy? and G- developing and allocating hu$an resources ade<uately# These functions are fre<uently considered at higher up level, 0ut the case can 0e $ade for their needed develop$ent at district level in the conte3t of decentrali.ation, and the increasing re<uire$ent for pu0lic structures to ensure the via0ility of their traditionally assigned roles# Aith respect to co$$unications2'E it /ould 0e useful to assess the district:s capacity in organi.ing and providing infor$ation +for e3a$ple, interventions such as infor$ation ca$paigns- to the co$$unities a0out ART and other &'( services availa0le, 0e it directly, 0y outsourcing, or through partnership# 9ecause this tool is intended for use at district2province level, it should include 0oth general ele$ents that address the operationality of the 0roader health syste$ at inter$ediate level and also ele$ents /hich address &'(1specific capacity re<uire$ent for the delivery of ART services# !ra/ing fro$ the literature and fro$ "ey infor$ant intervie/s, the proposed assess$ent tool under develop$ent /ould 0e $ost relevant if it too" a syste$1/ide approach, incorporating other closely related health service areas such as *& and T9, at least as pertains to &'( service deliveryOparticularly as it is often difficult to clearly de$arcate 0et/een &'( and other services# 21 ,ne "ey infor$ant noted that the selection of proposed do$ains includes all of the core A&, 0uilding 0loc" ele$ents, 0ut has si$ply 0ro"en so$e do/n into $ultiple do$ain areas? this si$ply allo/s for a $ore in depth analysis of any given 0uilding 0loc" and essentially gives strong H/eight: to this 0uilding 0loc" in the assess$ent# Regarding the &u$an Resources do$ain, the literature and the feed0ac" fro$ "ey infor$ant intervie/s suggests that it /ill 0e critical to e3tend the analysis around this do$ain 0eyond Iust 21
=egussie? &odgins? Travis, Phyllida et al# DSu0national &ealth Syste$s Perfor$ance Assess$ent8 ,0Iectives, hallenges and Strategies#E hapter GK in %ealth "y"te'" $erfor'ance a""e""'ent & de6ate", 'ethod" and e'$irici"' 2 edited 0y hristopher J#6# *urray, !avid 9# Evans# A&, 200)# clinical services11 e<ually relevant is &R capacity at progra$ $anage$ent level +e#g# &R shortages do not only concern clinical staff, 0ut also $anage$ent staff-# Aith respect to governance issues, the proposed do$ains only capture t/o "ey ele$ents8 DStrategic Planning for integrated &'( servicesE and DSta"eholder $anage$ent and coordination#E ,ur revie/ suggests the i$portance of incorporating indicators on accounta0ility $echanis$s +0oth up/ard and do/n/ard? is there e3ternal accounta0ility at district levelQ-# An i$portant ele$ent to consider in relation to Dsupervision of clinical servicesE is the <uestion around /hether $anagers have the Dreal authorityE to re/ard or sanction staff 0ased on perfor$ance and at /hat level does this authority lieQ The do$ain on sta"eholder coordination should loo" at coordination across different sectors and also across different actors +private providers, =5,s, agencies, 9,s, etc-# ,verall, the proposed do$ains are co$prehensive and this literature revie/ has 0rought to light a nu$0er of issues for consideration /hile developing specific indicators under these do$ain areas relevant to district2province level application# Conclusion 9ased on this revie/ of literature and "ey infor$ant intervie/s, 'F reco$$ends "eeping !2Trac" 1#0 Partners: proposed do$ains in the rapid assess$ent approach, and adding an additional do$ain a0out service integration, /hich /ill 0e pri$arily concerned /ith the &'( care and treat$ent service integration /ithin the larger provincial or district portfolio, particularly as &'( care overlaps /ith ele$ents of *& and T9 care# ,ther ite$s that 'F /ill consider as it proceeds /ith the design of tool options include assess$ent areas and indicators related to8 o$$unity lin"ages, including health syste$ co$$unication /ith co$$unities and health service delivery at co$$unity level Take Home Message in View of Development of a Rapid Assessment Tool Capacity is a multidimensional concept with strong interdependency between its diferent dimensions. A given organizational performance (i.e. providing a skilled care provider, trained and equipped in a timely fashion to a client of counseling services requires the e!pression of diferent capabilities from a district" sound human resources management, from recruiting to training to supervising# appropriate resourcing of $nances, goods and commodities# sound planning and work organization, etc. %iven this comple!ity and co&linearities, each assessment tool will organize dimensions of assessment according to a dominant paradigm (continuity of services, oversight of health facilities and providers, management and oversight systems, etc.. 'hese di(culties also afect the assessment of capacity of health districts, as a linchpin organization within national health systems. 'he literature is rich in facility assessment tools, but ) as shown in this review ) far poorer in assessments conducted at district level (and even more so with an *+,-A+./ care and treatment focus. 'he C.C 'rack 0.1 partners have ofered a set of capacity areas which $ts the speci$c performance e!pected from *ealth .istricts in their implementation countries. 'hese $t easily under the standard 2*3 building block model for the *ealth /ystem, and no ma4or modi$cation is recommended for the development of a rapid assessment tool. 'he greater challenge will be to identify appropriate questions, indicators, and data collection processes to be implemented at the .istrict level, through a rapid methodology, and capturing the most pertinent capacity elements as tentative predictors of .istrict performance in *+,-A+./ prevention care and treatment. &R capacity in $anage$ent Accounta0ility $echanis$s &'(2A'!S as 0oth a chronic condition and infectious disease Patients: roles in decision1$a"ing regarding &'( care and treat$ent Policy environ$ent o$$unications 'F /ill also consider the content and depth of verification ele$ents, /hich /ill include infor$ation collected fro$ a health facility to verify infor$ation collected at the provincial or district level# Ahile there are several tools concerned /ith $easuring <uality of care at a health facility and others concerned /ith the perfor$ance of the health syste$, very fe/ assess the health district or province as an institutional and operational unit# !ocu$enting the develop$ent, testing and use of the ! rapid assess$ent /ill fill a gap in the literature and assist others concerned /ith the i$portant issues related to the $anage$ent transition and sustaina0ility of &'( care and treat$ent services# Anne(es Anne3 1 4 Annotated 9i0liography Anne3 2 4 Ta0le of &ealth Syste$ Assess$ent *odels Applica0le to !istrict2Provincial 6evel Anne3 ) 4 6ist of Persons 'ntervie/ed Anne( - (nnotated .i/liography -. Alva0 Soumya0 #. &leinau0 A. Pomeroy0 &. o!an. Measuring the Impact of Health Systems Strengthening A Review of the !iterature 1SAID0 )ov. 2//3. This is a co$prehensive &ealth Syste$s Strengthening literature revie/ /hich see"s to su$$ari.e current efforts in $easuring health syste$ perfor$ance and to highlight the indicators and perfor$ance 0ench$ar"s $ost fre<uently used 0y the glo0al co$$unity# ,f particular use for the develop$ent of the ! assess$ent tool is the list of "ey indicators 0y 0uilding 0loc" +A&, $odel-# 2. Cassels0 Andre! 4 &at5a 6anovs,y. Strengthening Health Management in Districts and "rovinces 7H80 9eneva0 -33:. This is a $anual that provides guidance for a facilitated self1assess$ent on su01national pro0le$ identification, analysis and action planning, /hich focuses on the follo/ing 0road areas8 Finance, Personnel, Staff Training, Statistics, Supplies, Transport, *aintenance, &ealth Education o$$unity 'nvolve$ent# 't is not directly relevant to the purposes of the proposed ! district2provincial level assess$ent# ;. Chatora0 u"aro and Prosper Tumusiime. Health Sector Reform and District Health Systems District Health Management Team Training Modules# Module $ <ra==aville0 7H80 2//>. This is one of a set of four $anage$ent training $odules ai$ed at !istrict &ealth *anage$ent Tea$s in the countries of the African Region# *odule 1 has 0een developed to assist each tea$ $e$0er to /or" as a leader and $anager in leading health develop$ent in the district# 't is of particular relevance for the develop$ent of the assess$ent tool as it provides a useful fra$e/or" for translating the functions of the health syste$ at national level into e<uivalent roles at district level, according to 4 0road health syste$ function do$ains8 ste/ardship, resource generation, service delivery and financing# 't also redefines a nu$0er of "ey roles at province or regional level, particularly relevant in a conte3t of decentrali.ation# >. $amily Health International ?$HI@A #thiopia. Addis ABaBa. City Administration Health <ureau. Addis A%a%a HIV care and support service assessment. Addis ABaBa0 #thiopia0 $HI0 2//2 Aug. A descriptive cross1sectional study /as conducted to assess e3isting care and support services# This assess$ent loo"ed at &'(2A'!S care and support services at the $anage$ent and coordination level and the service provision level, focusing on Dho/ people /or"ing at service $anage$ent and coordination level organi.e their /or", /hat guidelines they use, training they give to service providers, and the needs they identify to 0e a0le to function opti$ally#E +P#1-# At the service provider level, it loo"s at /hat they do and /hat they need to function /ell# onclusions of interest8 the assess$ent 0egan /ith a discussion a0out role distri0ution a$ong the partners, including various govern$ent levels and =5,s# Although fe/ progra$$ers2providers address stig$a, feed0ac" fro$ service providers indicated that stig$a reduction interventions should 0e given overall higher priority# :. 9TCD Assessment of the District Health System &sing 'ualitative Methods E-33>F +See *aier et al, 1KK4- G. Health %etrics )et!or,0 2//GB. Strengthening (ountry Health Information Systems) Assessment and Monitoring Tool 9enevaD 7H8. The &ealth *etrics =et/or" +&*=- 0egan in 200G to help countries and other partners i$prove glo0al health 0y strengthening health infor$ation syste$s# This tool ans/ers the need for an effective assess$ent of the e3isting national &'S in order to esta0lish a 0aseline and to $onitor progress# See .nne4 2 for detail". _________________________________________________________________________________________ H. Health Systems 2//2/D HIV*AIDS "rogram Sustaina%ility Analysis Tool +HA"SAT, ABt Associates Inc0 2//H. +See 0elo/ and .nne4 2 for details#- I. Health Systems 2//2/. &sing HA"SAT for HIV "rogram Sustaina%ility Analysis) An Introductory -uide April 2/-/. <ethesda0 %DD ABt Associates Inc. &APSAT is a *icrosoft E3cel10ased tool for forecasting and analy.ing the sustaina0ility of &'( progra$s at national +country- level# &APSAT calculates resource needs for an &'(2A'!S progra$ and also co$pares proIected resource needs to e3pected resource availa0ility# The resources re<uired to provide these services are 0ro"en into three categories8 financial resources +donor and govern$ent funding-, hu$an resources for service delivery +e#g# doctors, nurses, la0 technicians, phar$acists, ad$inistrative staff-, and physical capital +0uildings, vehicles, la0oratory $achines-# This tool is directly relevant to the financial $anage$ent do$ain? one of the proposed tool designs /ill incorporate ele$ents fro$ this tool# See .nne4 2 for detail". 3. Hirschhorn0 L.0 A. $ullem0 C. Sha!0 7. Prosser0 and %. )oguera. Tool to Assess Site "rogram Readiness for Initiating Antiretroviral Therapy or (apacity for ./isting ART sites <oston0 %AD 6ohn Sno!0 Inc.0 2//; This tool, /hich can 0e used either for site self1assess$ent or 0y e3ternal revie/ers, /as designed to provide sites and progra$s /ith a set of criteria to assess a siteRs readiness to i$ple$ent ART or the current capacity and needs of an e3isting progra$, and to identify "ey areas that need strengthening# The rating syste$ identifies sites along G progressive stages of readiness, /hich can 0e adapted for the ! tool# This tool is also particularly useful for its develop$ent of do$ain areas along the % A&, 0uilding 0loc"s for ART1specific progra$s# See .nne4 2 for detail". -/. Islam0 %.0 ed. 2//H. Health Systems Assessment Approach) A How0To Manual SuBmitted to the 1.S. Agency "or International Development in collaBoration !ith Health Systems 2//2/0 Partners "or Health e"ormplus0 Juality Assurance Pro5ect0 and ational Pharmaceutical %anagement Plus. Arlington0 VAD %anagement Sciences "or Health. +See Thi *ai ,ahn, 200K- SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS --. Israr0 S.%.0 A. Islam. -ood -overnance and Sta%ility) a case study from "akistan Int 6 Health Plann %gmt 2//GA 2-D ;-;K;2:. PuBlished online in 7iley InterScience E!!!.interscience.!iley.comF D8ID -/.-//2/hpm.I:2 This paper argues that good governance, characteri.ed 0y transparency, accounta0ility and $eaningful co$$unity participation, is an essential co$ponent of sustaina0ility for donor1 funded health syste$s proIects in the pu0lic health sector# 't descri0es the failure of an effort to decentrali.e Pa"istan:s health syste$, an effort /hich also encouraged co$$unity participation and de$ocratic decision $a"ing in a classically hierarchical $anage$ent structure# The authors introduce a Sustaina0le *anage$ent Approach Dthat can 0e used to ensure the sustaina0ility of health syste$s proIects, particularly those funded 0y international organi.ations in developing countriesE +p# )1)-# The approach consists of these para$eters8 participation and consensus orientation? 0uilding institutional capacity? strategic vision and appropriate leadership? effectiveness, efficiency and responsiveness? and accounta0ility, and includes a list of output and outco$e indicators# '$portant conclusion8 D,ften health sector refor$s fail to achieve their intended results $ainly due to a failure in addressing the co$ple3 dyna$ics of the e3isting syste$# Esta0lishing and sustaining an ena0ling environ$ent is i$perative for introducing and successfully i$ple$enting a large1scale proIectE +p# )24-# -2. &ielmann0 Arn"ried A. Assessing district health needs# services# and systems) protocols for rapid data collection and analysis A"rican %edical and esearch $oundation0 %acmillan #ducation Ltd. E)airoBi0 &enya0 -33-F. Revie/ed as part of Sa$0o, 6#5# et al# +ool" and Method" for %ealth Sy"te' .""e""'ent& Inventory and -evie(. 5eneva, A&,, 1KKM# -;. &loss*Juiroga0 <. E#d.F. In1.nt) District Health Management Tools) 2acilitator3s Manual <erlin0 2//> DSince the $id 1KM0s, the health district as an operational unit has 0eco$e the essential ele$ent of health policy concepts in lo/ inco$e countries +&arare conference in 1KMF-E +p#2-# This $anual is a training guide and reference for trainers, facilitators or presenters /ho have so$e e3perience /ith !istrict &ealth *anage$ent# The concept and principles of Pri$ary &ealth are for$ this approach to !istrict &ealth *anage$ent# 9esides technical "no/ledge, !istrict &ealth *anagers need leadership a0ility, co$$unications s"ills, process1oriented thin"ing and the capacity to co1operate in local and regional net/or"s# This e3periential, participatory training approach pro$otes practical "no/ledge and s"ills, gender2diversity1sensitivity, and the e3change of ideas and personal e3periences# See .nne4 2 for detail". ->. &olyada0 Lena %.Sc. Health Systems Strengthening and HIV*AIDS) Annotated 4i%liography and Resources Partners "or Health e"ormplus. $unded By 1.S. Agency "or International Development. ABt Associates Inc. %arch 2//>. Four resources /ere selected for revie/ fro$ this 9i0liography8 Ta/fi" @ ;inoti, 2002? &irschhorn et al 200)? =oguera )t al, 200)? and ,"era et al, 200)# -:. La$ond0 A.0 L. <ro!n0 &. %acintyre. Measuring (apacity in the Health Sector) a (onceptual 2ramework Int 6 Health Plann %gmt 2//2A -HD ;*22. PuBlished online in 7iley InterScience E!!!.interscience.!iley.comF D8ID -/.-//2/hpm.G>3 and La$ond0 A.0 L. <ro!n. A -uide to Monitoring and .valuation of (apacity04uilding Interventions in the Health Sector in Developing (ountries %#AS1# #valuation %anual Series0 )o. H. %arch 2//;. %#AS1# #valuation Pro5ect. 'n this pu0lication +availa0le under a peer1revie/ed for$at and a $ore detailed report 0y *EAS7RE Evaluation-, 6aFond and 9ro/n propose a conceptual fra$e/or" for understanding and $easuring capacity in the health sector# They revie/ type of indicators to 0e considered along the input1process1output1outco$e continuu$ 0y level of analysis, fro$ the &ealth Syste$ to the ,rgani.ation onto the individual &ealth Aor"er# The docu$ent revie/s assess$ent and $easure$ent approaches availa0le at the ti$e, 0ut is particularly pertinent for its conceptual argu$entation of the definition of capacity and identification of challenges and li$itations in its assess$ent and $easure$ent# Although the &ealth !istrict ,ffice can 0e approached as an ,rgani.ational Structure /ithin the &ealth Syste$, the revie/ does not provide enough focus on this specific level to infor$ the proposed ! district2provincial level assess$ent# -G. %aier0 <.0 . 9Lrgen0 A.A. &ielmann0 H.6. Dies"eld0 . &orte. Assessment of the district health system 5 using 6ualitative methods 9TC/7H8/ITHM9 HeidelBerg. E-33>F This $anual ai$s to help health Professionals arrive at a co$prehensive understanding of health needs, Services and Syste$s in a particular area through a process of rapid <ualitative data collection and analysis guided 0y a set of structured protocols# !ata is collected at district, facility and household level? infor$ation is o0tained 0y intervie/ing "no/ledgea0le infor$ants and 0y revie/ing locally availa0le docu$ents# ,f particular relevance for this proIect are the sections on 1- !istrict &ealth *anage$ent @ Support Syste$s and 2- o$$unity participation and traditional health syste$s# See .nne4 2 for detail". -H. %a,omBe SD0 %. Hochgesang0 A. 6ahn0 H. T!eya0 <. Hedt. Assessing the 6uality of data aggregated %y antiretroviral treatment clinics in Malawi <ulletin o" the 7orld Health 8rgani=ation. 2//I AprA IG E>FD ;-/*;->. This study assessed the <uality of <uarterly aggregate su$$ary data co$piled and reported 0y ART facilities +Dsite reportE- as co$pared to the Dgold standardE facility su$$ary data co$piled independently 0y the *inistry of &ealth supervision tea$ +Dsupervision reportE-# 't e3plores the various factors influencing data <uality and highlights supervision and hu$an resources for record "eeping +cler"s- as t/o actiona0le areas /hich positively affect data <uality# Also outlined in this article are several reco$$endations to ensure data <uality, /hich can 0e translated into relevant assess$ent indicators for the &*'S2*@E do$ain of the tool# -I. %inistry o" Health*CamBia. 7am%ia HIV * AIDS Service "rovision Assessment Survey 899:. Lusa,a0 CamBia0 %inistry o" Health0 2//G 6ul. The >&SPA survey $easures the capacity of health facilities to provide preventive services as /ell as to $eet the care and support needs of people living /ith &'(2A'!S and their fa$ilies through t/o data collection instru$ents8 the facility resources audit <uestionnaire and the health /or"er intervie/ <uestionnaire# The core &'(2A'!S health services co$ponents assessed include8 &'(2A'!S1related outpatient and inpatient care that includes general health syste$ $anage$ent? 'nfection prevention and co$pliance to standard precautions? &'(2A'!S testing and counseling? Antiretroviral therapy? Prevention of $other1to1child trans$ission services +P*TT-? &ealth $anage$ent infor$ation syste$s +record "eeping- relevant to &'(2A'!S? 6a0oratory diagnostics for &'(, tu0erculosis, $alaria and $ost co$$on ST's, and? Availa0ility and $anage$ent of essential $edications, supplies, and treat$ent services related to &'(2A'!S# The indicators herein /ill 0e useful for develop$ent of the verification piece of the assess$ent tool# See .nne4 2 for detail". -3. %SH0 2//;. Human Resource Management Rapid Assessment Tool for HIV*AIDS .nvironments CamBridge0 %AD %SH. httpD//erc.msh.org/ne!pages/english/tool,it/hrNhivNassessmentNtool. pd" This tool outlines a process to help an organi.ation to <uic"ly assess the perfor$ance of its hu$an resource $anage$ent syste$ and develop an action plan for $a"ing necessary i$prove$ents, /ith a focus on &'(2A'!S /or"place strategies# 't contains 2% &R* co$ponents +su01do$ains- /hich are grouped /ithin five 0road areas of &R*8 &R* capacity +staffing, 0udget, and planning-? personnel policy and practice? perfor$ance $anage$ent? training? &R* data# This tool can serve as a reference for the types of &R* issues that $ust 0e addressed at every organi.ational level in order to 0etter plan, staff and i$ple$ent &'(2A'!S progra$s# 2/. %anagement Sciences "or Health. Health Systems in Action) An eHand%ook for !eaders and Managers CamBridge0 %AD %anagement Sciences "or Health0 2/-/. AvailaBle online at httpD//!!!.msh.org/resource*center/health*systems*in*action.c"m and as a CD*8%. This hand0oo" is a co$prehensive, practical guide /hich includes a set of tools and resources that address co$$on issues in leading and $anaging health services? it is also availa0le in electronic version to facilitate access to e3ternal lin"ages# The hand0oo" is designed to address various "ey ele$ents of an effective health syste$, /hich include strong leadership and $anage$ent? good governance? /ell1crafted plans? professional hu$an resource $anage$ent? sound financial $anage$ent? good $anage$ent of $edicines and health products? $onitoring and evaluation focused on results? and the delivery of high1<uality health services# For purposes of the tool design, this hand0oo" /ill serve as a good reference $aterial for concepts and approaches regarding each of the % A&, 0uilding 0loc"s# 2-. )ash0 D et al. Strategies for More .;ective Monitoring and .valuation Systems in HIV "rogrammatic Scale0up in Resource0 limited settings) Implications for Health Systems Strengthening 6ournal o" Ac'uired Immune De+ciency Syndrome0 Vol. :20 Supp.-0 )ov.-0 2//3. This article discusses co$$on challenges to *@E syste$s used in the rapid scale1up of &'( services as /ell as innovations that $ay have relevance to syste$s used to $onitor, evaluate, and infor$ health syste$s strengthening# 't is particularly relevant for the &*'S2*@E do$ain of the assess$ent tool as it provides guiding principles for sustaina0le national *@E syste$s /hich can 0e adapted into indicators for su01national level application# 22. )oguera0 %.0 D. Alt0 L. Hirschhorn0 C. %aponga0 P. 8se!e0 and A. Sam* ABBenyi. 7im%a%we) Antiretroviral Therapy "rogram 5 Issues and <pportunities for Initiation and ./pansion Arlington0 VAD D#LIV#/6ohn Sno!0 Inc.0 2//; This report presents the findings of a four1/ee" assess$ent of the readiness and capacity of >i$0a0/e:s health sector to deliver the range of services and $anage the health co$$odities re<uired for effective antiretroviral +ART- treat$ent# The assess$ent loo"s at all the "ey functions of the logistics syste$ re<uired for the ART progra$, /hich /ill 0e relevant for the develop$ent of the phar$acy supply2logistics do$ain of the assess$ent tool 0eing developed for !# 2;. )ordBerg #0 H. 8ganga0 S. &a=iB!e0 6. 8nyango. Rapid assessment of an African district health system Test of a planning tool Int 6 Health Plann %anage. -33; 6ul*SepAIE;FD2-3*;; The authors report on a rapid health syste$ assess$ent conducted in rural ;enya in 1KK1# The assess$ent included a self1ad$inistered <uestionnaire for each health facility? intervie/s /ith officers in charge of each health institutions in the su01district, and a revie/ of records and reports at each facility# 5enerally, the focus /as on service provision and the R1&FA is considered to 0e a stronger tool for these purposes? ho/ever, /e $ay adapt an open1ended <uestion used in this tool for <ualitative infor$ation on the greatest challenges faced at the !istrict2province level# 2>. )yen!a0 6.0 D. Alt0 A. &arim0 T. &u"a0 6. %Boyane0 O. 8uedraogo0 and T. Simoyi. 7im%a%we HIV = AIDS !ogistics System Assessment Arlington0 Va.D 6ohn Sno!0 Inc./D#LIV#0 "or the 1.S. Agency "or International Development0 2//:. The 6'AT +6ogistics 'ndicator Assess$ent Tool- and 6SAT +6ogistics Syste$ Assess$ent Tool- tools assess the DhealthE of the logistics syste$ for &'(2A'!S related co$$odities and supplies# These are facility1level assess$ents that include "ey infor$ant intervie/s and o0servation /hich use <uantitative indicators to assess various aspects of logistic syste$s for &'(2A'!S progra$s# The ai$ of the assess$ent tools is to understand the challenges facing the logistics syste$s and to o0tain a description of the supply chain syste$ for several co$$odities# The ele$ents fro$ these tools /ill 0e adapted for use in the Phar$acy2logistics supply do$ain of the ! assess$ent tool# See .nne4 2 for detail". 2:. 8,era0 A.0 6. Seruto,e0 #. %adraa0 and #. )amagala. Scaling &p Antiretroviral Therapy &gandan ./perience Dra"t. 9eneva0 S!it=erlandD 7orld Health 8rgani=ation0 %ay 2//;. This docu$ent is a case study on the early years of AR( therapy scale1up in 7ganda +20021 200)-? it provides an overvie/ of the factors /hich influenced the success of this scale up and in the process highlights so$e of the critical ele$ents to AR( progra$s /hich could 0e relevant for inclusion in the ! assess$ent tool# 2G. 8roBaton )0 P. )saBagasani0 #. #,ochu0 6. 8,i0 S. &ironde0 T. Lippeveld. "romoting unity of purpose in district health service delivery in &ganda through partnerships# trust %uilding and evidence0%ased decision0making #duc Health EABingdonF. 2//H AugA2/E2FD:I. #puB 2//H Aug 2/. This pu0lication presents selected results of the 7P&,6! proIect in 7ganda, a TF% $illion 7SA'!1funded health and education sector proIect# 't does not present a district health assess$ent $ethodology, 0ut discusses i$portant concepts in district capacity# The proIect /as structured around t/o pillars of intervention8 trust 0uilding and evidence 0ased planning and decision1$a"ing# The for$er is central to the social capital literature 0ut possi0ly under1 appreciated in approaches to assessing district capacity# Also essential, are t/o ele$ents in the strategic approach8 Dunity of purposeE /ithin the district $anage$ent tea$ and a$ong district partners +unity and consistency of purpose are central concepts of <uality $anage$ent in the 0roader $anage$ent literature-? and the develop$ent of Dcore valuesE, such as tea$/or", e$po/er$ent, e3cellence, innovation, D0oundarylessnessE, and responsi0le speed of progra$ i$ple$entation# Partnership /as another central strategic ele$ent, translated into the districts supporting grants to S, partners# Finally, other ele$ents of capacity referred to in this pu0lication are $ore traditionally integrated in capacity assess$ent tools /ithin a health syste$? this includes use of <uality i$prove$ent processes, partnership /ith S,s, and institutionali.ation of "ey practices supported 0y the 7P&,6! proIect# 6i$itation8 this paper does not offer ho/ to operationali.e or $easure the district capa0ilities directly or indirectly related to these topics# This deserves consideration in vie/ of the develop$ent of the ! assess$ent tool# 2H. Population Council. Hori=onsA SHAA)D Society "or Service to 1rBan Poverty. The "!HA0friendly achievement checklist A self0 assessment tool for hospitals and other medical institutions caring for people living with HIV * AIDS +"!HA, )e! Delhi0 India0 Population Council0 Hori=ons0 2//;. The P6&A1friendly Achieve$ent hec"list is intended as a self1assess$ent tool for $anagers to use in gauging ho/ /ell their facility +hospital, clinic, or depart$ent- reaches, serves, and treats &'(1positive patients# This gives $anagers an opportunity to identify institutional strengths and /ea"nesses, consider /ays to address the /ea"nesses, and later to assess progress to/ard P6&A1friendliness# The tool co$ponents can serve as a $odel for the verification piece of the rapid assess$ent# See .nne4 2 for detail". 2I. Pro5ect Concern International0 I0STAR +Integrated System for Transformation# Assessment and Results, &ser -uide EPCI and #DC0 2//:F '1STAR is a co$prehensive approach to 0uilding effective and sustaina0le non1govern$ental organi.ations +=5,s- and net/or"s that are a0le to contri0ute to i$proving the health and develop$ent of the co$$unities they serve# The cornerstone of '1STAR is a capacity self assess$ent# The tool 0ears no direct relevance to the develop$ent of the ! rapid assess$ent tool# 23. SamBo0 L.9. et al. Tools and Methods for Health System Assessment) Inventory and Review 9eneva0 7H80 -33I. This docu$ent su$$ari.es 2% tools and $ethods that revie/ all or part of the health syste$# ,verall, $ost tools revie/ inputs, outputs, and outco$es of specific health services2progra$s rather than assess insitutional factors influencing i$ple$entation# For the $ost part, <uantitative indicators +for deter$ining service outputs and health status- are used# Tools included in this inventory that /ere revie/ed in the literature revie/ include *aier et al, 1KK4# ;/. SamBo et al0 Tools Assessing the <perationality of District Health Systems. <ra==aville0 7H80 2//;. Assess$ent of the operationality of a district health syste$ can 0e descri0ed as the revie/ of the organi.ation and $anage$ent of a health syste$ in ter$s of its structures, $anagerial processes, priority health activities, co$$unity participation and the availa0ility and $anage$ent of resources? it does not include the assess$ent of its perfor$ance# The tools presented here include a health facility and a district <uestionnaire /hich are ad$inistered through a self1 assess$ent $ethodology# The do$ains included in this fra$e/or" are relevant for the ! tool, particularly the do$ains on structures, $anagerial processes, co$$unity health initiatives and availa0ility of resources# See .nne4 2 for detail". ;-. Sarriot0 #ric. Issue "aper) Supervision of Health (are in Developing (ountries Juality Assurance Pro5ect0 1niversity esearch Corporation E-333F. This report presents supervision as 0oth a control and a service function of $anage$ent# 't presents several positive and negative supervisory 0ehaviors influencing provider perfor$ance? a facilitative supervision description? and a diagra$ on the $anage$ent culture of supervision +0alancing oncern for People vs# oncern for Tas"- /hich /ill 0e relevant for the develop$ent of indicators for the supervision do$ain# ;2. Sarriot0 #ric0 6. icca0 L. yan0 6. <asnet0 and S. Arscott*%ills. Measuring sustaina%ility as a programming tool for health sector investments>report from a pilot sustaina%ility assessment in ?ve @epalese health districts Int 6 Health Plann %gmt 2//3A 2>D ;2GK ;:/. PuBlished online in 7iley InterScience E!!!.interscience.!iley.comF D8ID -/.-//2/hpm.-/-2 'n this report, the authors develop a standardi.ed set of assess$ent tools to $easure G) indicators along si3 co$ponents of assess$ents $easured for the $ost part at district level according to % $ain co$ponents# ,f "ey interest /ere the co$ponents loo"ing at !istrict level structures: capacity and via0ility# The study also identified a range of central functions +e#g#, 0udgeting, planning, policy$a"ing, esta0lishing standards and protocols, hu$an resources allocation- outside the control of the districts and therefore not relevant for direct assess$ent at this level# ;;. Sarriot0 #ric0 Shamim 6ahan0 and SustainaBility #valuation Team. Sustaina%ility of the Saidpur and "ar%atipur &r%an Health Model +4angladesh, 2ive Aears After the .nd of (oncern3s (hild Survival "roBect $inal #valuation eport*6anuary -/0 2/-/. This report details the syste$atic assess$ent of all co$ponents of the oncern Aorld/ide1 adapted Hsustaina0ility fra$e/or": /hich allo/ed strategic reco$$endations to 0e $ade to $unicipalities and sta"eholders, in evaluating the sustaina0ility of health outco$es and revie/ing changes in the t/o $unicipalities studied# There /as li$ited direct relevance to the develop$ent of the ! rapid assess$ent tool, as *unicipal &ealth !epart$ents share only so$e of the responsi0ilities co$$on to a &ealth !istrict and do not oversee curative services# ;>. Shediac*i=,allah %C0 L <one. -33I. "lanning for the sustaina%ility of community0%ased health programs) conceptual frameworks and future directions for research# practice and policy Health #duc es -;E-FD IHK-/I. Shediac1Ri."allah offers a definition /hich synthesi.es a diversity of concepts and approaches a0out sustaina0ility, specifically in health pro$otion progra$s# For her, sustaina0ility refers to the general pheno$enon of continuation of a health1enhancing progra$, and she offers three $ain $echanis$s through /hich this can 0e o0served8 1- The $aintenance of health 0enefits achieved through the initial progra$? 2- The continuation of progra$ activities /ithin an organi.ational structure +institutionali.ation-? and )- The $aintenance of health 0enefits through 0uilding the capacity of the recipient co$$unity# This definition focuses on the ulti$ate 0enefit for the co$$unities, and recogni.es a /ide array of sta"eholders as responsi0le for the sustaina0ility of health progra$s# Factors in the proIect design +negotiation, effectiveness, duration, financing, type, training-, factors in the organi.ational setting +institutional strength, integration, leadership-, and factors in the co$$unity environ$ent +socioecono$ic1political environ$ent and participation-, interact to influence sustaina0ility, /hich is achieved through a continuation of the initial progra$, or its institutionali.ation /ithin a ne/ +local- organi.ational structure, or through the develop$ent of the capacity of the recipient co$$unity# The $ain relevance to the ! district2province assess$ent tool is the recognition of the interconnectedness of different sta"eholders# +This suggests that the a0ility of districts to partner, cooperation, provide guidance to other partners is a capacity area deserving e3a$ination#- 9eyond this, this paper does not offer enough institutional level focus to provide $easure$ent tools or resources# ;:. Stein 6.0 S. Le!in0 L. $airall0 P. %ayers0 . #nglish0 A. <hee,ie0 #. <ateman0 %. C!arenstein. 4uilding capacity for antiretroviral delivery in South Africa) a 6ualitative evaluation of the "A!SA "!&S nurse training programme <%C Health Serv es. 2//I )ov -IAID2>/. This article descri0es the evaluation of a training progra$ for P& nurses in the $anage$ent of adult lung diseases and &'(2A'!S, including ART# The authors used <ualitative $ethods and analy.ed data the$atically# ,utco$e of interest8 training all P& nurses in use of this guideline, as opposed to ART nurses only, /as perceived to 0etter facilitate the integration of A'!S care /ithin the clinics# ;G. Ta!+,0 O.0 S. &inoti0 and 9.C. <lain. Introducing Antiretroviral Therapy +ART, on a !arge Scale) Hope and (aution "rogram "lanning -uidance 4ased on .arly ./perience from Resource0!imited and Middle0Income (ountries 7ashington DC0 1SAD Academy "or #ducational Development 9loBal Health0 Population and )utrition 9roup0 )ovemBer 2//2. This paper provides progra$ planning and $anage$ent guidance to resource1li$ited countries that see" to i$ple$ent e3panded ART services# 'n addition, this paper includes guidance for esti$ating progra$ costs, hu$an resources and training re<uire$ents, and e3a$ples of co$$unication $essages specific to ART progra$s, /hich /ill 0e relevant for the develop$ent of the design of the rapid assess$ent tool# ;H. Thi %ai 8anh et al0 Assessing "rovincial Health Systems in Vietnam) !essons from Two "rovinces %arch 2//3. <ethesda0 %DD Health Systems 2//2/ pro5ect0 ABt Associates Inc. This report presents data fro$ the first t/o provincial health syste$ assess$ents conducted in (ietna$# The &SA tool /as developed to ena0le policy$a"ers and progra$ $anagers to underta"e a co$prehensive vie/ of si3 $aIor health syste$s functions delineated 0y A&, +governance, finance, hu$an resources, service delivery, phar$aceutical $anage$ent, and health infor$ation-# The tool allo/s users to assess each health syste$ function using a set of perfor$ance indicators# 't /ill 0e a "ey reference in the develop$ent of the rapid assess$ent tool# See .nne4 2 for detail". ;I. Travis0 Phyllida et al. QSuBnational Health Systems Per"ormance AssessmentD 8B5ectives0 Challenges and Strategies.R Chapter :3 in Health systems performance assessment ) de%ates# methods and empiricism / edited By Christopher 6.L. %urray0 David <. #vans. 7H8 2//;. This chapter of the pu0lication highlights "ey considerations regarding the purpose and challenges of health syste$s perfor$ance assess$ents, /hich /ill guide the design of the ! tool# ,f "ey interest are the discussions around the various types of infor$ation proposed for collection at su01national level? the application of the A&, health syste$s fra$e/or" at the local level? specific challenges for data collection and use at su01national level# ;3. 1SAID Child Survival and Health 9rants Program. R0H2A for core Maternal# @eonatal# and (hild Health +M@(H, services at the primary level E2//HF EDH8 %oduleF The Rapid &ealth Facility Assess$ent +R1&FA- /as developed in 200% 0y 'F *acro in colla0oration /ith *EAS7RE Evaluation and a panel of e3perts fro$ 7S P(,s, 7SA'!, and other cooperating agencies# Pilot testing has sho/n that it is suita0le for use 0y !istrict &ealth *anage$ent Tea$s +!&*Ts-, as /ell as =5,s# 't is a relatively rapid instru$ent for $easuring a s$all set of "ey indicators to give a U0alanced scorecardU for *=& services at the pri$ary health care level +including an optional $odule for use /ith &As for co$$unity outreach services-# 't identifies "ey 0ottlenec"s to <uality service delivery# !o$ains include structure and ad$inistration, planning , 0udget $anage$ent, and coordination# The tool co$0ines indicator scores for each do$ain /ith other indicators of capacity and perfor$ance collected fro$ health facilities, to create an overall score for !&*T# 'ndicators collected at health facility level for this purpose include8 guidelines, supervision, training, data for decision $a"ing, access or availa0ility of services and <uality1related issues li"e staffing, infrastructure, supplies, drugs, infection control, co$$unity2provider relations, &A technical perfor$ance, and client satisfaction# See .nne4 2 for detail". >/. 1SAID Center "or Development In"ormation and #valuation. M.AS&RI@- I@STIT&TI<@A! (A"A(ITA Recent "ractices In Monitoring and .valuation TIPS 2///0 )umBer -:. This grey pu0lication provides infor$ation on the $easure$ent of institutional capacity, including so$e tools that $easure the capacity of an entire organi.ation as /ell as others that loo" at individual co$ponents or functions of an organi.ation# The discussion concentrates on the internal capacities of individual organi.ations, rather than on the entire institutional conte3t in /hich organi.ations function# 't is fairly generic, possi0ly $ore appropriate to civil society organi.ation and provides no district1level focus# Anne3 presents lin"s to a nu$0er of tools and a full set of assess$ent <uestions fro$ the ,rgani.ational apacity Assess$ent Tool +,AT-# >-. 7H8. Innovative (are for (hronic (onditions) 4uilding 4locks for Action. 7H80 2//2. This docu$ent presents a fra$e/or" for chronic care, /hich e$phasi.es patient, fa$ily, and co$$unity involve$ent# 't proposes specific 0uilding 0loc"s for health care organi.ation /hich include pro$ote continuity and coordination? encourage <uality care through leadership and incentives? organi.e and e<uip health care tea$s? support self1$anage$ent and prevention? use infor$ation syste$s# This $odel has 0roader relevance to the rapid assess$ent and /ill 0e incorporated into one of the tool designs# See .nne4 2 for detail". >2. 7H8. .very%ody3s %usiness) strengthening health systems to improve health outcomes ) 1H<3s framework for action 7orld Health 8rgani=ation0 9eneva E2//HF. This docu$ent presents a conceptual fra$e/or" for health syste$s /hich highlights si3 "ey 0uilding 0loc"s in any health syste$8 Service delivery? &ealth /or"force? 'nfor$ation? *edical products, vaccines @ technologies? Financing? 6eadership and governance# This fra$e/or" /ill serve as a "ey source of co$parison for the proposed ! do$ain areas# See .nne4 2 for detail". >;. 7H8. "atient Monitoring -uidelines for HIV (are and Antiretroviral Therapy +ART, %#AS1# #valuation. 7H80 2//G. This docu$ent provides guidelines to aid in the develop$ent of an effective national &'( care and antiretroviral therapy +ART- patient $onitoring syste$# The focus of these guidelines is the list of essential $ini$u$ standard &'( care and ART patient $onitoring data ele$ents and ho/ their collection facilitates clinical care and $easure$ent of agreed upon indicators# The list is 0ro"en do/n into four categories8 de$ographic infor$ation? &'( care and fa$ily status? ART su$$ary? and patient level encounter infor$ation# This docu$ent provides good detailed infor$ation on the specific "inds of data re<uired for patient $onitoring, /hich should 0e aggregated and collected at district level and could 0e useful in developing assess$ent indicators for the &*'S2*@E do$ain# Anne( 2 +a/le of Health System (ssessment Models (pplica/le to )istrict'0rovincial Level +see E3cel spreadsheet- Anne( ; Individuals ,ontacted 1phone, interview or email2 from 3'45'4676 to 8'77'4676 )ame Title/8rgani=ation 9eti.a.u, Sisay Sirgu WHO 9oni, Tony Ofce of Health, Infectious Diseases, an !ut"ition# $%&ID !oherty, Julie &'t, Inc Ford, Sara %"( )echnical &*iso", +a,acit- .uilin/0&ID%)&1 )2o Eichler, Rena )echnical )ea3 4eae"#Health %-ste3s %t"en/thenin/, 5+HI6 E$ery, 9o0 Ofce of Health, Infectious Diseases, an !ut"ition# $%&ID &ei0y, Ji$ 5eical Ofce", 7lo'al Health .u"eau#$%&ID &odgins, Steve 7lo'al 4eae"shi, )ea3 4eae", 5+HI6 6ion, Ann 6"o8ect Di"ecto", Health %-ste3s 20920 :&'t, Inc; =egussie , Eyerusale$ ;e0ede WHO#HI< De,a"t3ent, I5&I )ea3 Sei$s, 6a Rue 5%H Taye, A$y %"( &nal-st, &'t, Inc