Early stages of performance measurement

Indeed, numerous technical questions arise when analyzing and interpreting performance measures. Among the most important are: what has caused the observed performance and to what practitioners, organizations or agencies should variations in performance be attributed? In the best case, the present services could also contribute to the answers of these questions.

As noted by the previous WHO Director General Dr Gro Harlem Brundtland in her introductory message related to the issuance of the world health report: Health Systems: Improving Performance (June 2000);

Quote 1, “The way health systems are designed, managed and financed affects people’s lives and livelihoods. The difference between a well-performing health system and one that is failing can be measured in death, disability, impoverishment, humiliation and despair…”

The ongoing challenge, as already expressed in the document is still to gain a better understanding of the factors that make a difference between failure and success.

Quote 2, “If policy-makers are to act on measures of performance, they need a clear understanding of the key functions that health systems have to undertake. The report defines four key functions: providing services; generating the human and physical resources that make service delivery possible; raising and pooling the resources used to pay for health care; and, most critically, the function of stewardship – setting and enforcing the rules of the game and providing strategic direction for all the different actors involved.”

These building blocks were better described in the document “Systems thinking for health systems strengthening” issued in 2009 and, even further refined within a broader context, through the draft document under the title “ Handbook for supporting the development of Health System Guidance – Supporting Informed Judgments for Health System Policies. WHO Collaborating Centre for Health System Development issued in July 2011 in partnership with Swiss Centre for International Health.

With regard to GFATM specifically, Performance-Based Funding (PBF) is one of its core principles and that approach is integrated into every phase of the full life cycle of a grant. It provides a platform for the vast majority of grants to demonstrate that they can convert financing into results, enabling further funds to be committed to successful programs reaching people in urgent need, therefore, PBF is key to the GFATM’s credibility.

Saying that, the Final Report of the High-Level Independent Review Panel on Fiduciary Controls and Oversight Mechanisms of the GFATM issued in September 19, 2011 contains interesting judgments in relation to the strengths and weaknesses of the Global Fund today, and a set of practical recommendations for making real improvements.

Within the framework of the proposed services, it is worth highlighting Number 6 “Get Serious about Results” related recommendations:

Recommendation 6.1. Measure Outcomes, not Inputs. The Panel has found that the culture of the Global Fund has become one driven by the measurement of documentation, and not by health impact The Panel therefore recommends the several actions for the Global Fund to invest in high-quality data.

Even more interestingly, recommendation 6.2 Focus on Quality and Value, rather than Quantity. The organization should also shift the way it measures itself so as to focus on quality, not just outputs.

According to a new study led by the London School of Hygiene & Tropical Medicine even countries with a relatively low income can make big improvements to the health of their populations (particularly visible in the area of maternal and child health) by adopting a winning formula for strengthening health systems. The researchers identified a set of common characteristics associated with success that have allowed the five study countries to make sustained progress towards achieving the MDGs, sometimes in the face of political uncertainty. Key success factors include: leadership by individuals with a commitment to health gain; capacity within the individuals and institutions necessary to design and implement health reform; continuity to provide the stability that is required for reforms to succeed; the ability to seize windows of opportunity; and the ability to take context into account in order to develop appropriate and relevant policies. To date, these features are not fully taken into consideration by the aforementioned WHO evaluation framework.

Overall, health and programs systems are still in the relatively early stages of performance measurement, and major improvements are still needed in data collection, analytical methodologies, and policy development and implementation.

To maximize its effect, performance measurement needs to be aligned with other aspects of system design, such as financing, market structure, accountability arrangements, risk management and regulation. Finally, a great deal of attention needs to be paid to the political context within which any performance-measurement scheme is implemented. It is already clear that careful attention to these broader health system aspects will be taking into consideration through appropriate hyper parameters in the model.


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