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Primary Health Care Management Advancement Programme
ASSESSING
INFORMATION NEEDS
MODULE 1
USER S GUIDE
ACA KHAN FOUNDATION
Primary Health Care Management Advancement Programme
ASSESSING
INFORMATION NEEDS
Jack Reynolds
University Research Corporation
MODULE 1
USER S GUIDE
Aga Khan Health Services
University Research Corporation
Center for Human Services
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ISBN : 1-882839-00-5
Library of Congress Catalog Number : 92-75449
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Dedicated to
Dr. Duane L. Smith (1939-1992) ,
Dr. William B. Steeler (1948-1992)
and all other health leaders, managers and workers
who follow their example
in the effort to bring quality health care to all in need.
A village health education session in Peru
Photo by Y. Pouliquen for WHO
The Primary Health Care Management
Advancement Programme
An overview
The main constraint reported by practically all countries is
inadequate information for the managerial process...to provide
systematic and analytical information for continuous assess
ment of the situation, determination of priorities, improvement
of management and evaluation. The information generated by
the traditional health system is, in most countries, quite insuf
ficient 1.
The main purpose of the Primary Health Care Management Advance
ment Programme (PHC MAP) is to help local PHC management teams
collect, process and analyse useful management information.
Initiated by the Aga Khan Foundation, PHC MAP is a collaborative
programme of the Aga Khan Health Network2 and PRICOR3.
An experienced design team and equally experienced PHC practitioner
teams have worked together to develop, test and refine management
advancement procedures. PHC projects in several countries have partici
pated, including those in Bangladesh, Chile, Colombia, the Dominican
Republic, Guatemala, Haiti, India, Indonesia, Kenya, Pakistan, Senegal,
Thailand, and Zaire. They have also taken an active role in pretesting the
PHC MAP materials to make sure that they are understandable, easy to
use and helpful to PHC managers.
Management information needs are changing in PHC. There has been
a gradual movement in recent years toward decentralising PHC manage
ment. Central governments have begun to shift responsibility for PHC to
local managers and communities. Managers are being given specific goals
and are being held accountable for achieving them. This movement is likely
to continue and will place new responsibilities on local PHC managers.
1
Evaluation of the Strategy for Health for All by the Year 2000, Geneva; World Health Organization, May
1987.
2
The network includes the Aga Khan Foundation, the Aga Khan Health Services and the Aga Khan
University, all of which are involved in the strengthening of primary health care,
3
Primary Health Care Operations Research, a worldwide project of the Center for Human Services
funded by the Agency for International Development.
Module 1: Information needs
ii
They will have to do more of their own planning, carry out more of their
own monitoring, and make more of their own management decisions.
To be successful they will need better, more timely, and more
useful management information.
Although a great deal of effort has gone into developing management
information systems (MIS) at central levels, much of this information is of
little use at the local level.
Generally, the problem isn’t a lack of information (there is an excess of
information), but a lack of useful information for local planning and
monitoring. In addition, many local managers do not have the tools or
training necessary to collect and process their own management data.
This problem exists in practically all PHC programmes. Appropriate,
accurate, and timely information is absolutely essential to good manage
ment. Managers need to know what must be done and to monitor what is
being accomplished. Without this information, a manager cannot provide
knowledgeable leadership, improve productivity, assess needs, or mobilise
resources.
PHC MAP includes nine units called modules. Each module is designed
to help managers collect, process, and interpret information for a different
management purpose. The nine modules are briefly described on the next
pageThere is a user’s guide for each module which defines basic terms,
provides guidelines for using the module, and explains how to adapt it to
fit local conditions.
The modules are not expected to be adopted exactly as written. Rather,
they are expected to be modified and have been prepared accordingly. For
example, the modules include sample data collection and data processing
instruments (checklists, questionnaires, templates, forms, etc.) that show
how to gather and process data manually. These tools can be photocopied,
revised, or rearranged, as needed. Most modules also include optional
computer programs and instructions. There is also a Hyperpad program
for each module. These programs graphically describe each module and
take users step-by-step through the module’s procedures. Computers are
helpful, but not necessary to use the modules. PHC MAP modules can be
applied manually, without using a computer at all.
Module 1: Information needs
1. Assessing information needs.
This module helps managers to identify information needs, set priorities, and
determine which PHC MAP modules are likely to be of most use to them.
a
3
2. Assessing community health needs and coverage.
This module provides PHC managers with simple tools to gather required data on
community health needs for planning programme strategies and resource use. The
managers can use the same instruments later to assess programme effects on health
knowledge, behaviour, and coverage, as well as programme impact on morbidity
and mortality.
3. Planning and assessing health worker activities.
A module that supervisors and other managers can use to help field workers and
clinic staff plan their work better. It shows how to identify individuals in need of
services, set realistic targets, assess individual performance, and take corrective
action, if warranted.
4. Surveillance of morbidity and mortality.
The module describes the basic indicators of morbidity and mortality to be included
in a PHC surveillance system. It discusses how to set up a surveillance system, how
to monitor the occurrence of diseases, how to identify causes of mortality and
morbidity, and how to use that information to improve programme planning and
implementation.
5. Monitoring and evaluating progammes.
Lists of indicators and guidelines that managers can use to monitor PHC and
management activities for short periods. Managers can also use them to construct
a project-specific "mini-MIS."
6. Assessing the quality of service.
Simple, but comprehensive, discussion guides and checklists of essential service
resources and processes. Supervisors can use these to assess the quality of care
provided and to set priorities for improving service delivery.
7. Assessing the quality of management.
Discussion guides and checklists for assessing PHC management services (planning,
training, supervision, etc.).
8. Cost analysis.
This module can help PHC managers to set up simple systems to monitor costs
themselves. They can also make projections about future revenues and expenses.
9. Sustainability analysis.
Guidelines and tools that managers can use to develop and analyse alternative
strategies for sustaining health improvement, service coverage, and the PHC
services and resources needed to do so.
Module L Information needs
iv
These modules focus on information that is essential in the traditional
management cycle of planning-doing-evaluating. The relationship be
tween the modules and this cycle is illustrated below. Module 1 helps to
identify information needs within the entire cycle. Module 2 produces
information for needs assessments and evaluation. Module 3 is used in
planning. Modules 4 and 5 are used in monitoring and evaluation. Modules
6 and 7 focus on monitoring. Module 8 is useful in evaluation. Module 9
is used in both needs assessments and planning.
PHC MAP modules and
the planning - evaluation cycle
MODULES
1. Information needs
2. Community needs
3. Work planning
4. Surveillance
5. Monitoring indicators
6. Service quality
7. Management quality
8. Cost analysis
9. Sustainability
It is important to note that the modules focus on selective information
needs. They complement information that most managers already have or
routinely produce, such as annual plans, routine financial reports, and
formal evaluations.
Module 1: Information needs
V
The entire series can be installed to strengthen overall planning and
monitoring. But each module can also be used independently to deal with
particular information needs as they arise.
Several managers guides supplement these modules. These are briefly
described below.
PHC MAP manager’s guides
Better management: 100 tips.
Short, handy hints recommended by leading managers and management
experts for becoming a better manager. Topics include running meetings,
planning, and getting the most out of your staff.
Problem-solving.
Helpful hints from PHC managers describing how they have solved such
common problems as: how to help illiterate health workers and how to be
sure there are enough supplies. It also includes guidelines and tools for
problem-solving.
Computers.
An up-to-date guide on selecting computers, printers, and related
equipment. It includes suggestions for selecting software and making sure
it all works.
The computerised PRICOR thesaurus.
The thesaurus is a listing of key steps in the provision of each PHC
service (immunization, antenatal care, etc.). It includes suggested questions,
indicators, and data sources for monitoring the key steps in each process.
This 400-page computerised version of the thesaurus includes menus and
an index for easy access to each section.
Who are these materials for ?
The primary audience for PHC MAP is the local PHC manager. Both
new and experienced managers can benefit from using the modules. The
modules can be used in an ongoing programme or in setting up a new
service or programme. Others who may wish to use PHC MAP modules
are NGO managers, management teams, communities, outside consultants,
and researchers.
Each module also has a facilitator’s guide to assist trainers, teachers,
consultants, and others to help managers learn how to adapt and use the
materials in their own programmes. A number of training centres are
Module 1: Information needs
vi
expected to incorporate PHC MAP materials into their curricula and
workshops.
Health and management services
MANAGEMENT
SERVICES
HEALTH SERVICES
GENERAL
OTHER HEALTH CARE
PHC household visits
Health education
Water supply, hygiene and
sanitation
School health
Childhood disabilities
Accidents and injuries
Sexually transmitted diseases
HIV/AIDS
Malaria
Tuberculosis
Treatment of minor ailments
Chronic, non-communicable
diseases
MATERNAL CARE
Antenatal care
Safe delivery
Postnatal care
Family planning
CHILD CARE
Breast feeding
Growth monitoring
Nutrition education
Immunization
Acute respiratory infection
Diarrhoeal disease control
Oral rehydration therapy
Planning
Personnel management
Training
Supervision
Financial management
Logistics management
Information management
Community organisation
The modules contain guidelines and tools for collecting information on
each of the principal PHC and management support services. For example,
Module 2, Assessing community health needs and coverage, includes a
sample questionnaire for each PHC service. Module 6, Assessingthequality
of service, contains discussion guidelines and checklists for assessing the
quality of those services. Module 9, Sustainability analysis, includes lists
of factors that affect sustainability, and "What-if analysis" tables to enable
you to examine the effects of various strategies on sustainability.
How should I begin?
Glance through the materials to get an idea of what they contain. Then,
you should begin with Module 1: Assessing information needs. This module
will help you get a picture of how the modules and other materials fit
together. It will help you to choose the modules that are most appropriate
for your situation.
Module 1 can be done at your desk or in a small group session.
Experience in field tests has shown that it helps to involve your manage
ment team and community representatives in the MAP process.
Module 1: Information needs
vii
Someone who has a background in MIS, programme evaluation, or
applied research can act as a facilitator and lead a workshop on MAP and
Module 1. The Facilitators guide explains what to do. Allow 4-6 hours for
the introduction to PHC MAP and completion of Module 1, depending on
the size of the group. There is also a computer program on Hyperpad that
you can use. This program will guide you through the steps in Module 1.
When you have completed Module 1 you should have a pretty good
understanding of PHC MAR You will also know your priority management
information needs, which modules will be most useful to you, and what you
need to do next.
How to use the computer programs
There are several computer diskettes that come with this series. The
labels describe what each diskette includes. There is a "README" file on
each diskette that provides instructions for using the files on that diskette.
The User’s guides also describe how to use most of these programs.
The Hyperpad files need to be installed on your computer before they
can be used. Open the README file for the installation instructions. The
PRICOR thesaurus also has a README file that describes how to use the
thesaurus.
You can view the README file on your computer screen or print it out.
To view it, insert the diskette in one of your drives (say A), and then type
type A:readme | more, and press <Enter>. Press the <pause> key to
stop and start scrolling the file. To print a copy, insert the diskette and type
print A:readme, and press <Enter>.
Module 1: Information needs
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The Primary Health Care Management Advancement
Programme has been funded by the Aga Khan Foundation
Canada, the Commission of the European Communities, the
Aga Khan Foundation U.S.A., the Aga Khan Foundations
head office in Geneva, the Rockefeller Foundation, the
Canadian International Development Agency, Alberta Aid,
and the United States Agency for International Develop
ment under two matching grants to AKF USA. The first of
these grants was "Strengthening the Management, Monitor
ing and Evaluation of PHC Programs in Selected Countries
of Asia and Africa" (cooperative agreement no. OTR-0158A-00-8161-00, 1988-1991); and the second was "Strength
ening the Effectiveness, Management and Sustainability of
PHC/Mother and Child Survival Programs in Asia and
Africa" (cooperative agreement no. PCD-0158-A-00-110200, 1991-1994). The development of Modules 6 and 7 was
partially funded through in-kind contributions from the
Primary Health Care Operations Research project (PRICOR)
of the Center for Human Services under its cooperative
agreement with USAID (DSPE-6920-A-00-1048-00).
This support is gratefully acknowledged. The views and
opinions expressed in the PHC MAP materials are those of
the authors and do not necessarily reflect those of the
donors.
All PHC MAP material (written and computer files) is in
the public domain and may be freely copied and distributed
to others.
3
Contents
s
INTRODUCTION ....................................................................................... 1
THE PHC MAP framework..................................................................... 3
Systems framework ................................................................................ .4
Relationship between framework and modules..................................... 9
Defining your health system - setting boundaries ............................. 11
LEVEL 1: QUICK START.......................................................................... 13
•-3
LEVEL 2 : DESCRIBING YOUR PHC'SYSTEM AND
IDENTIFYING KEY INDICATORS .......................................................... 17
Step 1: List the project’s principal health and management
services .................................................................................................... 17
Step 2 : Define the principal inputs, processes and outcomes
of these service ........................................................................................18
Step 3 : Identify your information needs ............................................ 19
Step 4 : Summarise your information priorities ............................... 22
LEVEL 3 : DETAILED QUESTIONS ...................................................... 23
PHC programme goals, target groups, services and coverage
• Question 1. Do you have enough information about the health
status of your target groups? ................................................................. 24
• Question 2. Do you have enough information about the coverage
of each PHC service? ............................................................................. 27
Work planning, surveillance, monitoring, quality assessment
• Question 3. Do you have enough information about your target
groups to plan PHC activities? .............................................................. 31
• Question 4. Is there adequate information about changes in
morbidity and mortality? ....................................................................... 33
• Question 5. Do you have adequate indicators to monitor your
PHC services? ....................................................................................... 34
Module 1: Information needs
• Question 6. Do you know enough about the quality of your
health services? ....................................................................................... 36
PHC management, costs and sustainability
• Question 7. Do you have adequate indicators to monitor your
management services? ............................................................................ 39
• Question 8. Do you know enough about the effectiveness of your
management services? ............................................................................ .41
• Question 9. Do you have enough information about the cost of
your programme and its services? ....................................................... 43
• Question 10. Do you have adequate information to determine how
to sustain the PHC programme in the future? ....................................45
APPENDIX A : Setting priorities among information needs .............. 49
B : Worksheets ......................................................................50
ACRONYMS AND ABBREVIATIONS...................................................... 52
GLOSSARY.................................................................................................53
Module 1: Information needs
Acknowledgements
The first draft of this module was reviewed and field tested in 1991 by a number of
PHC specialists and field managers. The module was also reviewed and critiqued
by the PHC MAP Technical Advisory Committee at a meeting in Bangkok in
September, 1991. The module was completely restructured and tested again.
Feedback from those tests led to two more revisions. The module was reviewed
again by participants at the International Conference on Management and Sus
tainability of PHC Programmes, held in Bangkok in May, 1992. Minor changes
resulted in this final version. Special thanks are due to Paul Richardson, who
participated in several field tests and summarised the field test results, and Mary
Millar, who developed the Facilitator’s Guide for the module, which was very helpful
in preparing this revised draft. All of these contributions were invaluable and greatly
appreciated.
Reviewers:
Donald Belcher • Veterans Administration, Seattle, WA, USA
Gilbert M. Bernham • Johns Hopkins School of Public Health, Baltimore, MD, USA
Bobby Zachariah • Price Waterhouse Associates, Kingston, Jamaica
David H. Peters • Johns Hopkins School of Public Health, Baltimore, MD, USA
Al Henn • AMREF, Nairobi, Kenya
Pierre Claquin and Ronald Wilson • Aga Khan Foundation, Geneva
Asif Aslam, Melvyn Lobo Inam-ul-Haq, Khatidja Husein • Aga Khan University,
Karachi, Pakistan.
Field tests:
Countries
Bangladesh
Pakistan
Thailand
Dominican Republic
India
Indonesia
Participating organisations, field test facilitators
Aga Khan Community Health Project; Social Marketing
Programme; The Asia Foundation; Facilitator: Barkat-eKhuda, URC/Bangladesh, Dhaka, Bangladesh
Aga Khan University, Facilitator: Khatidja Husein, Aga
Khan University, Karachi, Pakistan
Ministry of Public Health, Srisaket; Facilitator: Peerasit
Kamnuansilpa, Health and Population Research Corpora
tion, Bangkok, Thailand
CARE, MUDE, Adoplafan, Aguas Vivientes, Caritas; Facili
tator: Linda Ashburn, University Research Corporation,
Santo Domingo, Dominican Republic
Junagadh PHC Project, Sidhpur Sustainable Health System
Project, Gujarat; Facilitator: Neeraj Kak, University Research
Corporation, Bethesda, Maryland, USA
Department of Health, Jakarta; Facilitator: Sandi lljanto,
University of Indonesia
Module 1: Information needs
A social worker examines a boy’s glasses in northern Portugal
Photo by K. Hinckley for AKF
.23
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23
Introduction
Purpose
This module will help managers identify information
needs, set priorities, and determine which PHC MAP module(s) will be most useful to them. Worksheet A at the end
of the module can be pulled out and used to help you keep
track of your information needs.
What you need to complete this module
Although it is not essential, it would help to know your
programme’s objectives, target groups, the current coverage
figures for your major health services, and the indicators that
are currently used by your programme. You should also read
the overview of PHC MAP first, if you have not already done
so.
Content
This guide asks 10 questions about important information
that most PHC managers need for planning and monitoring
their programmes. If you have adequate information, you
may not need the modules. But if you have important gaps,
or you need to have additional information, the guide will
help you determine what you need. It will also suggest
which modules in the MAP series can help you gather and
process that information - simply and rapidly.
Procedures
• If you want to go through this module quickly, go to Level
1: Quick start and just review the questions and descrip
tions of the modules. That may be all you need to
Module 1: Information needs; introduction
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Module 1: Information needs; introduction
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Facilitators
can help
You can go through the module on your own. However,
experience has shown that it is best to get your management
team and community representatives involved in the MAP
process. They usually have a lot to contribute, and it is useful
to have different perspectives represented at the beginning.
Involving them will also ensure that they understand and
support the decisions that will be made.
A facilitator can be helpful if you want to hold a work
shop on Module 1. The Facilitator’s guide provides instruc
tions for running a workshop and includes sample transpar
encies and handouts. Allow 4-6 hours for completion of the
overview of PHC MAP and Module 1, depending on the size
of the group. This module, like all the others, can be adapted
to fit your situation, and you are encouraged to do so.
There is also a computerised version of this module on
Hyperpad, which is included on the accompanying diskettes.
You enter your choices right on worksheets on the computer
screen. When finished, you can print out a summary of your
information audit.
If] if]
various information needs in detail and to decide which
modules will be most useful to you.
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• Level 3: Detailed questions asks you to examine
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• If you prefer to go through this module more systemati
cally, skip to the next section, Level 2: Describing your
PHC system. That will probably take a few hours,
depending on the size of your programme and your
familiarity with the kind of information currently gath
ered.
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determine which module(s) to start with. The first 6
questions deal with PHC services, the next 4 with man
agement.
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The purpose of Module 1 is to help managers identify
information needs, set priorities, and determine which PHC
MAP modules are likely to be most useful to them. Manag
ers will need to conduct an information audit, which is a
systematic assessment of information needs compared with
information currently collected. The audit can help you to
identify information gaps (and the MAP modules that can
help you fill them). And it also can help you identify
information that is no longer needed (which you probably
shouldn’t collect anymore).
These modules focus on essential information that is
needed in the traditional management cycle of planning
doing-evaluating. As mentioned in the overview, each mod
ule is related to one or more parts of that cycle. That
relationship is shown in the matrix below.
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The PHC MAP framework
Module 1 : Information needs
Module 2: Community needs
Needs
assessment
Planning
Monitoring
Evaluation
X
X
X
X
X
X
X
X
Module 3 : Work planning
Module 4: Surveillance
Module 6. Service quality
X
X
Module 7 : Management quality
X
Module 5: Monitoring indicators
X
Module 8 • Cost analysis
Module 9: Sustainability
X
X
X
X
The modules do not attempt to provide all information
that managers use, nor do they constitute a complete
management system or even a complete management in
formation system. They do not teach managers how to plan,
for example. Planning and other basic management func
tions are adequately covered in widely available textbooks
and manuals. The PHC MAP modules are designed to help
local PHC managers gather and analyse selective informa
tion that experience has shown they often need but do not
have. Thus, in some cases the modules will complement
information already collected. In others they may help
Module 1: Information needs; introduction
4
Use all
or some
modules
managers fill important gaps.
The entire series of modules can be installed to
strengthen overall planning and monitoring. But each mod
ule can also be used independently to deal with a particular
information need as it arises.
In many cases the information produced by one module
complements another. For example, cost analysis data from
Module 8 can be a useful input to sustainability analysis in
Module 9. If data from monitoring (Module 5) identify a
problem in PHC services, then Module 6 can be used to
examine the quality of services more carefully and to pin
point the problem so that it can be resolved.
The next section provides a brief overview of the systems
framework used in the PHC MAP modules. It is important
to understand this framework so that you can determine
which modules you might need. The overview is followed
by 10 questions summarised in Level 1: Quick start. Level 2
helps you describe your programme in systems terms and
helps you determine the information needed for each PHC
and management service. Level 3 helps you look at each of
the 10 questions in more detail, so that you can do a more
comprehensive assessment. When you have completed this
module, you should have a good idea of your management
information needs and the modules that can help you meet
those needs.
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Systems framework
The PHC MAP framework is based on a "systems" model.
Different types of information are collected through each
module. If you are not familiar with systems terminology,
then the following section may help you understand how the
MAP framework classifies information. If you are familiar
with systems terminology, skip to the next section.
We realise that you might be used to slightly different
terms. Some people have been taught that objectives are
short-term goals. We distinguish between goals and objecfives because it allows more precision in planning. In this
series, an objective is defined as a planned output or effect.
A goal is a planned impact.
Module L Information needs; introduction
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Terminology
Some key terms you need to know
INDICATORS
INPUTS
PROCESSES
OUTCOMES
Indirect measures of all of the following
Resources: personnel, equipment, information, money
Activities, tasks
All programmatic changes, outputs, effects, and impacts
Outputs
Effects
Impacts
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Products and services provided
Changes in knowledge, attitudes, behaviour/practice
Changes in health, fertility, and other status
OBJECTIVES
Planned outputs and/or effects
GOALS
Planned impacts
See the Glossary for more detailed definitions
3
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Some people have been taught that outputs and out
comes are the same. We use "outcome" to include any
programmatic result. Thus, we distinguish between three
types of outcomes: outputs (the immediate products and
services produced by the programme), effects (the knowl
edge, attitude, and behaviour/practice changes that result
from the outputs) and impacts (changes in health or fertility
status due to the effects). Again, we make these distinctions
because it allows us to be more precise in selecting indicators
for planning and evaluation.
Any programme, including PHC programmes, can be
seen as consisting of inputs, processes, and outcomes, as
shown in Figure 1. In the PHC MAP series, these, and related
terms, have specific meanings and relationships.
Inputs are resources (staff, money, supplies, trucks, etc.)
that are invested in a programme and processed in various
ways (counselling, diagnosis, referral, etc.) to produce outFigure 1: A simple system-oral rehydration therapy
INPUTS
(resources)
Example:
health worker
ORS packets
•
PROCESSES
(activities)
OUTCOMES
(results)
diagnose diarrhoea
prescribe ORT
Improved health
Module 1: Information needs; introduction
6
comes (the results of the programme on knowledge, behavi
our, health, etc.).
This simple model can be expanded, as shown in Figure
2, to distinguish between three different types of outcomes.
The immediate results are called outputs. These are the
products and services produced by the programme. Ex
amples are growth monitoring cards distributed (a product),
children weighed and pregnant women contacted (both
services).
These outputs are expected to have effects on client
knowledge, attitudes, skills, and especially, behaviour.
A mother, for example, is supposed to gain knowledge about
the value of using ORT, gain the skills to mix the solution
properly, become motivated to use the solution when her
child has diarrhoea, and then actually use it at the appropri
ate time.
Figure 2: A systems diagram of oral rehydration therapy
INPUTS
(resources)
_
Example:
hearth worker
ORS packets
PROCESSES
(activities)
diagnose diarrhoea &
prescribe ORT
> OUTPUTS
(products &
services)
ORS packet
given
— —>
EFFECTS
(knowledge,
attitudes,
behaviour)
use of ORS
packets
— —>
IMPACTS
(morbidity.
mortality,
fertility)
avoid
dehydration
and death
Ultimately, this should produce an impact on the health,
fertility, socio-economic, or other status of the target popu
lation. Children who receive ORT, for example, should avoid
becoming dehydrated and recover normally from diarrhoea.
There is a logical relationship in this chain of events that
is the key ingredient in both planning and evaluation.
Obviously, if the inputs aren’t adequate, the outputs won’t
be produced. And if outputs aren’t produced, we cannot
expect any effects. And without effects, we cannot expect
to have any impact on health. This logical linkage is called
an "IF - THEN" relationship.
IF the inputs are provided as planned, THEN the pro
cesses will be achieved.
• IF the processes are conducted as planned, THEN the
outputs will be achieved.
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IF the outputs are produced as planned, THEN the effects
will be achieved.
IF the effects are achieved as planned, THEN the impacts
will be achieved.
IF the impacts are achieved as planned, THEN the health
needs will be met.
Figure 3: The systems framework and
the planning-evaluation cycle
Planning 4 ■■■■■■■■ ..
■—u ■
INPUTS ◄—PROCESSES
IMPLEMENT
(activities)
(resources)
◄-OUTPUTS ◄-EFFECTS
(prod/serv)
(KAP)
■ ■■
■
IM PACTS
(health status)
INPUTS —► PROCESSES —► OUTPUTS —►EFFECTS —►IMPACTS
1
3
!
Monitoring/evaluation
This logical link between what goes into a PHC service
at the beginning and what comes out at the end, is an
extremely important management concept. Many managers
only look at what goes into a programme. Some also look
at a few indicators of what comes out. If something goes
wrong, they do not know why. PHC MAP helps managers
gather information at key points in this logical process so
that they can identify where something goes wrong, and
then take action. The logic works backwards, also.
• IF these needs are to be met, THEN these impacts will
have to be achieved.
• IF these impacts are to be achieved, THEN these effects
will have to be achieved.
• IF these effects are to be achieved, THEN these outputs
will have to be achieved.
• IF these outputs are to be achieved, THEN these pro
cesses will have to be achieved.
• IF these processes are to be achieved, THEN these inputs
will be needed.
3
Module 1: Information needs; introduction
,
■
NEEDS
8
Thus, the systems relationships can be used in two ways.
First in planning, by working backwards from health needs
to identify needed impacts, effects, outputs, processes, and
finally, inputs. Second, in monitoring and evaluation, by
working forward to make sure that what was planned was
actually carried out, that inputs were processed as planned
to produce outputs, which led to effects then impacts, and
that this met the health needs.
Figure 4: A system diagram of management
and services relationships
Management services
PHC services
When viewed this way, the systems framework is simply
a variation of the traditional planning and evaluation cycle.
But its advantage is that it can be used to identify logical
links between what is needed and what should be invested
in a programme; and between what is invested and what is
actually achieved. As we shall see, that provides a structure
for selecting indicators for planning and monitoring/evaluation.
Management services support the PHC services. Each
management activity (training, supervision, etc.) can be seen
as a subsystem that is designed to.improve the PHC service
system. That is, there are inputs to training (trainers,
training materials, classrooms, etc.), which are processed to
Module 1: Information needs; introduction
9
produce outputs (lectures given, materials distributed, peo
ple trained, etc.). Those outputs are supposed to have effects
on the trainees. They are to increase their knowledge, skills,
and/or motivation.
All of these management services are designed as sys
tems, just like the PHC services are. But the impact of-----------------management is indirect. Management outcomes are inputs Management
to the service systems. The end product of a training Outcomes
programme for CHWs should be a better qualified CHW,
who then provides better service to the target population.
Figure 4 illustrates this relationship.
Relationship between framework and modules
The PHC MAP framework breaks all PHC information
into 5 categories: inputs, processes, outputs, effects,
and impacts, these categories help to identify information
needs. Figure 5 shows which modules produce which types
of data.
Figure 5: Categories of information produced by MAP modules
INPUTS
(resources)
PROCESSES
(activities)
OUTPUTS
(products/services)
EFFECTS
(K AP)
IMPACTS
(health status)
3 Work planning
3 Work planning
2 Community needs
3 Work planning
2 Community needs
3 Work planning
5 Monitoring
6 Service quality
7 Management quality
8 Cost analysis
9 Sustainability
5 Monitoring
6 Service quality
7 Management quality
8 Cost analysis
9 Sustainability
5 Monitoring
6 Service quality
7 Management quality
4 Surveillance
9 Sustainability
9 Sustainability
Bold lettering indicates the primary type of data collected for each module.
The MAP modules can help you identify and collect infor
mation you need. This should help you do a better job of
planning because you will know what the health and
service needs are. It should help you monitor progress
better, because if something does go wrong, you will have
an idea of where it happened in the system and be able to
get additional information about the cause so that you can
correct the problem.
Module 1: Information needs; introduction
10
Module 2 is especially useful in helping you collect
effect and impact data. Those data tell you what your
coverage levels and health status are. This information can
help you in two ways.
First, it tells you what the need is for health care, which
will help you do a better job of setting goals and objectives.
Second, it tells you how effective your programme has been
in achieving coverage and improving health status, which
helps you do a better job of evaluating the effects and
impacts of your programme.
Planning
and
Monitoring
Module 3 will help you get specific output information
to determine who is and is not receiving needed
PHCservices and products. That will help you set service
priorities among your target population and monitor
health worker performance in providing those services. The
module also produces input, process, and effect data that will
help you improve work planning and performance assess
ments.
Module 4 will help you get specific impact data on the
incidence, trends, and outbreaks of specific diseases so that
you can take action quickly to deal with these threats to
health status. The module will also help you identify causes
of diseases and death so that you can adapt your PHC
interventions accordingly.
Module 5 will help you identify and select a few simple
indicators of inputs, outputs, and effects for each of your
PHC and management services. This will be especially
useful for monitoring your programme on a regular, peri
odic, or short-term basis.
Modules 6 and 7 emphasise process data, which will
enable your supervisors to assess the quality of service.
Module 6 addresses PHC services and Module 7 deals with
management services. In addition to process data, these
modules also help you gather selective information on key
inputs to and outputs of your services.
Modules 8 and 9 emphasise inputs summarised as
costs and revenues. Both will help you examine and explain
how resources are used to provide and support services.
Module 1-. Information needs; introduction
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Module 8 helps you analyse recent revenues and expendi
tures. Module 9 helps you look at future options for contin
uing your programme.
Defining your health system
Setting boundaries
PHC programmes are only a part of the larger health
system. Health products and services are typically provided
by government and non-governmental organisations, pri
vate providers, pharmacies, schools, and others. Before you
begin, you should define your PHC system. For example, if
your organisation collaborates with the Ministry of Health
(MOH) to provide immunization services, should your "sys
tem" include the MOH services?
Most managers intuitively draw "boundaries" around the
parts of the system that they control or those for which they
have responsibility. This is how they define their informa
tion needs. They need information on the services and other
activities that fall inside those boundaries.
However, in some cases they may need to have informa
tion about some of the activities of other agencies that affect
their programmes. Examples would be vaccines provided by
the MOH, the outcome of referrals to a neighbouring hos
pital, and distribution of Vitamin A by an NGO in their
catchment areas. If your programme falls into this category,
then you should draw your boundaries so that they include
the parts of these other systems that you depend on. You
will want to collect some information on these activities. But
don’t collect too much. An important rule of thumb is:
collect only information that you need for your own plan
ning and monitoring.
Figure 6 : Setting boundaries for information needs
MOH
PHC
project
Module 1: Information needs; introduction
NGO
Information
boundaries
12
Two village Health Development Committee members bridge the
generation gap to ensure community co-operation for health in Kenya
Photo by Jean-Luc Ray for AKF
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13
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3
it
Level 1: Quick start
_~jj
Do you have enough information for planning and mon
itoring your PHC services and your management services?
Answer the questions in the following boxes and read the
descriptions of the modules. That may be all you need to
do to decide which module(s) you would find most useful.
’-1
MODULE 1 ASSESSMENT QUESTIONS : PHC SERVICES
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Do you have enough information about the health status of your target
groups?
—Do you have enough information about the coverage of target groups by
the appropriate PHC service?
‘ ai
V°u need more information, go to Module 2.
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Module 2. Assessing community health needs and coverage.
This module provides PHC managers with simple tools to gather
required data on community health needs for planning programme
strategies and resource use. The managers can use the same
instruments later to assess programme effects on health knowledge,
behaviour and coverage, as well as programme impact on morbidity and
mortality.
Do you have enough information about where your target groups live, who
needs the most attention, and the effectiveness of your health workers in
reaching those people?
If not, use Module 3.
Module 1: Information needs; level 1
14
Module 3. Planning and assessing health worker activities.
A module that supervisors and other managers can use to help field
workers and clinic staff plan their work better. It shows how to identify
individuals in need of services, set realistic targets, assess individual
performance, and take corrective action, if warranted.
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Do you have enough information about the incidence of diseases?
Do you have enough information about the causes of disease outbreaks and
deaths?
If not, use Module 4.
Module 4. Surveillance of morbidity and mortality. The
module describes the basic indicators of morbidity and mortality to be
included in a PHC surveillance system. It discusses how to set up a
surveillance system, monitor the incidence and other rates of diseases,
how to identify causes of mortality and morbidity, and how to use that
information to improve programme planning and implementation.
Do you have the appropriate outcome and activity indicators to monitor
your health services?
If not, use the first part of Module 5.
Module 5. Monitoring and evaluating programmes. The first
part of this module contains lists of indicators and guidelines that
managers can use to monitor PHC services for short periods. Managers
can also use them to construct a project-specific "mini-MIS."
Do you know enough about the quality of your health services?
If not, see Module 6.
Module 6. Assessing the quality of service. Simple, but com
prehensive, discussion guides and checklists of essential service re
sources and processes. Supervisors can use these to assess the quality
of care provided and to set priorities for improving service delivery.
b-
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Modules 1-6 (above) help you assess information needs for planning and
monitoring PHC services. Modules 5, 7, 8 and 9 deal with information
you need to plan and monitor management services.
Module 1: Information needs; level 1
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MODULE 1 ASSESSMENT QUESTIONS: PHC MANAGEMENT
SERVICES
_________
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Do you have the appropriate indicators to monitor your management
services?
If not, try the second part of Module 5.
Module 5. Monitoring and evaluating programmes. The sec
ond part of this module consists of lists of indicators and guidelines that
managers can use to monitor PHC management services. These can
also be used as part of a project-specific "mini-MIS".
Do you know enough about the quality of your management services?
If not, use Module 7.
Module 7. Assessing the quality of management. Discussion
guides and checklists for assessing PHC management services (planning,
training, supervision, etc.).
-3
X3
Do you have enough information about the cost of your programme and
its services?
If you need more information, try Module 8.
Module8. Cost analysis. This module will help PHC managers set
up simple systems to monitor costs themselves. They can also make
projections about future revenues and expenses.
Do you have adequate information to determine how to sustain your PHC
programme in the future?
If not, use Module 9.
Module 9. Sustainability analysis. Guidelines and tools that
managers can use to develop and analyse alternative strategies for
sustaining health improvement, service coverage, and the PHC services,
organisation and resources needed to do so.
Module 1: Information needs; level 1
16
Keeping a check on the distribution of medicine, as
here, in a Mali village, could be speeded up and
simplified by storing information on compact disks.
Photo by P Almsey for WHO
17
Level 2: Describing your PHC system and
identifying key indicators
Level 2 helps you define your programme in system
terms. This will help you identify the key pieces of informa
tion that you will need (indicators) for planning and moni
toring. The easiest way to do this is to summarise your
current services and the indicators that you believe you need
for each one. As you go through the module, you will
determine whether these are adequate for your purposes,
whether you can stop collecting some, and whether you need
to add others. Use Worksheet A to summarise your key
indicators by target group and service. Don’t worry if you
can’t fill them all out right away. As you go through the
various modules, you may decide to add to or delete from
this list Worksheet A can be a handy summary of your
management information needs.
Step 1: List the project’s principal
health and management services
Your programme probably provides 5-10 PHC services
(e.g., ANC, ORT, child immunization), and you probably have
3-5 management services that are important (e.g., supervi
sion, training, information system). List them on a piece of
paper. Use the list in the overview at the beginning of this
module as a checklist. An example of a completed list is
shown in the box on the next page. Use your own terms
and groupings of services. If possible, list the services in
priority order with the most important service listed first.
Module 1: Information needs; level 2
e
18
Health services
hi
w i$
Maternal care (ANC, PNC)
Family planning
Breastfeeding, growth monitoring, nutrition education
Child immunization
Diarrhoeal disease control/ORT
Vitamin A distribution (for night blindness)
Step 2: Define the principal inputs,
processes and outcomes of these services
Start with the highest priority service and identify the
principal inputs, processes, outputs, effects and impacts of
each service. These can be abbreviated as indicators (e.g.,
"CHW," "vaccines” for inputs. See Worksheet A, p. 20, for an
example). You can start from either end. That is, list the
desired impacts and work backwards, or start with inputs
and work forwards. The important thing is to identify
the most significant indicators and to make sure
that they are logically linked, so that you can assess
whether or not you have adequate information on
each of your services. Although the following example
is limited to two indicators per category, you can list as many
indicators as you wish. Consult Module 5 for examples of
important indicators for the various PHC and management
services.
Remember that inputs are resources (personnel, money,
materials, information); processes are activities or tasks
that staff carry out; outputs are the results of those activi
ties (products and services provided); and effects are the
improvements gained in knowledge, skills, attitudes, and
behaviour/practice. The ultimate result is the impact on
health status (mortality, morbidity, disability, fertility).
Module 1: Information needs; level 2
m is u iii w hi w w
Training (Staff, CHWs, TBAs)
Supervision
Accounting (financial management)
Logistics management (supplies, equipment)
MIS (information management)
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2.
3.
4.
5.
m
Management services
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2.
3.
4.
5.
6.
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19
This model applies to both PHC and management ser
vices, except that the management services usually stop at
effects. They are not usually intended to have a direct
impact on health. Instead, they are intended to improve the
PHC service inputs and processes and have an effect on the
knowledge, skills, and performance of staff.
Repeat this step for each of the first three or four services
on the priority list. If this exercise is being conducted by a
team, it may be useful to assign small groups to each of the
priority services so that several services can be done at once.
A blank worksheet is included in the appendices for your
use.
Figure 7: PHC services
breast feeding, growth monitoring, nutrition education
INPUTS —► PROCESSES—#► OUTPUTS --►EFFECTS —►
(resources)
(activities)
(products &
services)
CHWs
GM cards
weighing
counselling
child weighed
mother counselled
(morbidity,
mortality,
fertility)
mother understands
GM and nutrition
mother feeds better
weight gain
malnutrition rate
drops
13
Step 3: Identify your information needs
3
Scan through the worksheet and for each service listed
identify the most useful indicators for planning and moni
toring and determine whether your current information
system provides adequate data for these indicators. Mark
those indicators that are important, for which data are
missing or inadequate.
There is a separate worksheet B that you can use to
summarise your information needs. An example follows
worksheet A, and a blank form is included in appendix B.
The information needed is summarised in the sample work
sheet.
You may be able to complete your assessment from this
chart. The 10 questions that follow in the next section (Level
3) can help you to examine each information category in
more detail.
:3
-3
3
-3
73
3
Module 1: Information needs; level 2
IMPACTS
(knowledge,
attitudes,
behaviour/
practice)
N)
O
WORKSHEET A: DEFINING SERVICE INDICATORS
Instructions: 1) List each priority PHC or management service; 2)
Identify key indicators you need for planning and/or monitoring; 3) Identify those that are already available ( mark with an x);
4) Identify the low, medium and high priority items (e.g., with ', ", and ***); 5) Revise and update this list as you proceed through
Module 1 and other modules.
INPUTS
PROCESSES
OUTPUTS
EFFECTS
IMPACTS
(resources)
(activities)
(products and services)
(knowledge,
attitudes,
behaviour/
practice)
(morbidity,
mortality, fertility)
x
mother understands GM
& nutrition”
weight gain
mother feeds better
malnutrition drop’
TARGET
GROUP
SERVICE BF, GM, Nut. Ed.
Children < 2
CHWs
x
GM Cards
CHWs
x
Module 1: Information needs; level 2
child weighed
counselling**
mother counselled
assessment
supervisory contacts
x
CHW skill gain”
not applicable
counselling*
supervisory reports
x
productivity gain
not applicable
new acceptors
TFR decline’
x
1
SERVICE: Supervision
supervisors
x
Supervisor guidelines x
Women 15-49
SERVICE Family Planning
CHWs
x
contraceptives
x
home visiting
women contacted
counselling**
contraceptives distributed
visiting
communities visited
educating’
leaders trained
x
x
x
prevalence of use
birth interval increase
active volunteers’
not applicable
SERVICE Community Organ.
Community
Leaders
community organizer
community leaders
ffl
weighing
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x
x’
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x
not applicable
x’
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Module 1: Information needs; level 2
WORKSHEET B: SUMMARISING INFORMATION NEEDS Instructions: 1) after you list each question, summarise your general
information needs for each type of information under the appropriate module; 2) Identify the specific type of indicators needed
(if known); 3) set priorities for each needfe.g.,' for low, ” for medium, and
for high)
MODULE
SPECIFIC INDICATORS
GENERAL INFORMATION NEEDS
2 Community needs
impact
Change in total fertility rate
Change in third degree malnutrition
Total No. births to women 15-45 yrs/total women 15-45 yrs
No of cases of 3rd degree malnutrition among children <2
years/total number of children <2 years
coverage
Mothers understand GM and nutrition
Percent of mothers who understand GM/nutrition
Malnutrition trends of children <2 years
same as above
Contacts with community leaders; active community
volunteers; CHW skill gain
No and % community leaders contacted/month
No. of active volunteers; see module for skill gain
6 PHC service quality
Counselling of mothers on BF, GM, nutrition, FP
See module for checklists
7 Management services
See module for checklists
Counselling /coaching of HW by supervisors
Educating of community leaders by Community See module for checklists
Organisers
3. Work planning
4 Surveillance
morbidity
mortality
5. Indicators
PHC services
Management
8. Cost analysis
9 Sustainability
PRIORITIES
Ul
22
Common
priorities
5. the quantity of products and services provided (outputs)
6. staff performance (effects) and
7. the quantity and quality of available resources, especially
staff and supplies, equipment (inputs)
Your priorities may differ, of course, and they may change
over time. Use Worksheet B to summarise your information
needs and to identify the modules that are most likely to
help you fill those needs.
If you have a large number of "priorities,'' you may want
to use a priority-setting technique to identify the most
important of your information needs. See Appendix A for
some suggestions.
L i Li
pacts)
Lil
Areas of secondary importance are:
4. health status, especially the outbreak of diseases (im
It
1. what clients know and do (effects)
2. how well PHC services are provided (outputs), and
3. costs of services (inputs)
Li
If you have assessed more than one service you will
probably have a number of information needs identified on
your chart. Since it will probably not be feasible to meet all
of your needs at once, you will need to set priorities among
them once again. Management experience has shown that
the most important data needs usually occur in three areas:
It
Step 4: Summarise your information
priorities
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Module 1: Information needs; level 2
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Level 3: Detailed questions
This section consists of 10 questions, which are designed
to help you determine the information you need. The first
set of two questions deals with information about the
projects target groups, their health status, and coverage important information for assessing needs and evaluating
project effects and impact. The second set of four questions
helps you to identify information needed for planning PHC
service strategies and monitoring PHC services. The third
set of four questions addresses management issues, including
information needed to monitor management activities and
costs, and assess future project sustainability.
Questions for assessing information needs and selecting
appropriate PHC MAP modules
PHC GOALS, TARGET GROUPS, SERVICES, COVERAGE AND IMPACT
QI:
Q2 :
Do you have enough information about the health status of
your target groups? (2)
Do you have enough information about the coverage of each
PHC service? (2)
WORK PLANNING, MONITORING, QUALITY ASSESSMENT
Q3 :
Q4 :
Q5 :
Q6 :
Do you have enough information about your target groups’
needs to plan PHC activities? (3)
Do you have adequate information about changes in
morbidity and mortality? (4)
Do you have adequate indicators to monitor your PHC
services? (5)
Do you know enough about the quality of your PHC
services ? (6)
,, .
' '
continued next page
Module 1: Information needs; level 3
24
PHC MANAGEMENT, COSTS AND SUSTAINABILITY
Q7 : Do you have adequate indicators to monitor your managemer
services? (5)
Q 8 : Do you know enough about the quality of your manage
ment services? (7)
Q 9 : Do you have enough information about the costs of your
programme and its services? (8)
Q 10 : Do you have adequate information to determine how to sustain
your PHC programme in the future? (9)
r
bl
r
The numbers in parentheses refer to the relevant module.
Bl
PHC programme goals, target groups,
services, and coverage
The purpose of the first question is to determine whether
you are collecting adequate information about the health
status of your target groups (impact indicators). You need
this for needs assessment and evaluation. If you do not have
adequate data on health status, you may find that Module 2
can help you to get that information.
&
B
QUESTION 1. DO YOU HAVE ENOUGH INFORMATION ABOUT THE
HEALTH STATUS OF YOUR TARGET GROUPS?
Whether you are starting a new programme or continu
ing an ongoing one, you need this information for two
important reasons. First, to assess needs. What types of
health problems are there, and what are the priorities that
need to be addressed? Second, you need this information to
determine the impact that your programme is having on
health. Is health improving? Does more need to be done?
Is it time to switch priorities?
First, you need to know what is the current health status
of your target groups so that you can set reasonable goals
for the programme. You need clear goals to select the kinds
of PHC services to provide. By "goal" we mean the impact
your programme hopes to have on health. PHC goals are
usually stated as intended improvements in health status
Module 1: Information needs; level 3
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25
(mortality, morbidity, disability, fertility). Goals also identify
specific groups of people (often called "target groups") whose
health the programme is trying to improve (e.g., children
12-23 months of age; married women 15-45 years). Goals
are based on an assessment of health needs. For example,
if third degree malnutrition is high among young children, a
logical goal would be to reduce the prevalence of severe
malnutrition.
The second reason you need information about health
status is for evaluation: to assess the impact your pro
gramme is having on health. If you don’t know the impact
your programme is having, you may be providing services
that aren’t necessary or are a waste of time and money. Or
they may be very useful. The point is, you won’t know unless
you have the information. Without it you won’t be able to
do a good job of needs assessment or of evaluation.
WHY WE NEED GOALS:
"If you don't know where you are going, any road will get you there."
WHY WE NEED TO EVALUATE PROGRESS:
"If you don't know where you are, you may already be there.
Or you may not be."
Many PHC programmes already have clear goals, and
quite a few have current information on local disease pat
terns, causes of death and fertility patterns. If you do, you
may already have enough information on the health status
of your target groups
To do a quick assessment of your need for information
about health status, summarise your programme’s major
goals and target groups and list the indicators that you use
to measure them. Or, if you prefer, write out goal statements.
Ideally, goal statements should contain four items: 1) the type
of improvement desired, 2) the target group, 3) the amount
of change that should occur, and 4) the date for achieving
the goals. Examples of goal statements (and their indicators)
are shown on the next page.
Most PHC programmes have only 2-3 goals, although
they may provide several PHC services to achieve each goal.
For example, many PHC programmes try to reduce infant
Module 1: Information needs; level 3
26
Ul
• Indicator: No. of deaths of children
under 1 month of age/1.000 live births
• Indicator: No. of cases of 3rd degree
malnutrition among children <3 yrs/total No.
children <3 years
• Indicator: No. of new cases of polio
among children <5 years
• Indicator: Total births to women 15-45
years/total women 15-45 years
L
mortality through a combination of immunization, sanita
tion, nutrition, and ORT services. For now, just list your pro
gramme’s major goals. The services will be added in Step 2.
You should have at least one indicator for each major
goal. If you are using Worksheet A, list these indicators
under the impact column and check those for which you
already have data.
You do not need to assess health status regularly. Every
3-5 years is usually enough, since health status does not
change rapidly. Also, assessments of health status require
fairly large samples, especially for such rare events as ma
ternal deaths.
If you do not have enough information about the health
status of your target groups, take a look at Module 2. It
can help you collect information that you can use to make
reasonable estimates at reasonable costs. Use Worksheet B
to summarise the type of impact information you need to
collect.
til ill ill ill la
• Reduce neonatal mortality among urban
slum dwellers to a rate of 65 per 1,000 live
births by the end of 1994 (Mortality goal)
• Decrease the prevalence of 3rd degree
malnutrition among children under age 3 by 30
percent by September, 1995 (Morbidity goal)
• Decrease the incidence of polio among
children under age 5 to 0 (zero) by the year 2000
(Disability goal)
• Reduce the total fertility rate of women
in the programme area to 4.5 by the end of 1996
(Fertility goal)
Wl
INDICATORS
&
GOALS
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SiModule 1: Information needs; level 3
Z3
33
3
27
TARGET GROUPS
Children <2 yrs
■'3
HEALTH
GOALS
Reduce mortality • No. of deaths of children <1 yr/1,000 live
births
•No. of deaths of children <2 yrs/total No.
children <2 yrs
..3
33
Married women 15-49
yrs
Reduce
morbidity
•Percent of children <2 yrs with third degree
malnutrition
Reduce disability
•No. of cases of immunizable-preventable
disabilities/1,000 children <2 yrs
Reduce mortality • No of maternal deaths/10.000 pregnancies
Reduce fertility
33
■ 3
33
23
Z2
INDICATORS
•Total fertility rate
QUESTION 2. DO YOU HAVE ENOUGH INFORMATION ABOUT THE
COVERAGE OF EACH PHC SERVICE?
PHC programmes attempt to reach their goals by pro
viding one or more health services to their target groups.
Those services are expected to have positive effects on the
target groups. These effects are generally of three types: 1)
improved knowledge (e.g., about the benefits of ORT); 2)
improved skills (e.g., how to administer ORT); and 3) im
proved behaviour/practice (e.g., giving ORT to a child
who has diarrhoea). These effects must occur if the goals
are to be achieved. That is why it is not only important to
define them, but to measure them as well.
The purpose of Step 2 is to identify those services and
to determine whether you have adequate information about
the need for and the effects of each. The most important
piece of information needed is "coverage" data. Coverage
is defined as the proportion of the target group that
has received a service or is protected from a disease
or health problem. Some examples are shown on the
following page.
3
3
Module 1: Information needs; level 3
28
Examples of PHC coverage indicators
Service / Condition
Coverage indicator
% pregnant women delivering who had made 3
or more ANC visits
% women 15-44 yrs who received 2 doses of Tetanus
Tetanus toxoid immunization
toxoid vaccination
% deliveries assisted by trained attendant
Safe delivery
% married women (or couples) practising
Family planning
family planning
% children 18-23 mos breastfed until they were
Breast feeding
age 18 months
% children < 2 yrs weighed in the last 3 months
Growth monitoring
Child immunization
% children 12-23 mos. fully immunized
Acute respiratory infection
% ARI cases treated
% children < 5 yrs with diarrhoea/1,000 children
Diarrhoeal disease control
<5 yrs
Oral rehydration therapy
% children <5 yrs treated with ORT for the last
episode of diarrhoea
Water, sanitation, hygiene
% households with safe water/latrine
Vitamin A
% children 6-12 mos. received Vit A
Tuberculosis
% cases followed to cure
Malaria
% identified cases treated
Sexually transmitted diseases/HIV % target group infected who are treated
Disability
% children < 5 yrs disabled
Health education at home
% households (with target groups) receiving health
education during health worker visit in the past
year
Health education at school
% schools receiving or participating in health edu
cation activities
Drug supply
% communities with adequate supplies
Accidents & injuries
% No. accidents + injuries/1,000 population
Chronic, non-communicable
% target group with hypertension, chronic heart
diseases
disease, anaemia, diabetes
Antenatal care
For each of the target groups you identified, fill in the
following information on a piece of paper. Use the example
that follows as a guide.
Module 1: Information needs; level 3
Er
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29
TARGET GROUP
HEALTH SERVICES
Children < 2 yrs
Child immunization
Growth monitoring
Oral rehydration therapy
Nutrition education
% < 24 mos. fully immunized
% < 5 yrs weighed
% using ORT last episode
% < 2 yrs low weight for age
Married Women
15-49 yrs
Antenatal care & TT
% pregnant women enrolled in
ANC
No. of new acceptors
Family planning
=3
ic
.■3
.'3
3)
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COVERAGE INDICATORS
If there is a target group or a health service that
you think should be added to your programme, include that
also, even if you do not have any information about it.
Again, you should have at least one coverage indicator
for each PHC service. If you are using Worksheet A, copy
your coverage indicators to the Effects column and check
those for which you have already collected data. If you need
more data on coverage, consult Module 2.
Module 2 includes lists of important coverage, KAPJ and
health impact indicators for each PHC service. Module 5
also includes extensive lists of indicators that you may want
to consult. It will show you how to collect this information
about each of your target groups through rapid community
surveys. That information will be useful to you in two ways:
to assess health needs (so you can do better needs assess
ments), and to assess programme coverage (so that you
can do evaluation).
Module 2 includes sample questionnaires for each of the
PHC health services. It also includes guidelines and tools
for designing simple surveys, drawing cluster samples, pro
cessing and analysing data, and interpreting results. An
excerpt from the questionnaire on Antenatal Care is shown
in Exhibit 1.
As noted previously, assessments of health status will
usually require much larger samples than coverage surveys.
You may want to keep this in mind, and perhaps do an
impact assessment every 3-5 years and a coverage survey
every 1-2 years. Use Worksheet B to summarise the type of
coverage information you need to collect with Module 2.
Module 1: Information needs; level 3
m
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Exhibit 1: Excerpt of questionnaire in Module 2: Assessing health
needs and coverage
1
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30
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Complete for all women currently living in the household who have had
a pregnancy outcome during the past 24 months. The outcome may be
a live birth, stillbirth, or abortion. If the woman has had more than one
pregnancy, ask about the outcome of the most recent pregnancy.
rm
.
>
Excerpt from
RAPID SURVEY QUESTIONNAIRE: ANTENATAL
CARE AND CHILDBIRTH
i
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1. Study No. .
2. Province No.
3. Interviewer
4. Date of Interview
5. Identification Number (4 digits)
Cluster No.
Woman No. in Cluster
iw
IDENTIFICATION
NAME OF RESPONDENT
&6. How old are you (Probe)? years (if DK/NR, enter 99)
7. Did you receive antenatal care during your last pregnancy?
Yes
(1)
No
(0) Go to Q 11
DK/NR
(9) Go to Q. 11
8. How many times did you get antenatal care?times
(If DK/NR, enter 9)
9. How many months had you been pregnant before you got
antenatal care?
3 mo.(first trimester)
(1)
4-6 mo.fsecond trimester)
(2)
7-9 mo.fthird trimester)
(3)
DK/NR
(9)
(Questionnaire continues.- total of 19 items)
£
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Module 1: Information needs; level 3
£
31
dfl
J)
Work planning, surveillance, monitoring,
quality assessment
The purpose of the next four questions is to determine if
you are collecting adequate information about the perfor
mance of your health workers and your services. If you do
not have enough, or the right kind of monitoring information
to make sure everything is going as planned, then Modules
3, 4, 5, and 6 may be useful to you.
QUESTION 3. DO YOU HAVE ENOUGH INFORMATION ABOUT
YOUR TARGET GROUPS’ NEEDS TO PLAN PHC ACTIVITIES?
.-St
-St
Jfi
-Sfi
&
Do you have enough information about where your target
groups live, who needs the most attention, how best to
deliver it, and the effectiveness of your health workers in
reaching those people?
Module 3 will help you get specific information on each
individual in each target group. This will help you set
priorities for services. The module also helps your health
workers develop individual work plans to make sure that
they provide services to those who need them most. This
is a key piece of information that you need. It will help you
to increase coverage and to make sure that high-risk cases
are given priority. And that should lead to improved health
among your target groups. Module 3 also shows you how
to improve the performance of your health workers.
A summary of the contents of Module 3 is shown below
to give you an idea of what it offers. You can use this module
to help you with individual PHC services, although it is
written with a comprehensive PHC programme in mind.
Module 3: Planning and assessing health worker activities
Step 1: Describe and map the catchment area
Step 2: Identify community needs and available resources
Step 3. Set priorities among health problems and identify high-risk groftjro. <
Step 4: Plan PHC activities
Step 5: Develop job descriptions and recruit staff
Step 6: Develop individual work plans and schedules
Step 7: Assess job performance
3$
Module 1: Information needs; level 3
I) U U J
32
Module 3 contains a large number of sample forms that
you can use to plan and assess your health workers activities.
These include clinic and CHW registers, worksheets for
identifying high-risk mothers and children, and work plans.
One of these, a simplified work plan for a CHW’s household
visits, is shown below.
Exhibit 2: Simplified CHW monthly work plan
Work plan for: Lekha Village: Banglapur
Day
Day Schedule
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
May No. HH: 413
Schedule
Holiday
16
Supervision session;#188-197
#1-#17
17
18
#189-212
#18-36
#37-56
Day off
Day off
#57-76
#77-95
#96-114
#115-132
#133-150
Day off
Day off
#151-169
#170-187
19
20
21
22
23
24
25
26
27
28
29
30
31
#220-240
Day off
Day off
#241-256
#257-275
#276-299
#300-321
#322-345
Day off
Day off
#346-369
#370-390
#391-413
Staff meeting
Do you have this kind of information about your target
groups and your health workers’ assignments and perfor
mance? If you do not, then summarise the information you
need in Worksheet B. For each PHC service you offer, you
should have routine information to: 1) identify the people
who need the service (for target-setting); 2) schedule work
to provide the service to them (work planning); and 3) make
sure that the health workers provide the right service to the
right people at the right time (performance assessment).
Module 1: Information needs; level 3
33
QUESTION 4. DO YOU HAVE ADEQUATE INFORMATION ABOUT
CHANGES IN MORBIDITY AND MORTALITY?
It is especially important in developing countries to
monitor changes in disease patterns. Outbreaks of cholera,
a case of polio, changes in the nutrition status of young
children, an increase in deaths, all need to be monitored and
identified promptly so that action can be taken to deal with
the problem quickly.
Sometimes this data can be collected through routine
reporting systems, including vital event registration systems.
Vital event systems are not often found in developing
countries, but PHC programmes can set them up. Some
programmes set up "sentinel" systems. These are usually
health facilities that are designated to report information
regularly on the number of cases of certain diseases that
occur in their catchment areas. Special surveys, such as the
rapid surveys in Module 2, can also be used to collect data
on morbidity and mortality. Case/outbreak investigations
are another method. This usually involves a detailed inves
tigation of an unusual and serious event, such as a maternal
death or an outbreak of hepatitis.
Module 4 describes the basic indicators of morbidity and
mortality to be included in a PHC surveillance system. It
describes how to set up a surveillance system, how to
monitor the incidence and rates of diseases, how to identify
the causes of mortality and morbidity, and how to use that
information to improve programme planning and im
plementation.
Exhibit 3 illustrates one of the products of a surveillance
system. This is a chart showing a five-year trend in deaths
due to anaemia and malaria.
If you are interested in setting up a surveillance system
for your PHC programme, write that down in Worksheet B.
If you already have an idea of the major health indicators
you need to monitor, write those in Worksheet A. Or review
Module 4 first. It can help you identify indicators that are
appropriate for your programme and show you how to set
up a system to meet your needs.
Module 1: Information needs; level 3
Surveillance
systems
34
Exhibit 3: Anaemia and malaria deaths
1987 -1991
QUESTION 5. DO YOU HAVE ADEQUATE INDICATORS TO
MON
ITOR YOUR PHC SERVICES?
Regular monitoring of PHC services is very important
for three reasons. First, you want to make sure that the
services are provided as planned. Second, you want to know
when something goes wrong so that you can fix it. Third,
you want to make sure that any changes you make are
carried out as planned and that they actually work.
To do that you need to have certain crucial pieces of
information about each of your PHC services. In general,
you will want to know: 1) are the resources (staff, equipment,
supplies, etc.) adequate; 2) are the expected services and
products being provided; and 3) are the target groups learn
ing what they need to know and doing what they need to
do?
Module 5 is designed to help you identify those crucial
pieces of information so that you can put them into your
information system. The first part of this module contains
lists of important indicators for each of the PHC services.
An excerpt is shown in Exhibit 4. The second part contains
Module 1: Information needs; level 3
35
lists of management indicators, which are discussed later (see
question 7).
Exhibit 4: Excerpt from Module 5: Monitoring and
evaluating programmes
11.
Oral rehydration therapy
Effect indicators
11.3
11.4
11.5
Number or percentage of mothers who know how to prepare ORS solution, SSS
or local name.
Number or percentage of mothers who know how to administer ORS solution,
SSS or local name.
Number or percentage of mothers who used ORS solution or a recommended
home fluid (total volume increased) and continued feeding during their child’s last
diarrhoea episode (last month).
Output indicators
11.8
11.9
Number or percentage of health workers who counsel mothers on preparation
and administration of ORS solution.
Number or percentage of health workers who correctly showed the mother how
to prepare and administer ORS solution.
Input indicators
11.10
Number or percentage of health units which experienced stock shortages of ORS
packets in the last month.
43
4$
X
4
The indicators are organised by PHC service and system
categories. The impact indicators tell you whether the
programme is improving health status. The effects indica
tors tell you whether the PHC service is working. Is it
having the desired effect on the target group? Are they
learning what they need to know and doing what they need
to do? The output indicators tell you whether the project
is providing the target groups with the services and products
they need. And the input indicators tell you whether the
critical resources are adequate to produce the services and
products.
Module 5 helps you identify key points in the process to
monitor. If something does go wrong, you will have an idea
of where it happened and be able to take action quickly.
48
Module 1: Information needs; level 3
IB
36
Monitoring
indicators
Module 5 will also help you identify the parts of your
service delivery strategy that need the most attention.
Most PHC projects provide services through a combination
of fixed facilities, outreach, community participation, and
referrals. Module 5 can help you identify the indicators that
will be most useful for monitoring the activities of each.
Every good management information system should
include indicators to monitor service inputs and outputs on
a routine basis, as well as periodic surveys to assess pro
gramme processes, effects, and impacts.
You may want to examine your monitoring system to be
sure that it includes at least one key indicator from each
stage in the system. Module 5 can help you select a few
simple indicators of inputs, outputs, and effects for each of
your PHC services. You can enter the ones you select into
Worksheet A, either now or later. This module also shows
you how to set up your own MIS (Management Information
System) and provides guidelines for collecting and process
ing indicator data on a temporary or routine basis.
If you think that you need to improve your monitoring
of PHC services, write that down on Worksheet B, even if
you do not know exactly which indicators you need at the
moment.
QUESTION 6. DO YOU KNOW ENOUGH ABOUT THE QUALITY OF
YOUR PHC SERVICES’
Quality assessment concentrates largely on the service
delivery processes and key resources (supplies, staff, etc.).
Module 6 is a series of checklists that can be used by
managers and supervisors to identify the strengths and
weaknesses of each PHC service.
This is another very important piece of information
about the service delivery system. Module 6 will help you
look at processes, i.e., the way services are provided. How
much do you know about how people are processed through
your programme? How well are they treated by staff? Are
they given the essential information they need? Do they
understand what is going on and what they should do? Are
medical, education, and counselling standards adequately
followed?
IB
Module 1: Information needs; level 3
37
Exhibit 5: Example from Module 6. Checklist for acute
respiratory infection
For observation of service delivery, mark "yes" if the service provider
carries out these activities during service delivery. For interview questions, mark "yes" if the respondent answers correctly.
1.
2.
3._______
4._______
Health facility
_ Service provider
_ Observer/supervisor
_ Date
Take medical history
Did the service provider :
5. YES _ NO ______ Ask about presence/level of fever?
6. YES _ NO ______ Ask about duration of cough?
7. YES _ NO ______ Ask about activity level?
Ask about ability to drink?
NO
8. YES
9. YES _ NO ______ Ask about presence of sore throat?
10. YES _ NO ______ Ask about presence of earache?
11. YES __ NO ______ Ask about any past history of respiratory
problems (asthma)?
12. YES __ NO ______ Ask about family history of TB or other
respiratory illness?
13. YES__ NO______ Ask about any treatment administered?
Conduct physical examination
Did the service provider:
14. YES _ NO ______ Assess general status (alertness, muscle)
15. YES _ NO ______ Count respiratory rate?
16. YES _ NO ______ Take temperature?
17. YES _ NO ______ Observe breathing for chest indrawing?
18. YES _ NO______ Listen for stridor, wheeze, and/or hoarseness?
19. YES
NO______ Auscultate chest?
Examine throat for discharge, enlarged tonNO
20. YES
sils, or inflamed pharynx?
21. YES
NO______ Examine neck for tender glands?
_ Examine ears?
NO
22. YES
Observe colour of lips, ears, face, and nail
NO
23.YES
beds?
Module 1: Information needs; level 3
MM
38
This is one of the most popular modules in the PHC
MAP series because it helps managers and supervisors to
assess the quality of each PHC service quickly and objec
tively.
The checklists are based on exhaustive expert and field
experience. They can be easily adapted to fit local condi
tions. And they can be used to assess the work of an
individual health worker, the work of a group of workers, a
PHC service, or all services of the programme.
_________
If quality of service is a concern and you do not have
Quality
adequate information about the quality of each of your PHC
Checklist
services, then you may want to use Module 6. If you know
----------------- the indicators that you are especially interested in having,
list them in Worksheet A. Or you can do this later after
going through the module. But if you want to examine the
quality of your PHC services, write that down in Worksheet
B, even if you don’t have the specific indicators at this time.
An excerpt from the checklist on acute respiratory
infection (ARI) is shown to give an idea of the content of
these tools. Each checklist includes the major steps in the
service process, the essential supplies and equipment, and
perspectives of clients and service providers. The assess
ments are carried out through observation of services, lim
ited inventories of key supplies and equipment, and brief
interviews with some clients and providers. Discussion
guides, which can be used for semi-structured interviews as
well as focus group discussions, are also included.
If you are only interested in information about PHC
services, you can stop here and set priorities among your
information needs. However if you are also interested in
examining your programme’s management services
(planning, training, supervision, etc.), then continue.
PHC management, costs, and sustainability
The purpose of the last four questions is to help you
determine whether you are collecting adequate information
about the way the PHC programme is managed and the
effects that management has on the programme’s resources
and operations. If not, you may find Modules 5, 7, 8, and 9
helpful.
Module 1: Information needs; level 3
39
QUESTION 7. DO YOU HAVE ADEQUATE INDICATORS TO
MON
ITOR YOUR MANAGEMENT SERVICES?
Good management support is often a prerequisite to
successful PHC programmes. A recent assessment of eight
PHC programmes funded by the Aga Khan Foundation
Management is one of the most crucial determi
nants of successful primary health care. Good
planning, co-ordination, staffing, supervision,
monitoring and evaluation all contribute.1
concluded that managers need information about manage
ment services as much as they do about PHC services. They
need to know whether training is being carried out as
planned; whether supervision is having the desired effect on
health worker performance; whether the logistics system is
keeping essential supplies and equipment available; and
whether the community organisation strategy is leading to
better PHC services.
The following are the 8 management services that are
included in the PHC MAP modules. These have been
selected because experience has shown that they are the
most important ones that most PHC service programmes
include.
PHC management services
Planning
Personnel
Training
Supervision
Finances
Logistics
Information systems
Community organisation
1 Reynolds, J. and Stinson. W Lessons Learned from Primary Health Care Programmes Funded by the
Aga Khan Foundation. Aga Khan Foundation, Geneva and Washington DC, June, 1991.
Module 1: Information needs; level 3
40
Most PHC managers are responsible for only some
management services. Training may be done at the
central or regional rather than local level. Logistics man
agement may be limited to sending in requests to a central
warehouse for needed supplies. But the programme may be
completely responsible for community organisation and
supervision of health workers.. Usually, managers should be
most interested in the management services that they con
trol, since there is not much they can do about those that
they do not control.
If you are not monitoring some of these activities or are
not sure what would be appropriate indicators for monitor
ing management services, then take a look at the second
section of Module 5. It contains lists of indicators for each
of the management services listed above. These indicators
are arranged in the same categories as the PHC Service
indicators, that is, Inputs, Outputs, and Effects. Exhibit 6
shows some of the training indicators.
Exibit 6: Excerpt from Module 5. Monitoring and
evaluating programmes
2.
Number or percentage of participants in training who showed improvement between
the pre- and post-tests.
Output indicators
2.2
Number or percentage of health workers having received training or refresher training
in the last period for any intervention (or for specific interventions).
2.3
Number or percentage of training sessions that allowed participants to put new
knowledge and skills into practice during training (using real life cases or role play).
2.4
Number or percentage of training sessions in which technical content was complete
and accurate.
Input indicators
2.5
01-
G
E
£
g?
TRAINING
Effect indicators
2.1
SF
Number or percentage of health units using programme-specific information (from
MIS or supervision) about service quality to plan or focus training sessions given in
the last period.
£
B -
S
S?
B
S Module 1: Information needs; level 3
Si:
41
You can enter your priority indicators in Worksheet A.
And if you think you need to improve your monitoring of
management, write that down in Worksheet B, even if you
do not know exactly which indicators you need at this time.
This list of indicators should tell you whether you need
Module 5, and if so, where it would be most helpful to you.
As noted before, this module also can help you to identify
the strategic services that need attention (outreach, clinic
services, etc.) and can help you set up a project-specific MIS.
QUESTION 8. DO YOU KNOW ENOUGH ABOUT THE QUALITY OF
YOUR MANAGEMENT SERVICES?______________________________
Module 7 is similar to Module 6 as it contains checklists
for assessing your management processes (see Exhibit 7).
This can be used by managers, supervisors, and others to
identify the strengths and weaknesses of each management
service in the PHC programme.
If quality of management is a concern, and you do not
have adequate information about the quality of your man
agement services, then write down in Worksheet B the
services that you believe should be examined.
QUESTION 9. DO YOU HAVE ENOUGH INFORMATION ABOUT THE
COST OF YOUR PROGRAMME AND ITS SERVICES?______________
Module 8 can help you put this kind of information
together. You can examine costs and revenues over time,
compare the costs of the various PHC services, compute unit
Module 8 : Cost analysis
1. The total amount of resources spent
2. Expenditures compared with budgeted amounts
3. Distribution of costs by line item
4. Distribution of costs by site, facility, or location
5. Trends in costs over time
6. Projection of future costs
7. Average costs
8. Analysis of revenues, past and projected
9. Break-even analysis .when revenues equal or exceed expenditures
Module 1: Information needs; level 3
42
Exhibit 7: Excerpt from Module 7. Assessing the quality of
management information systems monitoring
An information system is organised around key indicators that measure a
programme’s progress. It is a systematic way of collecting, reporting, and using
data at all programme levels.
This checklist is intended for use in the assessment of management information
systems. Its objective is td help managers to enhance the quality of their
programmes by identifying and resolving problems in the management informa
tion systems area. It can be adapted for use in both vertical programmes and
integrated PHC efforts. The questions below can be answered through interviews,
document review, observation of management services, or a review of the health
facility. Some questions ask for the respondents opinion about the quality or
adequacy of specific tasks; in such cases the perspectives of managers, health
service providers, and community members should be taken into account. Areas
that are deemed inadequate can be further explored through focused discussions
with key informants. With modification, the checklist can be used as a basis for
an open-ended interview or group assessment.
Health facility
Service provider
Observer/supervisor
Date
Planning the information system
Health service indicators monitor the performance of a system or programme.
An information system is a group of these indicators that reveals the status of
the programme. These questions will help you determine if a basic information
system is in place.
Is there a list of indicators to be monitored
at district level?.
6- YES
NO Is there a list of indicators to be monitored at
health centre level?
Do these lists include indicators of:
7. YES
NO
Resource availability?
8. YES
NO
Access?
9. YES
NO
Utilisation?
10. YES
NO
Coverage?
11 YES
NO
Service quality?
12. YES
NO
Outcome?
13. YES
NO
Have information sources been identified for each
indicator?
14. YES
NO
Has the frequency of collection/compilation for
each indicator been established ?
15. YES
NO
Has an analysis procedure for each indicator been
established (including thresholds or standards)?
16. YES
NO
Have mechanisms for interpreting and discussing
results been established?
5. YES
NO
Module 1: Information needs; level 3
£?--
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Si
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43
a;
30
Exhibit 8: Excerpt from Module 8
Figure 2: North and Central expenditures
3)
=3J
3d
=30
3d
=3)
30
30
30
30
costs, compare expenditures with your budget, and so forth.
Module 8 actually shows you how to do 9 different types of
analysis, which are summarised below.
The first pages of this module display various cost graphs
that the module's computer programs generate. One of
these is shown above.
You can use the module to examine costs in various ways :
• By LOCATION (geographic area)
• By FACILITY (health centres, hospitals, depots)
• By PHC SERVICE (ORT, immunization clinic services)
• By BUDGET LINE item (personnel, travel, equipment)
30
-ffi
30
Jfi
30
Some managers have accounting systems that produce
some of this information or could do so with very little
additional effort. Others will have to put in a good deal of
effort to classify their expenditures by type of PHC service,
clinic site, time period, etc. For some managers, especially
those who have no control over their budgets, cost analysis
may not seem to be worth the effort. However, our field
tests have shown that when managers can demonstrate
Module 1: Information needs; level 3
44
Prospective
analysis
what PHC services actually cost, they can argue more
forcefully in defence of their budgets.
Many managers also have control over some portion of
their budgets and can shift funds from one area to another,
within limits, of course. Knowing what the costs are of the
various services can help managers make better reallocation
decisions.
Finally, as decentralisation of authority and responsibil
ity for PHC expands, more managers will find themselves
needing good cost information for planning their pro
grammes and for monitoring expenditures.
Experience has shown that it is not difficult nor time
consuming to conduct a cost analysis by budget line items.
However, it is difficult to compute the costs of each PHC
service (e.g., immunization) and their unit costs (e.g., the cost
per child immunized). If this type of cost analysis is desired,
it is best to do the analysis prospectively (i.e., from now on).
That is, the cost categories should be set up and costs
classified on an ongoing basis. This will not only be easier,
but more accurate than trying to do the analysis retrospec
tively (i.e., by reclassifying past costs).
But even if you cannot be completely accurate, Module
8 will show you how to make reasonable estimates of costs
if cost information is important to you.
If you plan to do a sustainability analysis (Module 9), you
will probably need cost estimates. Module 8 can help you
get that information.
If you do not know the costs of your programme and
services, you may want to look at Module 8. The module
will help you decide the cost information you need. Write
down in Worksheet B any PHC services and management
services in your programme for which you need cost infor
mation. Write "Overall PHC services" or "Overall manage
ment" if you only want total programme cost information.
SP
ST
£
£
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Si
EL
Sr
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BL.
----------------------- —__________________________
S
MINE HOW TO SUSTAIN YOUR PHC PROGRAMME IN THE FUTURE?
jfc.
The last in the series, Module 9, can help you to develop
and analyse various strategies for sustaining the health
g-
QUESTION 10. DO YOU HAVE ADEQUATE INFORMATION TO DETER-
Module 1: Information needs; level 3
3
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45
status of your target population and the PHC services and
resources needed to do that.
While many people look at sustainability only as a
funding issue (how will we get the money to continue?),
Module 9 starts from goals and works backwards to funding.
It first asks you to define your sustainability objectives:
Where do you want the programme to be in X number of
years? What outcomes should the programme be able to
achieve? What services should it be providing?
Next, it asks you to examine 10 factors that are common
threats to sustainability, to assess whether they will be
important for your programme, and to identify strategies for
addressing those that are threats (or opportunities). For
example, if the size of your target population increases, that
could strain the programme’s ability to provide adequate
services. If political commitment to the programme de
clines, that could lead to a decrease in support for the
programme. On the other hand, if political commitment
increases, that might lead to increased support and allow
you to expand services.
The module includes indicators you can use to assess
these factors and suggested strategies for dealing with those
that could be problems.
Some examples of strategies for dealing with political
commitment include: 1) dropping unpopular components;
2) appointing influential leaders to the board or advisory
Sustainability factors
Target group size
Target group KAP
PHC service quality
Management support
Organisational capacity
Political commitment
Personnel resources
Revenues
Expenditures
Environmental factors
33
Module 1: Information needs; level 3
46
committee; and 3) assisting communities in expressing their
needs to political leaders and donors.
The module also includes a financial assessment tool so
that you can project future revenues and expenditures,
taking the above factors and strategies into account.
This analysis enables you to test different assumptions
about coverage, service strategies, and revenue and expen
Ti
TI
Quick start - Basic sustainability analysis
Table 3 : Input estimates - enter revenues and expenses for the
current year.
Current
Yr
Yrl
Yr 4
Yr 3
Yr 2
Yr 5
343
370
400
432
467
504
Expenses
365
381
399
417
435
455
Balance
(22)
(ID
1
15
32
49
Table 4 : What-if analysis - enter projected annual % increase (+)
or decrease (-)
Negative Factors
(A + will increase costs or decrease
revenues)
(A - will decrease costs or increase
revenues)
Revenues (+R)
6.0% Expenses (+E)
3.0%
Organisational Capacity (-E)
3.0%
5.0%
In-kind Contributions (-E)
Political Commitment (+R)
0.0% Target Population Size (+E)
5.0% Target Population Coverage
(+E)
Environmental Factors (+R)
-3.0% Personnel Resources (+E)
1.0%
PHC Service Quality (+E)
-5.0%
Management Support (+E)
-4.5%
Inflation (+E)
e
E
Revenues
Positive Factors
(A + will increase revenues or decrease
costs)
( A - will decrease revenues or increase
costs)
iTt;
3.0%
5.0%
Module 1: Information needs; level 3
EL
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47
33
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-3
I
3
3
3
diture projections. You enter these assumptions in a "What
If" table and receive the results in a five-year projection of
revenues and expenditures. The module's computer program
produces figures shown in Table 3 and the accompanying
graph, based on the information you feed into the What-if
analysis.
Exhibit 9: Excerpt Module 9. Sustainability
Analysis
Projected revenues & expenditures
Year 1-5
3
3C
3
33
*3
33
33
^3J
4
%
If you do not know whether or how to sustain your
programme, your PHC services, or your management ser
vices, you may want to look at Module 9. If so, write that
down in Worksheet B.
Module 1: Information needs; level 3
49
Appendix A
Setting priorities among information needs
If you have been filling out Worksheets A and B as you’ve gone through
these questions, then you should have a summary of your programmes
goals, principal target groups, health and management services, coverage
objectives, key indicators, and information needs. If you haven’t done this
yet, now would be a good time to do so.
You may be able to determine your priorities by just reading over
Worksheet B. If that is not possible or if you have too many "high priority"
needs, then the following suggestions may help you to determine where to
begin.
1. Convene a group. List the information needs on a board or on a
handout. Ask each person to rank each item. Give the lowest item a score
of 1, the next lowest 2, and so forth. The highest ranked item would have
the highest score. Then total the scores of the group. Discuss the results.
Don’t just accept the scores. Try to come to a consensus as to which
information is highest priority, next highest, and so forth.
2. Identify rating criteria. Design a matrix to give each item a score
along 2, 3, or 4 criteria, such as:
• Importance: How great is the need for this piece of information?
• Cost to collect and process: How easy will it be to obtain this informa
tion?
• Utility: How useful will this information be for planning and/or evalu
ation?
Then do as above. Rate each information item on each
selected criterion, as shown below:
Information
Quality assessment: ANC
5
Quality assessment: Imm
Cost analysis: PHC
.5
8
4
Surveillance system
7
Community survey : needs
Cost*
Utility
Total
6
6
6
6
8
17
17
21
5
4
2
4
12
5
14
* The lower the cost, the higher the score, and vice versa.
Module 1: Information needs; appendix A
IB
Worksheets
WORKSHEET A: DEFINING SERVICE INDICATORS
Instructions: 1) List each priority PHC or management service; 2)
Identify-key indicators you need for planning and/or monitoring; 3) Identify those that are already available ( mark with an x);
4) Identify the low, medium and high priority items (e.g., with ", **, and ""’); 5) Revise and update this list as you proceed through
Module^ and.other modules.
TARGET ,
GROUP
INPUTS
PROCESSES
OUTPUTS
EFFECTS
IMPACTS
(resources)
(activities)
(products and services)
(knowledge,
attitudes,
behaviour/
practice)
(morbidity,
mortality, fertility)
Module 1: Information needs; appendix B
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Module 1: Information needs; appendix B
52
Acronyms and abbreviations
(til
ii tii ii tii tii tii tii it Ui
Acquired immune deficiency syndrome
Aga Khan Foundation
Antenatal care
Acute respiratory infection
Breast feeding
Community health worker
Don’t know
Family planning
Growth monitoring
Health worker
Information, education, communication
Knowledge, attitudes, practice (behaviour)
Management information system
Ministry of Health
Non-governmental organisation
No response
Oral rehydration salts
Oral rehydration therapy
Primary health care
Primary Health Care Management Advancement Programme
Postnatal care
Primary Health Care Operations Research
Sugar-salt solution
Sexually-transmitted disease
Tuberculosis
Traditional birth attendant
Total fertility rate
Tetanus toxoid
World Health Organization
tii
AIDS
AKF
ANC
ARI
BF
CHW
DK
FP
GM
HW
I EC
KAP
MIS
MOH
NGO
NR
ORS
ORT
PHC
PHC MAP
PNC
PRICOR
SSS
STD
TB
TBA
TFR
TT
WHO
Module 1: Information needs; acronyms
53
Glossary
Catchment (area): The geographic area surrounding one or more health
facilities. It refers to the population residing in that area, which includes
the programmes target groups.
Community health worker (CHW): A person indigenous to the com
munity who provides selected basic and limited health services to members
of the community. Includes village health workers, health guides, and other
terms.
Coverage: The proportion of a target group that has received a service or
is protected from a disease or health problem.
Goals: The impact your programme hopes to have on health. Goal
statements specify improvement desired, target group, amount of change
expected and date for achievement.
Indicator: An indirect measure of an event or condition. For example, a
baby’s weight for age is an indicator of the baby’s nutritional status.
Information audit: A systematic assessment of information needs com
pared with information currently collected.
Inputs: Resources (human, materials and supplies, equipment and facilities,
information and money).
Management: The art and science of getting things done through people.
Objectives: The output and/or effect your PHC programme hopes to have.
Outcomes: Results of your PHC programme, including outputs, effects
and impacts.
Outputs: Products and services provided by a PHC programme.
Effects: Changes in knowledge, skills, attitude, and behaviour (includ
ing coverage) as a result of a PHC programme.
Impacts: Changes in health status (mortality, morbidity, disability,
fertility) as a result of a PHC programme.
Primary health care: Essential health care, accessible at affordable cost
to the community and the country, based on practical, scientifically sound
and socially acceptable methods. It includes at least eight components:
health education, proper nutrition, water supply, basic sanitation, maternal
and child health care, immunization, control of common diseases and
injuries, prevention of local endemic diseases, essential drugs.
Processes: Activities or tasks carried out through the PHC programme.
Register: A written or printed record containing regular entries of events
or other items, such as name, address, births, deaths, symptoms, treatments
Module 1: Information needs; glossary
54
Risk factor: A characteristic of an individual or group that is associated
with an increased chance of contracting a disease, having a health problem,
or dying.
System: A set of discrete, but interdependent, components designed to
achieve one or more objectives.
Target group: Specific groups of people designated to receive a PHC
service, such as children under age 3.
Module 1: Information needs; glossary
PHC MAP MANAGEMENT COMMITTEE
Dr. Ronald Wilson • Aga Khan Foundation, Switzerland (Co-Chair)
Dr. Jack Bryant • Aga Khan University, Pakistan (Co-Chair)
Dr. William Steeler • Secretariat of His Highness the Aga Khan, France (Co-Chair)
Dr. Jack Reynolds • Center for Human Services, USA (PHC MAP Director)
Dr. David Nicholas • Center for Human Services, USA
Dr. Duane Smith • Aga Khan Foundation, Switzerland
Dr. Pierre Claquin • Aga Khan Foundation, Switzerland
Mr. Aziz Currimbhoy • Aga Khan Health Service, Pakistan
Mr. Kabir Mitha • Aga Khan Health Service, India
Dr. Nizar Verjee • Aga Khan Health Service, Kenya
Ms. Khatidja Husein • Aga Khan University, Pakistan
Dr. Sadia Chowdhury • Aga Khan Community Health Programme, Bangladesh
Dr. Mizan Siddiqi • Aga Khan Community Health Programme, Bangladesh
Dr. Krasae Chanawongse • ASEAN Institute for Health Development, Thailand
Dr. Yawarat Porapakkham • ASEAN Institute for Health Development, Thailand
Dr. Jumroon Mikhanorn • Somboon Vacharotai Foundation, Thailand
Dr. Nirmala Murthy • Foundation for Research in Health Systems, India
PHC MAP TECHNICAL ADVISORY COMMITTEE
Dr. Nirmala Murthy • Foundation for Research in Health Systems, India (Chair)
Dr. Krasae Chanawongse • ASEAN Institute for Health Development, Thailand
Dr. Al Henn • African Medical and Research Foundation (AMREF), formerly of
the Harvard Institute for International Development
Dr. Siraj-ul Haque Mahmud • Ministry of Planning, Pakistan
Dr. Peter Tugwell • Faculty of Medicine, University of Ottawa, Canada
Dr. Dan Kaseje • Christian Medical Commission, Switzerland, formerly of the
University of Nairobi, Kenya
KEY PHC MAP STAFF AT THE CENTER FOR HUMAN SERVICES
Dr. Jack Reynolds (PHC MAP Director)
Dr. Paul Richardson
Dr. David Nicholas
Dr. Wayne Stinson
Ms. Maria Francisco
Dr. Neeraj Kak
Ms. Lori DiPrete Brown
Ms. Pam Homan
Dr. Lynne Miller Franco
Ms. Mary Millar
SER’S GUIDE
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