At the start of the AHI initiative, agreement was reached to collect a selected number of core measures of quality across all Partnerships (described in more detail in the paper by Bryce et al. in this supplement) [14]. Two of these – health workers per capita and continuous stocks of essential commodities – reflect WHO guidance on monitoring and evaluation of HSS [7]. Other core measures that capture aspects of quality include specific coverage measures (e.g., intermittent preventive treatment for malaria in pregnancy, skilled attendant at birth, and appropriate management of selected childhood illness). Despite significant discussion and brainstorming, there remain a number of areas where consensus on specific indicators of quality within one or more of the HSS blocks could not be reached. As a consequence, the teams agree to report on their Partnership-specific activities to improve quality of care and measure quality annually.
In each project, quality is defined, measured, and targeted for improvement across many or all of the six WHO HSS building blocks, going well beyond the traditional focus on service quality. The measurement of the impact of these improvement efforts on quality is integrated into each Partnership impact evaluation plan. Data sources in use by the PHIT Partnerships for measuring quality fall into three main categories: 1) use of routinely available data (e.g., facility reports and health management information system (HMIS); 2) data collection tools developed within the intervention and integrated into routine project monitoring (e.g., facility surveys and mentor reports); 3) and measurement solely for interim and summative impact evaluations designed for baseline measurement, mid-course correction, and end-of-project assessment.
Despite the heterogeneity of interventions and independence of evaluation designs, there is significant overlap in approaches targeting the definition of quality (Table 3). While some of these measures overlap with WHO recommendations on measuring components of quality, others reflect the specific pathways through which each Partnership is working to strengthen the health system and improve population health.
Service delivery
The service delivery building block has the greatest range of measures of quality across the Partnerships. Many measures reflect the WHO recommendations around access, coverage, and patient-centeredness. Components include availability of services, reported utilization and coverage (access), quality of care per national protocols, timeliness, and patient and community satisfaction (patient-centered). This includes services delivered at facilities and by community-based health workers.
Health workforce
All the Partnerships measure and work to improve health care worker distribution and density and supervision activities as fundamental components of a human resource strategy. These are core components for Rwanda and Zambia, which are implementing a mentoring model for health facility staff. A few projects also target additional factors, including staffing levels at facilities, management of staff, retention levels, satisfaction, motivation, and the quality of care provided. A number of the Partnerships (Tanzania, Rwanda, and Ghana) also include a focus on strengthening the community health workers workforce through ensuring adequate staffing levels, training, and supervision of this cadre. To improve management and leadership skills of district health managers and their teams as key members of the health workforce, the Ghana team, with support from UNICEF, developed tools that were used to train all district health managers in the operational areas of the project. Mozambique measures the efficiency of allocating trained staff as an additional component of human resource system quality.
Information
Aligned with WHO priorities, ensuring data quality is the most common activity across projects, although specifics vary [15]. The PHIT Partnerships all focus on both the processes of measuring data quality and the level of data quality attained. Data utilization for decision making is a core component of quality within this building block, as well as attributes of the data utilized, such as timeliness and accuracy of required reporting.
Medical products, vaccines, and technologies
Based on WHO recommendation, a core indicator across the Partnerships is the availability of a set of tracer drugs and other commodities to assess health service readiness at the facility or community health worker (CHW) levels. However, the specific list of drugs and other commodities are tailored to reflect country guidelines. Additional measurement areas include equipment levels and overall strength of the district supply chain management system and availability of lab testing capacity.
Financing
Partnerships focus on assessing the quality of financial management, including the use of the PHIT project funds to support the planned activities. Three of the projects explicitly identify equitable or data-driven allocation of resources as a measure of quality of financial systems (overlapping with measures of quality of governance) (Table 4). In Rwanda, insurance coverage (a WHO identified area) and cost is measured as an additional area of financial quality.
Leadership and governance
While WHO focuses on the presence of relevant strategies and guidelines largely at the national level, the Partnerships are a practical operationalization of the governance and leadership building block at the provincial, district, or lower levels, with an emphasis on how systems are governed and managed locally. Ghana and Mozambique explicitly measure governance, focusing on collecting documentation of management and evidence-based allocation of resources including use in Ghana of a tool specifically designed to enable managers to make budget decisions based on need rather than previous allocations. Community participation and their perceived levels of good governance are measured in Zambia as an indicator of quality governance.