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Assessing Provincial and District Health System Capacity


to Sustain HIV/AIDS Care and Treatment ServicesA
Literature evie! "or CDC/P#P$A
Ilona Varallyay, Jennifer Yourkavitch, and Eric Sarriot. ICF Macro- May 28, 2!
Introduction
Since 2004, PEPFAR has supported four partners to rapidly scale up ART services through the
! Trac" 1#0 ART progra$#
1
These partners currently support 2% &'( care and treat$ent
progra$s in 1) countries
2
, including $ore than 1,000 ART treat$ent sites# They are creating
transition plans to facilitate the transfer of progra$ $anage$ent to *inistries of &ealth +*,&-
and local organi.ations, /hich can provide sustaina0le support for &'( care and treat$ent
progra$s over the long1ter$#
!uring the scale up phase, the focus of progra$ activity /as at the health facility level# The
transition no/ needs a co$prehensive approach to ensuring the capacity of *,& and local
partners at the district and provincial levels to sustain &'( care and treat$ent services# To this
end, Trac" 1#0 partners for$ed a provincial2district su01group and deter$ined core do$ains
)
of
health syste$ capacity to $anage &'( progra$ services# PEPFAR2!2&RSA see" to develop
a rapid assess$ent tool to $onitor provincial and district *,& capacity in each do$ain, /hich
/ill 0e used to assess the status of transition efforts#
This literature revie/ supports the effort to strengthen analytical approaches to provincial and
district health syste$ capacities to support &'( services 0y providing a rationale for the core
do$ains of assess$ent, and 0y identifying certain $ethodologies and conte3tual factors to
consider /hen designing the assess$ent tool# The authors revie/ed $ore than 40 sources on
health syste$s strengthening, specifically for &'( services and related areas, and discussed
related issues /ith health syste$s e3perts +Anne3 )-# This docu$ent su$$ari.es their findings
and reco$$endations, and includes an annotated 0i0liography +Anne3 1- and a detailed ta0le
that descri0es the $ain tools revie/ed +Anne3 2-# This literature revie/ lays a solid foundation
for developing a rapid assess$ent tool for provincial and district health syste$ capacity to
sustain &'( care and treat$ent services#
%ethodology o" the revie!
'F perfor$ed a syste$atic revie/ of pu0lished and unpu0lished +grey- literature on the
assess$ent of health syste$s capacity at various levels and also specifically relating to &'(
service delivery#
Search Strategy
'F identified sources fro$ a syste$atic search of co$puteri.ed data0ases +*edline, Popline,
!ialog 4includes 5lo0al &ealth, Federal Research in Progress +FE!R'P-, E*are, The 6ancet-,
1
The four partners are &arvard 7niversity School of Pu0lic &ealth, 'AP at olu$0ia 7niversity *ail$an School of Pu0lic &ealth, the
Eli.a0eth 5laser Pediatric A'!S Foundation, and A'!SRelief consortiu$ led 0y atholic Relief Services#
2

Trac" 1#0 countries include8 9ots/ana, ote d:'voire, Ethiopia, 5uyana, &aiti, ;enya, *o.a$0i<ue, =igeria, R/anda, South Africa, Tan.ania,
7ganda, >a$0ia
3
ore do$ains include8 strategic planning for integrated &'( services? hu$an resource $anage$ent for clinical services? supervision of clinical
services? health facility renovation2$aintenance2e<uip$ent? la0oratory services support? phar$acy supply2logistics2&*'S, *@E syste$s? <uality
$anage$ent2i$prove$ent syste$s? co$$unity lin"ages? sta"eholder $anage$ent and coordination? and financial $anage$ent of donor funding
for &'( services
a search of the electronic archives of relevant international organi.ations using the 5oogle search
engine +A0t, &ealth Syste$s 20220, *EAS7RE Evaluation, A&,, the Aorld 9an", F&', etc#-,
and 0y studying the 0i0liographies and reference lists of identified sources#
Searches used co$0inations of the follo/ing "ey/ords8
Peripheral health syste$ capacity B !istrict health tea$ capacity B Provincial level
capacity
&'(2A'!S care and treat$ent B &'( integrationB &'( B &'( infections B &'(
trans$ission
&ealth Services Perfor$ance B health planning
*anage$ent capacity B Essential functions B Supervision of
Assess$ent ofC B Revie/ ofC B Assess$ent tool B *ethodology B capacity assess$ent
Te$poral li$its /ere set to include sources fro$ the past 20 years? language restrictions /ere set
to include references in Spanish, French, and English#
Article Selection
!ocu$ents /ere eligi0le for inclusion in the literature revie/ if they addressed either health
syste$s strengthening at the su01national level? if they focused on health syste$s assess$ent at a
0roader level 0ut had lo/er level applications? if they addressed ART progra$s specifically? if
they addressed capacity assess$ent along one of the !2Trac" 1#0 partner1proposed Dore
!o$ainE areas? or if they addressed issues of sustaina0ility of health services#
For &'(1related resources, a te$poral li$it /as set to all docu$ents dated post12001, as this /as
the appro3i$ate ti$e that international organi.ations started scaling up the introduction of AR(s
in developing countries#
,verall, 4) docu$ents /ere identified, including 1F assess$ent tools, F of /hich /ere &'(1
focused#
&ey In"ormant Intervie!s
'n addition to the literature revie/ed, /e conducted se$i1structured "ey infor$ant intervie/s
/ith several international health e3perts, /ho$ /e felt could contri0ute to the discussions
around the selection of do$ain areas for the develop$ent of this tool# The selection of these
contacts /as 0ased on initial reco$$endations fro$ colleagues involved in health syste$s
strengthening and facility assess$ent /or", and then spanned out as each contact $ade
references to others in a relevant field# 'ndividuals fro$ A0t Associates 'nc, A'!STAR1T/o,
*&'P, *S&, 7SA'!, A&, provided infor$ation included in this literature revie/# All
contacts /ith infor$ants too" place 0et/een April 2%
th
and *ay 11
th
, 2010 +See Anne3 ) for list
of infor$ants-#
District Capacity !ithin a Health Systems Perspective
The $ost do$inant fra$e/or" for assessing the capacity and perfor$ance of the health syste$
as a /hole is the A&, Si3 9uilding 9loc"s *odel +A&,, 200F-# This $odel 0rea"s the health
syste$ functions into % 0road categories +Figure 0elo/-8
1# Service delivery: pac"ages? delivery $odels? infrastructure? $anage$ent? safety @ <uality?
de$and for care
2# Health workforce: national /or"force policies and invest$ent plans? advocacy? nor$s,
standards and data
)# Information: facility and population 0ased infor$ation @ surveillance syste$s? glo0al
standards, tools
4# Medical products, vaccines & technologies: nor$s, standards, policies? relia0le
procure$ent? e<uita0le access? <uality
G# Financing: national health financing policies? tools and data on health e3penditures? costing
%# Leadership and governance: health sector policies? har$oni.ation and align$ent? oversight
and regulation
*ost of the $ore recent health syste$s literature and tools adhere to this co$prehensive
conceptuali.ation# Ae focused our revie/ on the operational definition and $easure of capacity
at provincial and district levels and did not find reason to challenge the H0uilding 0loc"s: as an
overarching $odel for loo"ing at capacity and perfor$ance in the health section#
't is useful at this point to state i$portant pre$ises of our revie/#
Capacity is not Per"ormance
,rgani.ational apacity is the a0ility of an organi.ation to $eet its $andate and achieve its
o0Iectives#
4
Perfor$ance is ho/ effectively the sa$e organi.ation i$ple$ents its activities and
delivers its services# Those t/o concepts are o0viously related, 0ut they are distinct#
Perfor$ance can 0e assessed 0y the delivery of a good or service to clients# This can 0e
translated into a relatively s$all nu$0er of si$ple $etrics#
apacity, on the other hand, is far $ore $ultidi$ensional, and its develop$ent does not fit linear
patterns# These t/o characteristics have provided nu$erous challenges to the $easure$ent of
capacity over the years#
G
4
6aFond, A#, 6# 9ro/n, ;# *acintyre# Mea"urin# Ca$acity in the %ealth Sector& a Conce$tual Fra'e(ork. 'nt J &ealth Plann *g$t 2002? 1F8
)122# Pu0lished online in Ailey 'nterScience +///#interscience#/iley#co$- !,'8 10#10022hp$#%4K
5
'0id#
The District has a uni'ue and pivotal role in the health system
9ro/n and 6aFond again revie/ed the state of the art in assessing and $easuring capacity in the
health sector# 'n the figure 0elo/, their $odel helps visuali.e ho/ assessing each level has to 0e
analy.ed /ithin an overall syste$#
7nder this $odel, the !istrict fits at the level of the ,rgani.ation#
!epending on si.e and political ad$inistrative structures of each country, districts report directly
to a central level or through a regional ad$inistrative level# Provinces so$eti$es play the role of
districts, other ti$es act as regional or <uasi1central structures# Ahere health districts as
operational units are essential ele$ents of a health syste$,
%
the role of the province should 0e
clearly defined and $ay include $onitoring the perfor$ance of district health syste$s, training
district1level staff, and conveying central health policies, a$ong others#
F
ur focus here is on
structures ! district or province ! directly overseeing and organi"ing the work of service
delivery units and health workers#
Assessment challenges
The first challenge lies /ith the understanding and $easure$ent of capacity# The reader is
referred again to 9ro/n and 6aFond for a thorough treat$ent of the concepts and $easure$ent
challenges# 'n su$$ary8 capacity supports perfor$ance, 0ut the relationship 0et/een the t/o is
$ultidi$ensional, non1linear, and co$ple3#
6
;loss1Luiroga, 9# +Ed#-# In)Ent& *i"trict %ealth Mana#e'ent +ool"& Facilitator," Manual. 9erlin, 2004
7
hatora, Rufaro and Prosper Tu$usii$e# %ealth Sector -efor' and *i"trict %ealth Sy"te'". *i"trict %ealth Mana#e'ent +ea' +rainin#
Module", Module !. 9ra..aville, A&,, 2004#
Then, the uni<ue position of districts creates so$e challenges in the evaluation of its
perfor$ance 0ut also its capacity# For e3a$ple, assessing ho/ a district organi.es and
i$ple$ents supervision, or secures drugs and co$$odities to service providers, is certainly
0etter assessed at health facility level than in the district health office itself# Ahile this tension
$ostly affects $easures of perfor$ance, it $ay on occasion 0e relevant to the assess$ent of
district:s capacity as /ell# Si$ilarly so$e ele$ents of district capacity are deter$ined 0y central
level policy or resource allocation decisions# 'n other /ords, a district capacity assess$ent $ay
identify hu$an resources /ea"nesses, 0ut these $ay 0e e3pression of inade<uate policies or
interventions of a higher level#
The ta"e1ho$e $essage is that a Hdistrict capacity assess$ent:, 0y /hich an assess$ent is
conducted at district level e3clusively, $ust 0e understood /ith a proper appreciation for the
0oundaries and li$itations it carries +i#e# so$e capa0ilities of the districts are 0etter analy.ed
upstrea$ or do/nstrea$-#
evie! o" e(isting assessment models
)ature o" assessment methodologies and type o" indicators
The tools revie/ed included <ualitative and <uantitative assess$ent $ethodologies? a fe/
incorporated 0oth ele$ents# Approaches included self1assess$ents, facilitated self1assess$ents,
and traditional survey $ethodologies, al0eit $ainly at facility level# Assess$ents varied in the
level of applica0ility fro$ national to provincial to district to facility levels? for purposes of this
search, /e focused on relevant district and provincial level resources# =ational level tools that
could serve as a guide for the develop$ent of relevant su01national assess$ent criteria /ere also
included# The $ost co$$on data collection $ethodologies involved using secondary data,
docu$ent revie/, and sta"eholder intervie/s# So$e are rapid assess$ents? others are intended
for longer1ter$ i$ple$entation +See Anne3 2-#
'ndicators included 0oth <ualitative and <uantitative ele$ents# The different tools capture si$ilar
do$ain areas /ith distinct indicators, /hich /ill 0e assessed for relevance to the ! rapid
assess$ent tool# *any /ill have to 0e $odified to fit the conte3t of district2province, according
to the roles of the health syste$ at this level#
M
Domains o" assessment at provincial / district levels
Sa$0o presents a type of fra$e/or", /hich loo"s specifically at the !istrict level, assesses the
functionality of the syste$ according to 0roader categories, /hich in su$ capture all of the
A&, 0uilding 0loc"s8 1- the e3istence of functional district level management structures
+village2to/n health co$$ittee, health facility $anage$ent co$$ittee, !&*T, etc- 2- the
managerial process +planning, colla0oration, guidelines, supervision2 $onitoring, drug
$anage$ent, referral $echanis$s, &*'S- )- the health activities2interventions delivered 4- the
community health initiatives G- the availa0ility of locally $anaged health1related resources
+facility 0udget, cost recovery, hu$an resources, infrastructure, e<uip$ent, supplies-#
K
This
fra$e/or" does not loo" at health syste$ perfor$ance#
,ne health syste$ assess$ent tool /hich adheres to the A&, fra$e/or" /as adapted for use at
provincial level, adIusting the fra$e/or" for applica0ility at su01national level#
10
A close
8
'0id#
9
Sa$0o et al# +ool" .""e""in# the /$erationality of *i"trict %ealth Sy"te'"# 9ra..aville, A&,, 200)#
10
Thi *ai ,anh, et al# .""e""in# 0rovincial %ealth Sy"te'" in Vietna'& 1e""on" fro' +(o 0rovince"# *arch 200K# 9ethesda, *!8 &ealth
Syste$s 20220 proIect, A0t Associates 'nc#
analysis of the specific indicators used at provincial level should infor$ the develop$ent of the
! assess$ent# The governance core do$ain is captured through indicators such as8 1-
Responsiveness of govern$ent to pu0lic needs, 2- (oice of the people )- E3ercising local
technical oversight of health service <uality 4- Production of services needed 0y the pu0lic G-
'nfor$ation and reporting %- !irection, oversight and resource allocation tas"s carried 0y
govern$ent# The health financing core do$ain is captured through indicators such as8 1-
revenue collection 2- pooling and allocation of financial resources )- purchasing and provider
pay$ents# Service delivery is assessed /ith indicators such as8 1- availa0ility 2- general access,
coverage and utili.ation )- service outco$es 4- service delivery access and utili.ation G-
organi.ation of service delivery %- <uality assurance of care F- co$$unity participation in
service delivery# Human resources infor$ation such as &R planning, &R policies, perfor$ance
$anage$ent, and training and education are assessed# The pharmaceutical management
system do$ain captures ele$ents including relevant 0udget, policies2la/s2regulations,
procure$ent, storage @ distri0ution, appropriate use, access to <uality products, and financing#
The HIS co$ponent includes infor$ation on resources2policies2regulation, data collection and
<uality, data analysis, and use of infor$ation for $anage$ent#
Another assess$ent fra$e/or" intended for use at the district level captured the ele$ents of the
A&, si3 0uilding 0loc"s through F $odules, /hich loo"ed in turn at 1- !istrict health
$anage$ent and support syste$s 2- pri$ary health care facility infor$ation )- rural2district
hospital infor$ation 4- co$$unity participation and traditional health syste$s G- co$$unity
and household infor$ation %- patterns of $ortality#
11
Such an approach co$0ines household
level, facility level, and district level data collection# o$ponents /hich /ill 0e of particular
relevance to the develop$ent of the ! tool include those on district health $anage$ent and
support syste$s and on co$$unity participation2traditional health syste$s#
The A&, !istrict &ealth *anage$ent Tea$s Training *odules used in !R
12
have 0een
developed to assist each tea$ $e$0er to /or" as a leader and $anager in leading health
develop$ent in the district# The $ethodology is of particular relevance for the develop$ent of
the assess$ent tool as it provides a useful fra$e/or" for translating the functions of the health
syste$ at national level into e<uivalent roles at district level, according to four 0road health
syste$ function do$ains8 stewardship, resource generation, service delivery and financing#
't defines a nu$0er of "ey roles at province or regional level, particularly relevant in a conte3t of
decentrali.ation#
HIV*Speci+c esources
A nu$0er of tools focused on assessing &'( progra$s or service delivery specifically, though
pri$arily at either national or facility level# The do$ains of assess$ent are nonetheless pertinent
to the proposed ! assess$ent and can 0e adapted to suit district2provincial level applica0ility#
,ne tool
1)
translated the % A&, 0uilding 0loc"s into ART1specific do$ains and indicators in the
follo/ing /ay8
1- Site 6eadership and *odel +6eadership? *odel of &'( are? ART1Specific protocols-
2- Services and linical are +o$prehensive &'( care services other than ART? ART
delivery? Physical Space? o$$unity 'nvolve$ent-
11

*aier et al# .""e""'ent of the di"trict health "y"te' 2 u"in# 3ualitative 'ethod"# 5T>2A&,2'T&N5 &eidel0erg# +1KK4-#
12

hatora, Rufaro and Prosper Tu$usii$e# %ealth Sector -efor' and *i"trict %ealth Sy"te'". *i"trict %ealth Mana#e'ent +ea' +rainin#
Module", Module !. 9ra..aville, A&,, 2004#
13
&irschhorn, 6# et al# +ool to .""e"" Site 0ro#ra' -eadine"" for Initiatin# .ntiretroviral +hera$y or Ca$acity for E4i"tin# .-+ "ite"# 9oston,
*A8 John Sno/, 'nc# 200)#
)- &ealth 'nfor$ation *anage$ent, *onitoring, Evaluation, and Luality +&*'S? Luality
*anage$ent ART Progra$ *@E -
4- &u$an Resource apacity +Staffing needs? training and s"ills develop$ent?
*anage$ent, supervision and staff retention-
G- 6a0 apacity +6a0 procedures capa0ility? Luality standards-
%- !rug *anage$ent and Procure$ent +!rug *anage$ent and Phar$acy *anage$ent-
Ahile this assess$ent is intended for facility2site level i$ple$entation, these do$ain areas and
indicators can 0e $odified for use at su01national level#
Another relevant tool, &'(2A'!S Progra$ Sustaina0ility Analysis Tool 4&APSAT, focused on
assessing the sustaina0ility of &'(2A'!S progra$s +including (T, P*TT, ART, care and
support services, and prevention- through a co$puter10ased forecasting $odel#
14
This tool
calculates resource needs for an &'(2A'!S progra$ /ith a user defined set of service level
goals# &APSAT also co$pares proIected resource needs +focusing pri$arily on hu$an resources
and financial resources- to e3pected resource availa0ility and can 0e used to identify and report
e3pected gaps and resource i$0alances that $ade lead to inefficient or poor <uality service
delivery# 't captures the follo/ing do$ains8 1-de$ographic data 2- epide$iological data )-
financial data +trends in donor funding for &'(2A'!S progra$s and services and outline current
and potential funding possi0ilities 4- 6a0or data G- service volu$e data %- $edical data F- cost
data# E3a$ples of specific indicators include8 <uantity of health /or"ers? average salaries of
health /or"ers? ART drug regi$ens cost? nu$0er of patients on each ART regi$en? a$ount of
donor funding and internal revenue for &'(2A'!S currently and e3pected? cost of la0oratory
tests? etc# This tool is very co$prehensive and very in depth? only a very $odified and lighter
version of such a sustaina0ility assess$ent co$ponent could 0e pertinent for the ! rapid
assess$ent tool#
,f nota0le interest /ere $odels addressing the chronic nature of &'(2A'!S and the i$portance
of $aintaining the client at the center of any assess$ent fra$e/or"# Ahile such $odels /ere
pri$arily designed for developed1country conte3ts, /e identified such fra$e/or"s as highly
applica0le for the developing country conte3t as /ell# ,ne $odel
1G
loo"s at three core
co$ponents /ith respect to care for chronic conditions8 positive policy environment, the
community, and the health care organi"ation? of particular interest are the H0uilding 0loc"s: for
health care organi.ation /hich include promoting continuity and coordination? encouraging
$uality care through leadership and incentives? organi"ing and e$uipping health care
teams? supporting self%management and prevention? using information systems# Ahile the
focus of the ! assess$ent is at district2provincial level, this $odel highlights the i$portance
of 0earing in $ind the ulti$ate needs of the patient2client, /hich is relevant for district level
$onitoring and supervision# !ifferences 0et/een developing and developed country assess$ent
approaches lie in the assu$ption that certain capa0ilities are in place Has a given Hand that the
assess$ent can $ove to/ard those capacity areas /hich support higher standards of <uality care#
Domain*speci+c esources
A nu$0er of do$ain1specific tools /ere also revie/ed#
,ne tool focuses on assessing the logistics system for HI&'(I)S programs, using <uantitative
indicators to assess product availa0ility and inventory $anage$ent practices#
16
Specific
indicators address8 inventory control syste$s +'Ss-? logistics $anage$ent infor$ation syste$s
14
&ealth Syste$s 20220 proIect# 5"in# %.0S.+ for %IV 0ro#ra' Su"taina6ility .naly"i"& .n Introductory 7uide# April 2010# 9ethesda, *!8
A0t Associates 'nc#
15
A&,# 'nnovative are for hronic onditions8 9uilding 9loc"s for Action# A&,, 2002#
+6*'Ss-? and storage, logistics reporting, and ordering and institutional support# Another tool
focuses on hu$an resources $anage$ent for &'(2A'!S progra$s
17
# 't contains 2% &R*
co$ponents +su01do$ains- /hich are grouped /ithin five 0road areas of &R*8 &R* capacity
+staffing, 0udget, and planning-? personnel policy and practice? perfor$ance $anage$ent?
training? &R* data#
'F also revie/ed several articles and grey literature docu$ents addressing issues around scale
up of (*+ progra$s /hich highlight a nu$0er of "ey issues for consideration in the
develop$ent of this ! rapid assess$ent# ,ne report descri0es an assess$ent /hich focused
on t/o areas8 logistical re<uire$ents for ensuring a relia0le and consistent supply of <uality
antiretroviral drugs +AR(s- and related co$$odities, and infrastructure and personnel
re<uire$ents necessary to ensure their safe and effective use 0y patients#
18
't outlines "ey criteria
to assess site readiness for ART initiation /hich can 0e adapted into indicators for ART delivery
capacity at a higher level# This docu$ent also stresses the i$portance of a ro0ust supply chain to
$anage co$$oditiesOa "ey area for assess$ent at district2provincial syste$ic levelOand
outlines the "ey ele$ents for effective 6*'S#
Another report on the scale up of ART in 7ganda highlights a nu$0er of indicators according to
the A&, fra$e/or", and also includes a do$ain for Hco$$unications: and 'E, e3ploring
issues /hich influence the degree of co$$unity level a/areness of &'( services8 infor$ation on
the availa0ility of treat$ent, care, and support services at co$$unity level? infor$ation
ca$paigns? co$$unication $aterials such as 0oo"lets on AR( therapy? guides for service
providers on dispensing AR( drugs? details of all AR( drugsOdosage, phar$aco"inetics2
phar$acodyna$ics, side effects, drug interactions, etc#
1K
This ele$ent could 0e incorporated into
the ! o$$unity 6in"ages do$ain# Another article sites progra$ planning guidance for the
i$ple$entation of e3panded ART services and includes valua0le infor$ation on coordination
/ith other progra$s that could 0e useful in developing indicators for the DSta"eholder
*anage$ent and oordinationE core do$ain#
20
Analysis o" CDC/Trac, -./ Partners Proposed Core Domains
The proposed 11 Dore !o$ainsE proposed 0y ! Trac" 1#0 partners can all 0e lin"ed to one
of the A&, health syste$s 0uilding 0loc"s and, in their entirety, capture all of the ele$ents of
the A&, $odel +see ta0le 0elo/-# 7nli"e the A&, $odel, these include a do$ain for
assess$ent of co$$unity1related co$ponents#
,), proposed ,ore )omains *elevant -H Health System .uilding
.locks
Strategic Planning for 'ntegrated &'( Services 6eadership25overnance
&u$an Resource *anage$ent for linical
Services
&ealth Aor"force
Supervision of linical Services &ealth Aor"force @ Service !elivery
16
=yen/a, Ja0ulani, et al# >i$0a0/e &'( @ A'!S 6ogistics Syste$ Assess$ent# Arlington, (a#8 John Sno/, 'nc#2!E6'(ER, for the 7#S#
Agency for 'nternational !evelop$ent, 200G#
17
*S&, 200)# &u$an Resource *anage$ent Rapid Assess$ent Tool for &'(2A'!S Environ$ents# a$0ridge, *A8 *S&#
18
=oguera, *#, et al# 8i'6a6(e& .ntiretroviral +hera$y 0ro#ra' 2 I""ue" and /$$ortunitie" for Initiation and E4$an"ion. Arlington, (A8
!E6'(ER2John Sno/, 'nc#, 200)#
19

,"era, A# et al, *ay 200)# Scalin# 5$ .ntiretroviral +hera$y. 5#andan E4$erience# !raft# 5eneva, S/it.erland8 Aorld &ealth ,rgani.ation#
20

Ta/fi", P#, et al# Introducin# .ntiretroviral +hera$y 9.-+: on a 1ar#e Scale& %o$e and Caution. 0ro#ra' 0lannin# 7uidance ;a"ed on Early
E4$erience fro' -e"ource-1i'ited and Middle-Inco'e Countrie"# Aashington !, 7SA8 Acade$y for Educational !evelop$ent 5lo0al &ealth,
Population and =utrition 5roup# =ove$0er 2002#
&ealth Facility
Renovation2*aintenance2E<uip$ent
Service !elivery
6a0oratory Services Support *edical Products2vaccines2technologies @
Service !elivery
Phar$acy Supply26ogistics *edical Products2vaccines2technologies
&*'S, *@E Syste$s &ealth 'nfor$ation syste$
Luality *anage$ent2'$prove$ent Syste$s Service !elivery @ &ealth infor$ation syste$s
o$$unity 6in"ages n2a
Sta"eholder *anage$ent and oordination 6eadership25overnance
Financial *anage$ent of !onor Funding for
&'( services
&ealth Financing
$irst Leads "or the Development o" the CDC apid Assessment Tool
A couple of do$ain areas identified in the literature revie/ /hich are not e3plicitly captured in
the !1proposed do$ains, and /hich deserve consideration are co$ponents pertaining to
district2provincial health tea$ role in8 1- positive policy environ$ent, and 2- co$$unications#
Aith respect to policy environ$ent it $ay 0e useful to assess the district:s capacity in8
1- strengthening partnerships? 2- supporting legislative fra$e/or"s? )- integrating policies? 4-
providing leadership and advocacy? and G- developing and allocating hu$an resources
ade<uately# These functions are fre<uently considered at higher up level, 0ut the case can 0e
$ade for their needed develop$ent at district level in the conte3t of decentrali.ation, and the
increasing re<uire$ent for pu0lic structures to ensure the via0ility of their traditionally assigned
roles#
Aith respect to co$$unications2'E it /ould 0e useful to assess the district:s capacity in
organi.ing and providing infor$ation +for e3a$ple, interventions such as infor$ation
ca$paigns- to the co$$unities a0out ART and other &'( services availa0le, 0e it directly, 0y
outsourcing, or through partnership#
9ecause this tool is intended for use at district2province level, it should include 0oth general
ele$ents that address the operationality of the 0roader health syste$ at inter$ediate level and
also ele$ents /hich address &'(1specific capacity re<uire$ent for the delivery of ART services#
!ra/ing fro$ the literature and fro$ "ey infor$ant intervie/s, the proposed assess$ent tool
under develop$ent /ould 0e $ost relevant if it too" a syste$1/ide approach, incorporating
other closely related health service areas such as *& and T9, at least as pertains to &'(
service deliveryOparticularly as it is often difficult to clearly de$arcate 0et/een &'( and other
services#
21
,ne "ey infor$ant noted that the selection of proposed do$ains includes all of the
core A&, 0uilding 0loc" ele$ents, 0ut has si$ply 0ro"en so$e do/n into $ultiple do$ain
areas? this si$ply allo/s for a $ore in depth analysis of any given 0uilding 0loc" and essentially
gives strong H/eight: to this 0uilding 0loc" in the assess$ent#
Regarding the &u$an Resources do$ain, the literature and the feed0ac" fro$ "ey infor$ant
intervie/s suggests that it /ill 0e critical to e3tend the analysis around this do$ain 0eyond Iust
21

=egussie? &odgins? Travis, Phyllida et al# DSu0national &ealth Syste$s Perfor$ance Assess$ent8 ,0Iectives, hallenges and Strategies#E
hapter GK in %ealth "y"te'" $erfor'ance a""e""'ent & de6ate", 'ethod" and e'$irici"' 2 edited 0y hristopher J#6# *urray, !avid 9# Evans#
A&, 200)#
clinical services11 e<ually relevant is &R capacity at progra$ $anage$ent level +e#g# &R
shortages do not only concern clinical staff, 0ut also $anage$ent staff-# Aith respect to
governance issues, the proposed do$ains only capture t/o "ey ele$ents8 DStrategic Planning for
integrated &'( servicesE and DSta"eholder $anage$ent and coordination#E ,ur revie/ suggests
the i$portance of
incorporating indicators on
accounta0ility $echanis$s
+0oth up/ard and
do/n/ard? is there
e3ternal accounta0ility at
district levelQ-# An
i$portant ele$ent to
consider in relation to
Dsupervision of clinical
servicesE is the <uestion
around /hether $anagers
have the Dreal authorityE to
re/ard or sanction staff
0ased on perfor$ance and
at /hat level does this
authority lieQ The do$ain
on sta"eholder
coordination should loo"
at coordination across
different sectors and also
across different actors
+private providers, =5,s,
agencies, 9,s, etc-#
,verall, the proposed
do$ains are
co$prehensive and this
literature revie/ has
0rought to light a nu$0er
of issues for consideration
/hile developing specific
indicators under these
do$ain areas relevant to district2province level application#
Conclusion
9ased on this revie/ of literature and "ey infor$ant intervie/s, 'F reco$$ends "eeping
!2Trac" 1#0 Partners: proposed do$ains in the rapid assess$ent approach, and adding an
additional do$ain a0out service integration, /hich /ill 0e pri$arily concerned /ith the &'(
care and treat$ent service integration /ithin the larger provincial or district portfolio,
particularly as &'( care overlaps /ith ele$ents of *& and T9 care#
,ther ite$s that 'F /ill consider as it proceeds /ith the design of tool options include
assess$ent areas and indicators related to8
o$$unity lin"ages, including health syste$ co$$unication /ith co$$unities and
health service delivery at co$$unity level
Take Home Message in View of Development of a
Rapid Assessment Tool
Capacity is a multidimensional concept with strong
interdependency between its diferent dimensions. A given
organizational performance (i.e. providing a skilled care
provider, trained and equipped in a timely fashion to a client of
counseling services requires the e!pression of diferent
capabilities from a district" sound human resources
management, from recruiting to training to supervising#
appropriate resourcing of $nances, goods and commodities#
sound planning and work organization, etc.
%iven this comple!ity and co&linearities, each assessment tool
will organize dimensions of assessment according to a
dominant paradigm (continuity of services, oversight of health
facilities and providers, management and oversight systems,
etc..
'hese di(culties also afect the assessment of capacity of
health districts, as a linchpin organization within national health
systems. 'he literature is rich in facility assessment tools, but )
as shown in this review ) far poorer in assessments conducted
at district level (and even more so with an *+,-A+./ care and
treatment focus.
'he C.C 'rack 0.1 partners have ofered a set of capacity areas
which $ts the speci$c performance e!pected from *ealth
.istricts in their implementation countries. 'hese $t easily
under the standard 2*3 building block model for the *ealth
/ystem, and no ma4or modi$cation is recommended for the
development of a rapid assessment tool.
'he greater challenge will be to identify appropriate questions,
indicators, and data collection processes to be implemented at
the .istrict level, through a rapid methodology, and capturing
the most pertinent capacity elements as tentative predictors of
.istrict performance in *+,-A+./ prevention care and
treatment.
&R capacity in $anage$ent
Accounta0ility $echanis$s
&'(2A'!S as 0oth a chronic condition and infectious disease
Patients: roles in decision1$a"ing regarding &'( care and treat$ent
Policy environ$ent
o$$unications
'F /ill also consider the content and depth of verification ele$ents, /hich /ill include
infor$ation collected fro$ a health facility to verify infor$ation collected at the provincial or
district level#
Ahile there are several tools concerned /ith $easuring <uality of care at a health facility and
others concerned /ith the perfor$ance of the health syste$, very fe/ assess the health district or
province as an institutional and operational unit# !ocu$enting the develop$ent, testing and use
of the ! rapid assess$ent /ill fill a gap in the literature and assist others concerned /ith the
i$portant issues related to the $anage$ent transition and sustaina0ility of &'( care and
treat$ent services#
Anne(es
Anne3 1 4 Annotated 9i0liography
Anne3 2 4 Ta0le of &ealth Syste$ Assess$ent *odels Applica0le to !istrict2Provincial 6evel
Anne3 ) 4 6ist of Persons 'ntervie/ed
Anne( -
(nnotated .i/liography
-. Alva0 Soumya0 #. &leinau0 A. Pomeroy0 &. o!an. Measuring the
Impact of Health Systems Strengthening A Review of the !iterature
1SAID0 )ov. 2//3.
This is a co$prehensive &ealth Syste$s Strengthening literature revie/ /hich see"s to
su$$ari.e current efforts in $easuring health syste$ perfor$ance and to highlight the
indicators and perfor$ance 0ench$ar"s $ost fre<uently used 0y the glo0al co$$unity# ,f
particular use for the develop$ent of the ! assess$ent tool is the list of "ey indicators 0y
0uilding 0loc" +A&, $odel-#
2. Cassels0 Andre! 4 &at5a 6anovs,y. Strengthening Health
Management in Districts and "rovinces 7H80 9eneva0 -33:.
This is a $anual that provides guidance for a facilitated self1assess$ent on su01national pro0le$
identification, analysis and action planning, /hich focuses on the follo/ing 0road areas8
Finance, Personnel, Staff Training, Statistics, Supplies, Transport, *aintenance, &ealth
Education o$$unity 'nvolve$ent# 't is not directly relevant to the purposes of the proposed
! district2provincial level assess$ent#
;. Chatora0 u"aro and Prosper Tumusiime. Health Sector Reform and
District Health Systems District Health Management Team Training
Modules# Module $ <ra==aville0 7H80 2//>.
This is one of a set of four $anage$ent training $odules ai$ed at !istrict &ealth *anage$ent
Tea$s in the countries of the African Region# *odule 1 has 0een developed to assist each tea$
$e$0er to /or" as a leader and $anager in leading health develop$ent in the district# 't is of
particular relevance for the develop$ent of the assess$ent tool as it provides a useful fra$e/or"
for translating the functions of the health syste$ at national level into e<uivalent roles at district
level, according to 4 0road health syste$ function do$ains8 ste/ardship, resource generation,
service delivery and financing# 't also redefines a nu$0er of "ey roles at province or regional
level, particularly relevant in a conte3t of decentrali.ation#
>. $amily Health International ?$HI@A #thiopia. Addis ABaBa. City
Administration Health <ureau. Addis A%a%a HIV care and support
service assessment. Addis ABaBa0 #thiopia0 $HI0 2//2 Aug.
A descriptive cross1sectional study /as conducted to assess e3isting care and support services#
This assess$ent loo"ed at &'(2A'!S care and support services at the $anage$ent and
coordination level and the service provision level, focusing on Dho/ people /or"ing at service
$anage$ent and coordination level organi.e their /or", /hat guidelines they use, training they
give to service providers, and the needs they identify to 0e a0le to function opti$ally#E +P#1-# At
the service provider level, it loo"s at /hat they do and /hat they need to function /ell#
onclusions of interest8 the assess$ent 0egan /ith a discussion a0out role distri0ution a$ong
the partners, including various govern$ent levels and =5,s# Although fe/
progra$$ers2providers address stig$a, feed0ac" fro$ service providers indicated that stig$a
reduction interventions should 0e given overall higher priority#
:. 9TCD Assessment of the District Health System &sing 'ualitative
Methods E-33>F
+See *aier et al, 1KK4-
G. Health %etrics )et!or,0 2//GB. Strengthening (ountry Health
Information Systems) Assessment and Monitoring Tool 9enevaD
7H8.
The &ealth *etrics =et/or" +&*=- 0egan in 200G to help countries and other partners i$prove
glo0al health 0y strengthening health infor$ation syste$s# This tool ans/ers the need for an
effective assess$ent of the e3isting national &'S in order to esta0lish a 0aseline and to $onitor
progress# See .nne4 2 for detail".
_________________________________________________________________________________________
H. Health Systems 2//2/D HIV*AIDS "rogram Sustaina%ility Analysis Tool
+HA"SAT, ABt Associates Inc0 2//H.
+See 0elo/ and .nne4 2 for details#-
I. Health Systems 2//2/. &sing HA"SAT for HIV "rogram Sustaina%ility
Analysis) An Introductory -uide April 2/-/. <ethesda0 %DD ABt
Associates Inc.
&APSAT is a *icrosoft E3cel10ased tool for forecasting and analy.ing the sustaina0ility of &'(
progra$s at national +country- level# &APSAT calculates resource needs for an &'(2A'!S
progra$ and also co$pares proIected resource needs to e3pected resource availa0ility# The
resources re<uired to provide these services are 0ro"en into three categories8 financial resources
+donor and govern$ent funding-, hu$an resources for service delivery +e#g# doctors, nurses, la0
technicians, phar$acists, ad$inistrative staff-, and physical capital +0uildings, vehicles,
la0oratory $achines-# This tool is directly relevant to the financial $anage$ent do$ain? one of
the proposed tool designs /ill incorporate ele$ents fro$ this tool# See .nne4 2 for detail".
3. Hirschhorn0 L.0 A. $ullem0 C. Sha!0 7. Prosser0 and %. )oguera. Tool
to Assess Site "rogram Readiness for Initiating Antiretroviral
Therapy or (apacity for ./isting ART sites <oston0 %AD 6ohn Sno!0
Inc.0 2//;
This tool, /hich can 0e used either for site self1assess$ent or 0y e3ternal revie/ers, /as
designed to provide sites and progra$s /ith a set of criteria to assess a siteRs readiness to
i$ple$ent ART or the current capacity and needs of an e3isting progra$, and to identify "ey
areas that need strengthening# The rating syste$ identifies sites along G progressive stages of
readiness, /hich can 0e adapted for the ! tool# This tool is also particularly useful for its
develop$ent of do$ain areas along the % A&, 0uilding 0loc"s for ART1specific progra$s# See
.nne4 2 for detail".
-/. Islam0 %.0 ed. 2//H. Health Systems Assessment Approach) A
How0To Manual SuBmitted to the 1.S. Agency "or International
Development in collaBoration !ith Health Systems 2//2/0 Partners
"or Health e"ormplus0 Juality Assurance Pro5ect0 and ational
Pharmaceutical %anagement Plus. Arlington0 VAD %anagement
Sciences "or Health.
+See Thi *ai ,ahn, 200K-
SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS
--. Israr0 S.%.0 A. Islam. -ood -overnance and Sta%ility) a case
study from "akistan Int 6 Health Plann %gmt 2//GA 2-D ;-;K;2:.
PuBlished online in 7iley InterScience E!!!.interscience.!iley.comF
D8ID -/.-//2/hpm.I:2
This paper argues that good governance, characteri.ed 0y transparency, accounta0ility and
$eaningful co$$unity participation, is an essential co$ponent of sustaina0ility for donor1
funded health syste$s proIects in the pu0lic health sector# 't descri0es the failure of an effort to
decentrali.e Pa"istan:s health syste$, an effort /hich also encouraged co$$unity participation
and de$ocratic decision $a"ing in a classically hierarchical $anage$ent structure# The authors
introduce a Sustaina0le *anage$ent Approach Dthat can 0e used to ensure the sustaina0ility of
health syste$s proIects, particularly those funded 0y international organi.ations in developing
countriesE +p# )1)-# The approach consists of these para$eters8 participation and consensus
orientation? 0uilding institutional capacity? strategic vision and appropriate leadership?
effectiveness, efficiency and responsiveness? and accounta0ility, and includes a list of output and
outco$e indicators# '$portant conclusion8 D,ften health sector refor$s fail to achieve their
intended results $ainly due to a failure in addressing the co$ple3 dyna$ics of the e3isting
syste$# Esta0lishing and sustaining an ena0ling environ$ent is i$perative for introducing and
successfully i$ple$enting a large1scale proIectE +p# )24-#
-2. &ielmann0 Arn"ried A. Assessing district health needs#
services# and systems) protocols for rapid data collection and
analysis A"rican %edical and esearch $oundation0 %acmillan
#ducation Ltd. E)airoBi0 &enya0 -33-F.
Revie/ed as part of Sa$0o, 6#5# et al# +ool" and Method" for %ealth Sy"te' .""e""'ent&
Inventory and -evie(. 5eneva, A&,, 1KKM#
-;. &loss*Juiroga0 <. E#d.F. In1.nt) District Health Management
Tools) 2acilitator3s Manual <erlin0 2//>
DSince the $id 1KM0s, the health district as an operational unit has 0eco$e the essential ele$ent
of health policy concepts in lo/ inco$e countries +&arare conference in 1KMF-E +p#2-# This
$anual is a training guide and reference for trainers, facilitators or presenters /ho have so$e
e3perience /ith !istrict &ealth *anage$ent# The concept and principles of Pri$ary &ealth
are for$ this approach to !istrict &ealth *anage$ent# 9esides technical "no/ledge, !istrict
&ealth *anagers need leadership a0ility, co$$unications s"ills, process1oriented thin"ing and
the capacity to co1operate in local and regional net/or"s# This e3periential, participatory training
approach pro$otes practical "no/ledge and s"ills, gender2diversity1sensitivity, and the e3change
of ideas and personal e3periences# See .nne4 2 for detail".
->. &olyada0 Lena %.Sc. Health Systems Strengthening and
HIV*AIDS) Annotated 4i%liography and Resources Partners "or
Health e"ormplus. $unded By 1.S. Agency "or International
Development. ABt Associates Inc. %arch 2//>.
Four resources /ere selected for revie/ fro$ this 9i0liography8 Ta/fi" @ ;inoti, 2002?
&irschhorn et al 200)? =oguera )t al, 200)? and ,"era et al, 200)#
-:. La$ond0 A.0 L. <ro!n0 &. %acintyre. Measuring (apacity in the
Health Sector) a (onceptual 2ramework Int 6 Health Plann %gmt
2//2A -HD ;*22. PuBlished online in 7iley InterScience
E!!!.interscience.!iley.comF D8ID -/.-//2/hpm.G>3
and
La$ond0 A.0 L. <ro!n. A -uide to Monitoring and .valuation of
(apacity04uilding Interventions in the Health Sector in Developing
(ountries %#AS1# #valuation %anual Series0 )o. H. %arch 2//;.
%#AS1# #valuation Pro5ect.
'n this pu0lication +availa0le under a peer1revie/ed for$at and a $ore detailed report 0y
*EAS7RE Evaluation-, 6aFond and 9ro/n propose a conceptual fra$e/or" for understanding
and $easuring capacity in the health sector# They revie/ type of indicators to 0e considered
along the input1process1output1outco$e continuu$ 0y level of analysis, fro$ the &ealth Syste$
to the ,rgani.ation onto the individual &ealth Aor"er# The docu$ent revie/s assess$ent and
$easure$ent approaches availa0le at the ti$e, 0ut is particularly pertinent for its conceptual
argu$entation of the definition of capacity and identification of challenges and li$itations in its
assess$ent and $easure$ent# Although the &ealth !istrict ,ffice can 0e approached as an
,rgani.ational Structure /ithin the &ealth Syste$, the revie/ does not provide enough focus on
this specific level to infor$ the proposed ! district2provincial level assess$ent#
-G. %aier0 <.0 . 9Lrgen0 A.A. &ielmann0 H.6. Dies"eld0 . &orte.
Assessment of the district health system 5 using 6ualitative
methods 9TC/7H8/ITHM9 HeidelBerg. E-33>F
This $anual ai$s to help health Professionals arrive at a co$prehensive understanding of health
needs, Services and Syste$s in a particular area through a process of rapid <ualitative data
collection and analysis guided 0y a set of structured protocols# !ata is collected at district,
facility and household level? infor$ation is o0tained 0y intervie/ing "no/ledgea0le infor$ants
and 0y revie/ing locally availa0le docu$ents# ,f particular relevance for this proIect are the
sections on 1- !istrict &ealth *anage$ent @ Support Syste$s and 2- o$$unity participation
and traditional health syste$s# See .nne4 2 for detail".
-H. %a,omBe SD0 %. Hochgesang0 A. 6ahn0 H. T!eya0 <. Hedt.
Assessing the 6uality of data aggregated %y antiretroviral treatment
clinics in Malawi <ulletin o" the 7orld Health 8rgani=ation. 2//I
AprA IG E>FD ;-/*;->.
This study assessed the <uality of <uarterly aggregate su$$ary data co$piled and reported 0y
ART facilities +Dsite reportE- as co$pared to the Dgold standardE facility su$$ary data co$piled
independently 0y the *inistry of &ealth supervision tea$ +Dsupervision reportE-# 't e3plores the
various factors influencing data <uality and highlights supervision and hu$an resources for
record "eeping +cler"s- as t/o actiona0le areas /hich positively affect data <uality# Also
outlined in this article are several reco$$endations to ensure data <uality, /hich can 0e
translated into relevant assess$ent indicators for the &*'S2*@E do$ain of the tool#
-I. %inistry o" Health*CamBia. 7am%ia HIV * AIDS Service
"rovision Assessment Survey 899:. Lusa,a0 CamBia0 %inistry o"
Health0 2//G 6ul.
The >&SPA survey $easures the capacity of health facilities to provide preventive services as
/ell as to $eet the care and support needs of people living /ith &'(2A'!S and their fa$ilies
through t/o data collection instru$ents8 the facility resources audit <uestionnaire and the health
/or"er intervie/ <uestionnaire# The core &'(2A'!S health services co$ponents assessed
include8 &'(2A'!S1related outpatient and inpatient care that includes general health syste$
$anage$ent? 'nfection prevention and co$pliance to standard precautions? &'(2A'!S testing
and counseling? Antiretroviral therapy? Prevention of $other1to1child trans$ission services
+P*TT-? &ealth $anage$ent infor$ation syste$s +record "eeping- relevant to &'(2A'!S?
6a0oratory diagnostics for &'(, tu0erculosis, $alaria and $ost co$$on ST's, and? Availa0ility
and $anage$ent of essential $edications, supplies, and treat$ent services related to &'(2A'!S#
The indicators herein /ill 0e useful for develop$ent of the verification piece of the assess$ent
tool# See .nne4 2 for detail".
-3. %SH0 2//;. Human Resource Management Rapid Assessment
Tool for HIV*AIDS .nvironments CamBridge0 %AD %SH.
httpD//erc.msh.org/ne!pages/english/tool,it/hrNhivNassessmentNtool.
pd"
This tool outlines a process to help an organi.ation to <uic"ly assess the perfor$ance of its
hu$an resource $anage$ent syste$ and develop an action plan for $a"ing necessary
i$prove$ents, /ith a focus on &'(2A'!S /or"place strategies# 't contains 2% &R*
co$ponents +su01do$ains- /hich are grouped /ithin five 0road areas of &R*8 &R* capacity
+staffing, 0udget, and planning-? personnel policy and practice? perfor$ance $anage$ent?
training? &R* data# This tool can serve as a reference for the types of &R* issues that $ust 0e
addressed at every organi.ational level in order to 0etter plan, staff and i$ple$ent &'(2A'!S
progra$s#
2/. %anagement Sciences "or Health. Health Systems in Action) An
eHand%ook for !eaders and Managers CamBridge0 %AD %anagement
Sciences "or Health0 2/-/. AvailaBle online at
httpD//!!!.msh.org/resource*center/health*systems*in*action.c"m
and as a CD*8%.
This hand0oo" is a co$prehensive, practical guide /hich includes a set of tools and resources
that address co$$on issues in leading and $anaging health services? it is also availa0le in
electronic version to facilitate access to e3ternal lin"ages# The hand0oo" is designed to address
various "ey ele$ents of an effective health syste$, /hich include strong leadership and
$anage$ent? good governance? /ell1crafted plans? professional hu$an resource $anage$ent?
sound financial $anage$ent? good $anage$ent of $edicines and health products? $onitoring
and evaluation focused on results? and the delivery of high1<uality health services# For purposes
of the tool design, this hand0oo" /ill serve as a good reference $aterial for concepts and
approaches regarding each of the % A&, 0uilding 0loc"s#
2-. )ash0 D et al. Strategies for More .;ective Monitoring and
.valuation Systems in HIV "rogrammatic Scale0up in Resource0
limited settings) Implications for Health Systems Strengthening
6ournal o" Ac'uired Immune De+ciency Syndrome0 Vol. :20 Supp.-0
)ov.-0 2//3.
This article discusses co$$on challenges to *@E syste$s used in the rapid scale1up of &'(
services as /ell as innovations that $ay have relevance to syste$s used to $onitor, evaluate, and
infor$ health syste$s strengthening# 't is particularly relevant for the &*'S2*@E do$ain of
the assess$ent tool as it provides guiding principles for sustaina0le national *@E syste$s
/hich can 0e adapted into indicators for su01national level application#
22. )oguera0 %.0 D. Alt0 L. Hirschhorn0 C. %aponga0 P. 8se!e0 and
A. Sam* ABBenyi. 7im%a%we) Antiretroviral Therapy "rogram 5 Issues
and <pportunities for Initiation and ./pansion Arlington0 VAD
D#LIV#/6ohn Sno!0 Inc.0 2//;
This report presents the findings of a four1/ee" assess$ent of the readiness and capacity of
>i$0a0/e:s health sector to deliver the range of services and $anage the health co$$odities
re<uired for effective antiretroviral +ART- treat$ent# The assess$ent loo"s at all the "ey
functions of the logistics syste$ re<uired for the ART progra$, /hich /ill 0e relevant for the
develop$ent of the phar$acy supply2logistics do$ain of the assess$ent tool 0eing developed for
!#
2;. )ordBerg #0 H. 8ganga0 S. &a=iB!e0 6. 8nyango. Rapid
assessment of an African district health system Test of a planning
tool Int 6 Health Plann %anage. -33; 6ul*SepAIE;FD2-3*;;
The authors report on a rapid health syste$ assess$ent conducted in rural ;enya in 1KK1# The
assess$ent included a self1ad$inistered <uestionnaire for each health facility? intervie/s /ith
officers in charge of each health institutions in the su01district, and a revie/ of records and
reports at each facility# 5enerally, the focus /as on service provision and the R1&FA is
considered to 0e a stronger tool for these purposes? ho/ever, /e $ay adapt an open1ended
<uestion used in this tool for <ualitative infor$ation on the greatest challenges faced at the
!istrict2province level#
2>. )yen!a0 6.0 D. Alt0 A. &arim0 T. &u"a0 6. %Boyane0 O. 8uedraogo0
and T. Simoyi. 7im%a%we HIV = AIDS !ogistics System Assessment
Arlington0 Va.D 6ohn Sno!0 Inc./D#LIV#0 "or the 1.S. Agency "or
International Development0 2//:.
The 6'AT +6ogistics 'ndicator Assess$ent Tool- and 6SAT +6ogistics Syste$ Assess$ent Tool-
tools assess the DhealthE of the logistics syste$ for &'(2A'!S related co$$odities and supplies#
These are facility1level assess$ents that include "ey infor$ant intervie/s and o0servation /hich
use <uantitative indicators to assess various aspects of logistic syste$s for &'(2A'!S progra$s#
The ai$ of the assess$ent tools is to understand the challenges facing the logistics syste$s and
to o0tain a description of the supply chain syste$ for several co$$odities# The ele$ents fro$
these tools /ill 0e adapted for use in the Phar$acy2logistics supply do$ain of the !
assess$ent tool# See .nne4 2 for detail".
2:. 8,era0 A.0 6. Seruto,e0 #. %adraa0 and #. )amagala. Scaling &p
Antiretroviral Therapy &gandan ./perience Dra"t. 9eneva0
S!it=erlandD 7orld Health 8rgani=ation0 %ay 2//;.
This docu$ent is a case study on the early years of AR( therapy scale1up in 7ganda +20021
200)-? it provides an overvie/ of the factors /hich influenced the success of this scale up and in
the process highlights so$e of the critical ele$ents to AR( progra$s /hich could 0e relevant for
inclusion in the ! assess$ent tool#
2G. 8roBaton )0 P. )saBagasani0 #. #,ochu0 6. 8,i0 S. &ironde0 T.
Lippeveld. "romoting unity of purpose in district health service
delivery in &ganda through partnerships# trust %uilding and
evidence0%ased decision0making #duc Health EABingdonF. 2//H
AugA2/E2FD:I. #puB 2//H Aug 2/.
This pu0lication presents selected results of the 7P&,6! proIect in 7ganda, a TF% $illion
7SA'!1funded health and education sector proIect# 't does not present a district health
assess$ent $ethodology, 0ut discusses i$portant concepts in district capacity# The proIect /as
structured around t/o pillars of intervention8 trust 0uilding and evidence 0ased planning and
decision1$a"ing# The for$er is central to the social capital literature 0ut possi0ly under1
appreciated in approaches to assessing district capacity# Also essential, are t/o ele$ents in the
strategic approach8 Dunity of purposeE /ithin the district $anage$ent tea$ and a$ong district
partners +unity and consistency of purpose are central concepts of <uality $anage$ent in the
0roader $anage$ent literature-? and the develop$ent of Dcore valuesE, such as tea$/or",
e$po/er$ent, e3cellence, innovation, D0oundarylessnessE, and responsi0le speed of progra$
i$ple$entation# Partnership /as another central strategic ele$ent, translated into the districts
supporting grants to S, partners# Finally, other ele$ents of capacity referred to in this
pu0lication are $ore traditionally integrated in capacity assess$ent tools /ithin a health syste$?
this includes use of <uality i$prove$ent processes, partnership /ith S,s, and
institutionali.ation of "ey practices supported 0y the 7P&,6! proIect#
6i$itation8 this paper does not offer ho/ to operationali.e or $easure the district capa0ilities
directly or indirectly related to these topics# This deserves consideration in vie/ of the
develop$ent of the ! assess$ent tool#
2H. Population Council. Hori=onsA SHAA)D Society "or Service to
1rBan Poverty. The "!HA0friendly achievement checklist A self0
assessment tool for hospitals and other medical institutions caring
for people living with HIV * AIDS +"!HA, )e! Delhi0 India0 Population
Council0 Hori=ons0 2//;.
The P6&A1friendly Achieve$ent hec"list is intended as a self1assess$ent tool for $anagers to
use in gauging ho/ /ell their facility +hospital, clinic, or depart$ent- reaches, serves, and treats
&'(1positive patients# This gives $anagers an opportunity to identify institutional strengths and
/ea"nesses, consider /ays to address the /ea"nesses, and later to assess progress to/ard
P6&A1friendliness# The tool co$ponents can serve as a $odel for the verification piece of the
rapid assess$ent# See .nne4 2 for detail".
2I. Pro5ect Concern International0 I0STAR +Integrated System for
Transformation# Assessment and Results, &ser -uide EPCI and #DC0
2//:F
'1STAR is a co$prehensive approach to 0uilding effective and sustaina0le non1govern$ental
organi.ations +=5,s- and net/or"s that are a0le to contri0ute to i$proving the health and
develop$ent of the co$$unities they serve# The cornerstone of '1STAR is a capacity self
assess$ent# The tool 0ears no direct relevance to the develop$ent of the ! rapid assess$ent
tool#
23. SamBo0 L.9. et al. Tools and Methods for Health System
Assessment) Inventory and Review 9eneva0 7H80 -33I.
This docu$ent su$$ari.es 2% tools and $ethods that revie/ all or part of the health syste$#
,verall, $ost tools revie/ inputs, outputs, and outco$es of specific health services2progra$s
rather than assess insitutional factors influencing i$ple$entation# For the $ost part, <uantitative
indicators +for deter$ining service outputs and health status- are used# Tools included in this
inventory that /ere revie/ed in the literature revie/ include *aier et al, 1KK4#
;/. SamBo et al0 Tools Assessing the <perationality of District
Health Systems. <ra==aville0 7H80 2//;.
Assess$ent of the operationality of a district health syste$ can 0e descri0ed as the revie/ of the
organi.ation and $anage$ent of a health syste$ in ter$s of its structures, $anagerial processes,
priority health activities, co$$unity participation and the availa0ility and $anage$ent of
resources? it does not include the assess$ent of its perfor$ance# The tools presented here
include a health facility and a district <uestionnaire /hich are ad$inistered through a self1
assess$ent $ethodology# The do$ains included in this fra$e/or" are relevant for the !
tool, particularly the do$ains on structures, $anagerial processes, co$$unity health initiatives
and availa0ility of resources# See .nne4 2 for detail".
;-. Sarriot0 #ric. Issue "aper) Supervision of Health (are in
Developing (ountries Juality Assurance Pro5ect0 1niversity
esearch Corporation E-333F.
This report presents supervision as 0oth a control and a service function of $anage$ent# 't
presents several positive and negative supervisory 0ehaviors influencing provider perfor$ance? a
facilitative supervision description? and a diagra$ on the $anage$ent culture of supervision
+0alancing oncern for People vs# oncern for Tas"- /hich /ill 0e relevant for the develop$ent
of indicators for the supervision do$ain#
;2. Sarriot0 #ric0 6. icca0 L. yan0 6. <asnet0 and S. Arscott*%ills.
Measuring sustaina%ility as a programming tool for health sector
investments>report from a pilot sustaina%ility assessment in ?ve
@epalese health districts Int 6 Health Plann %gmt 2//3A 2>D ;2GK
;:/. PuBlished online in 7iley InterScience
E!!!.interscience.!iley.comF D8ID -/.-//2/hpm.-/-2
'n this report, the authors develop a standardi.ed set of assess$ent tools to $easure G) indicators
along si3 co$ponents of assess$ents $easured for the $ost part at district level according to %
$ain co$ponents# ,f "ey interest /ere the co$ponents loo"ing at !istrict level structures:
capacity and via0ility# The study also identified a range of central functions +e#g#, 0udgeting,
planning, policy$a"ing, esta0lishing standards and protocols, hu$an resources allocation-
outside the control of the districts and therefore not relevant for direct assess$ent at this level#
;;. Sarriot0 #ric0 Shamim 6ahan0 and SustainaBility #valuation
Team. Sustaina%ility of the Saidpur and "ar%atipur &r%an Health
Model +4angladesh, 2ive Aears After the .nd of (oncern3s (hild
Survival "roBect $inal #valuation eport*6anuary -/0 2/-/.
This report details the syste$atic assess$ent of all co$ponents of the oncern Aorld/ide1
adapted Hsustaina0ility fra$e/or": /hich allo/ed strategic reco$$endations to 0e $ade to
$unicipalities and sta"eholders, in evaluating the sustaina0ility of health outco$es and
revie/ing changes in the t/o $unicipalities studied# There /as li$ited direct relevance to the
develop$ent of the ! rapid assess$ent tool, as *unicipal &ealth !epart$ents share only
so$e of the responsi0ilities co$$on to a &ealth !istrict and do not oversee curative services#
;>. Shediac*i=,allah %C0 L <one. -33I. "lanning for the
sustaina%ility of community0%ased health programs) conceptual
frameworks and future directions for research# practice and policy
Health #duc es -;E-FD IHK-/I.
Shediac1Ri."allah offers a definition /hich synthesi.es a diversity of concepts and approaches
a0out sustaina0ility, specifically in health pro$otion progra$s# For her, sustaina0ility refers to
the general pheno$enon of continuation of a health1enhancing progra$, and she offers three
$ain $echanis$s through /hich this can 0e o0served8 1- The $aintenance of health 0enefits
achieved through the initial progra$? 2- The continuation of progra$ activities /ithin an
organi.ational structure +institutionali.ation-? and )- The $aintenance of health 0enefits through
0uilding the capacity of the recipient co$$unity# This definition focuses on the ulti$ate 0enefit
for the co$$unities, and recogni.es a /ide array of sta"eholders as responsi0le for the
sustaina0ility of health progra$s#
Factors in the proIect design +negotiation, effectiveness, duration, financing, type, training-,
factors in the organi.ational setting +institutional strength, integration, leadership-, and factors in
the co$$unity environ$ent +socioecono$ic1political environ$ent and participation-, interact to
influence sustaina0ility, /hich is achieved through a continuation of the initial progra$, or its
institutionali.ation /ithin a ne/ +local- organi.ational structure, or through the develop$ent of
the capacity of the recipient co$$unity#
The $ain relevance to the ! district2province assess$ent tool is the recognition of the
interconnectedness of different sta"eholders# +This suggests that the a0ility of districts to partner,
cooperation, provide guidance to other partners is a capacity area deserving e3a$ination#-
9eyond this, this paper does not offer enough institutional level focus to provide $easure$ent
tools or resources#
;:. Stein 6.0 S. Le!in0 L. $airall0 P. %ayers0 . #nglish0 A. <hee,ie0
#. <ateman0 %. C!arenstein. 4uilding capacity for antiretroviral
delivery in South Africa) a 6ualitative evaluation of the "A!SA "!&S
nurse training programme <%C Health Serv es. 2//I )ov -IAID2>/.
This article descri0es the evaluation of a training progra$ for P& nurses in the $anage$ent of
adult lung diseases and &'(2A'!S, including ART# The authors used <ualitative $ethods and
analy.ed data the$atically# ,utco$e of interest8 training all P& nurses in use of this
guideline, as opposed to ART nurses only, /as perceived to 0etter facilitate the integration of
A'!S care /ithin the clinics#
;G. Ta!+,0 O.0 S. &inoti0 and 9.C. <lain. Introducing Antiretroviral
Therapy +ART, on a !arge Scale) Hope and (aution "rogram
"lanning -uidance 4ased on .arly ./perience from Resource0!imited
and Middle0Income (ountries 7ashington DC0 1SAD Academy "or
#ducational Development 9loBal Health0 Population and )utrition
9roup0 )ovemBer 2//2.
This paper provides progra$ planning and $anage$ent guidance to resource1li$ited countries
that see" to i$ple$ent e3panded ART services# 'n addition, this paper includes guidance for
esti$ating progra$ costs, hu$an resources and training re<uire$ents, and e3a$ples of
co$$unication $essages specific to ART progra$s, /hich /ill 0e relevant for the develop$ent
of the design of the rapid assess$ent tool#
;H. Thi %ai 8anh et al0 Assessing "rovincial Health Systems in
Vietnam) !essons from Two "rovinces %arch 2//3. <ethesda0 %DD
Health Systems 2//2/ pro5ect0 ABt Associates Inc.
This report presents data fro$ the first t/o provincial health syste$ assess$ents conducted in
(ietna$# The &SA tool /as developed to ena0le policy$a"ers and progra$ $anagers to
underta"e a co$prehensive vie/ of si3 $aIor health syste$s functions delineated 0y A&,
+governance, finance, hu$an resources, service delivery, phar$aceutical $anage$ent, and
health infor$ation-# The tool allo/s users to assess each health syste$ function using a set of
perfor$ance indicators# 't /ill 0e a "ey reference in the develop$ent of the rapid assess$ent
tool# See .nne4 2 for detail".
;I. Travis0 Phyllida et al. QSuBnational Health Systems
Per"ormance AssessmentD 8B5ectives0 Challenges and Strategies.R
Chapter :3 in Health systems performance assessment ) de%ates#
methods and empiricism / edited By Christopher 6.L. %urray0 David <.
#vans. 7H8 2//;.
This chapter of the pu0lication highlights "ey considerations regarding the purpose and
challenges of health syste$s perfor$ance assess$ents, /hich /ill guide the design of the !
tool# ,f "ey interest are the discussions around the various types of infor$ation proposed for
collection at su01national level? the application of the A&, health syste$s fra$e/or" at the
local level? specific challenges for data collection and use at su01national level#
;3. 1SAID Child Survival and Health 9rants Program. R0H2A for
core Maternal# @eonatal# and (hild Health +M@(H, services at the
primary level E2//HF EDH8 %oduleF
The Rapid &ealth Facility Assess$ent +R1&FA- /as developed in 200% 0y 'F *acro in
colla0oration /ith *EAS7RE Evaluation and a panel of e3perts fro$ 7S P(,s, 7SA'!, and
other cooperating agencies# Pilot testing has sho/n that it is suita0le for use 0y !istrict &ealth
*anage$ent Tea$s +!&*Ts-, as /ell as =5,s# 't is a relatively rapid instru$ent for $easuring
a s$all set of "ey indicators to give a U0alanced scorecardU for *=& services at the pri$ary
health care level +including an optional $odule for use /ith &As for co$$unity outreach
services-# 't identifies "ey 0ottlenec"s to <uality service delivery#
!o$ains include structure and ad$inistration, planning , 0udget $anage$ent, and coordination#
The tool co$0ines indicator scores for each do$ain /ith other indicators of capacity and
perfor$ance collected fro$ health facilities, to create an overall score for !&*T# 'ndicators
collected at health facility level for this purpose include8 guidelines, supervision, training, data
for decision $a"ing, access or availa0ility of services and <uality1related issues li"e staffing,
infrastructure, supplies, drugs, infection control, co$$unity2provider relations, &A technical
perfor$ance, and client satisfaction# See .nne4 2 for detail".
>/. 1SAID Center "or Development In"ormation and #valuation.
M.AS&RI@- I@STIT&TI<@A! (A"A(ITA Recent "ractices In
Monitoring and .valuation TIPS 2///0 )umBer -:.
This grey pu0lication provides infor$ation on the $easure$ent of institutional capacity,
including so$e tools that $easure the capacity of an entire organi.ation as /ell as others that
loo" at individual co$ponents or functions of an organi.ation# The discussion concentrates on
the internal capacities of individual organi.ations, rather than on the entire institutional conte3t
in /hich organi.ations function# 't is fairly generic, possi0ly $ore appropriate to civil society
organi.ation and provides no district1level focus# Anne3 presents lin"s to a nu$0er of tools and a
full set of assess$ent <uestions fro$ the ,rgani.ational apacity Assess$ent Tool +,AT-#
>-. 7H8. Innovative (are for (hronic (onditions) 4uilding 4locks
for Action. 7H80 2//2.
This docu$ent presents a fra$e/or" for chronic care, /hich e$phasi.es patient, fa$ily, and
co$$unity involve$ent# 't proposes specific 0uilding 0loc"s for health care organi.ation /hich
include pro$ote continuity and coordination? encourage <uality care through leadership and
incentives? organi.e and e<uip health care tea$s? support self1$anage$ent and prevention? use
infor$ation syste$s# This $odel has 0roader relevance to the rapid assess$ent and /ill 0e
incorporated into one of the tool designs# See .nne4 2 for detail".
>2. 7H8. .very%ody3s %usiness) strengthening health systems to
improve health outcomes ) 1H<3s framework for action 7orld
Health 8rgani=ation0 9eneva E2//HF.
This docu$ent presents a conceptual fra$e/or" for health syste$s /hich highlights si3 "ey
0uilding 0loc"s in any health syste$8 Service delivery? &ealth /or"force? 'nfor$ation? *edical
products, vaccines @ technologies? Financing? 6eadership and governance# This fra$e/or" /ill
serve as a "ey source of co$parison for the proposed ! do$ain areas# See .nne4 2 for
detail".
>;. 7H8. "atient Monitoring -uidelines for HIV (are and
Antiretroviral Therapy +ART, %#AS1# #valuation. 7H80 2//G.
This docu$ent provides guidelines to aid in the develop$ent of an effective national &'( care
and antiretroviral therapy +ART- patient $onitoring syste$# The focus of these guidelines is the
list of essential $ini$u$ standard &'( care and ART patient $onitoring data ele$ents and ho/
their collection facilitates clinical care and $easure$ent of agreed upon indicators# The list is
0ro"en do/n into four categories8 de$ographic infor$ation? &'( care and fa$ily status? ART
su$$ary? and patient level encounter infor$ation# This docu$ent provides good detailed
infor$ation on the specific "inds of data re<uired for patient $onitoring, /hich should 0e
aggregated and collected at district level and could 0e useful in developing assess$ent indicators
for the &*'S2*@E do$ain#
Anne( 2
+a/le of Health System (ssessment Models (pplica/le to )istrict'0rovincial Level
+see E3cel spreadsheet-
Anne( ;
Individuals ,ontacted 1phone, interview or email2 from 3'45'4676 to 8'77'4676
)ame Title/8rgani=ation
9eti.a.u, Sisay Sirgu WHO
9oni, Tony Ofce of Health, Infectious Diseases, an !ut"ition#
$%&ID
!oherty, Julie &'t, Inc
Ford, Sara %"( )echnical &*iso", +a,acit- .uilin/0&ID%)&1 )2o
Eichler, Rena )echnical )ea3 4eae"#Health %-ste3s %t"en/thenin/,
5+HI6
E$ery, 9o0 Ofce of Health, Infectious Diseases, an !ut"ition#
$%&ID
&ei0y, Ji$ 5eical Ofce", 7lo'al Health .u"eau#$%&ID
&odgins, Steve 7lo'al 4eae"shi, )ea3 4eae", 5+HI6
6ion, Ann 6"o8ect Di"ecto", Health %-ste3s 20920 :&'t, Inc;
=egussie , Eyerusale$ ;e0ede WHO#HI< De,a"t3ent, I5&I )ea3
Sei$s, 6a Rue 5%H
Taye, A$y %"( &nal-st, &'t, Inc