Measurement and evaluation

Measurement and evaluation provide the means to assess the quality of health services and generate the information necessary to inform subsequent plans and actions, either to maintain or improve aspects of quality health services. At the national and sub-national levels, this information helps to feed and drive informed decision-making, policy development and transparency, strengthening trust among communities more broadly. At the facility level, this information supports informed decision-making at the point of care. And at the community level, it helps to feed and drive people-centred considerations in improving health services – ensuring that these perspectives are also considered among other metrics for assessing health service quality. Purposefully engaging the community in measurement and evaluation helps to strengthen accountability and trust in the quality of health services provided and allow systems to respond to emerging needs and expectations.

Most countries have some form of broad health system monitoring and evaluation in place, and related information systems. Where possible, quality measurement efforts should align with these system-wide efforts. The WHO Primary health care monitoring and evaluation framework proposes a core set of indicators for countries to integrate into their health system measurement approaches, as well as a series of additional indicators that can support more detailed efforts on health systems monitoring and improvement, across different technical areas.

While the measurement tools within this Toolkit draw on a large existing body of work from WHO, the WHO  Primary health care monitoring and evaluation framework is seen as a foundational resource from which countries should work, representing a consolidated list of global indicators that can inform efforts to improve the quality of health services.

Being able to critically review and contextualize measurement frameworks is important, as is balancing the need for data with the burden of data collection. Beyond the selection of indicators, a critical consideration for measurement efforts at all levels is how the information gathered can then be used to inform improvement processes. Regarding the measurement and evaluation of the quality of health services, it is important to be able to answer some key questions:

• What is being measured/evaluated?
• Why is it being measured/evaluated?
• How is it being measured/evaluated?
• When, or how often, is it being measured/evaluated?

The tools in this Toolkit category help those developing such measurement frameworks to apply them in practice and use them to inform decision-making. A systematic approach can help to better organize measurement approaches to be lean, efficient and effective, thereby informing the key actions that need to be taken, without being a burden to health care workers. The figure below illustrates one such approach that also helps frame the tools in this part of the Toolkit. The three-step process considers the national strategic direction on quality, which informs the quality measurement approach and subsequent use of the data. The approach can help guide the organization, selection and visualization of indicators and data to inform strategic decision-making for action on quality. This should be considered across the entire health system and will be applicable to each level, from national, through to the facility and community. Nationally, this information can inform the national strategic direction on quality, update/modify or develop new standards supporting quality of care, as well as inform oversight and regulatory authorities. Sub-nationally and locally, in facilities, this information can inform management, operational and supervision support, hold improvement interventions accountable and help to build trust in engagement with communities.