1. Primary Healthcare Frameworks Primary Healthcare Improvement Global Stakeholder Meeting WHO 6-8 April, 2016 Anbrasi Edward

2. Evidence of Strategies to Strengthen Performance of Health Organizations

3. Evolution of Afghanistan’s BSC 2004 BSC for BPHS 2009 BSC for HMIS 2007 BSC for EPHS NHSPA 09-13 BPHS+EPHS NHSPA 07 BPHS+EPHS NHSPA 08 BPHS+EPHS NHSPA 04 NHSPA 05 NHSPA 06 2002…. MOPH, Donor and NGO investments: policy, health infrastructure, workforce, drugs, protocols, guidelines

4. Afghanistan Balanced Score Card – Health Service Delivery

5. Performance by BSC Domains: National Median Score ↑11* ↑19*** ↑13.7* ↑29*** ↑27*** * p<0.05 *** p<0.0001 Edward A, Kumar B, Kakar F, Salehi AS, Burnham G, et al. (2011) Configuring Balanced Scorecards for Measuring Health System Performance: Evidence from 5 Years’ Evaluation in Afghanistan. PLoS Med 8(7): e1001066. doi:10.1371/journal.pmed.1001066

6. Hospital BSC Trends - 2007 to 2009/10 8.6* 11.1* 4.8 3 7.6* 5.8 6* * p<0.05

7. Evidence of the Scorecard Strategy • 1st pioneers to integrate BSC for National Health Systems • Benchmarking successfully employed for service delivery through contracting mechanisms for provincial comparisons • Significant progress in all domains • Facilitated a culture of measurement and accountability to inform policy analysis and planning • Scorecard innovations for hospital performance and health information systems

8. Limitations • Skewed SC: input/process not outcome measures • Linked facility HH surveys • Non-users • Lacked measures for community oriented health services • Facility teams not equipped with problem solving/QI tools • Bias (observer, courtesy, not risk adjusted) • Inadequate documentation of strategic inflection points • removal of user fees increased service utilization? • investment of resources, policy changes etc?

9. BSC and Performance Improvement Ap to Jun Y01 July Y01 July Y00 Jan Y01 Mar/Apr Y01 July Y01 Performance improvement strategies BSC Provincial/NGO dissemination Assessment Assessment BSC National dissemination Strategic Inflection Points -Policy /Strategy change - Resources -QI /PS methods Iterative Process

10. Further innovations • Rapid developments in the heath system landscape • New policies, standards, strategies, tools • HS reconfiguration; sub-centers, health posts, mobile clinics • Epidemiological transitions • Security Constraints • Reconciling indicators from other measurement systems – HMIS

11. Cascading the Scorecard Two-Way Influence Two-Way Influence Two-Way Influence Organizational SC with all domains and indices for policy and planning at the national level National SC Provincial SC for managers and NGOs at the provincial level to benchmark and improve performance NGO/Provincial SC Facility and QI Team SC Select Indicators Facility/Team SC BSC CSC Community SC will include indicators of CHW/Shura activities, referral and feedback on quality of services Community SC Edward, A., K. Osei-Bonsu, et al. (2015). "Enhancing governance and health system accountability for people centered healthcare: an exploratory study of community scorecards in Afghanistan." BMC Health Serv Res 15: 299.

12. Community SC Process

13. Siadara Community Scorecard

14. Siadara Action Plan

15. Health Facility Teams and Communities jointly engage for PHC Improvement

16. PAHO Renewing PHC in the Americas

17. Designing Health System Performance Assessment Framework - Multiphase Strategy

18. PAHO Multidimensional HSPA

19. PAHO HSP Progressive 110 Indicator Framework Level A- 30-50 core performance indicators for each domain for countries in early stage of institution Level B- 50+ expanded, to include additional indicators, for countries with advanced information systems Level C- Comprehensive for progressive health systems to accommodate changes in technology and other healthcare environment factors

20. PAHO PHC Oriented BSC

21. Design QI Frameworks for Child HealthEvidence of QI Strategies -A Selected Review & Compendium of QI Models Evidence of short term small scale improvements, but failed to create learning organizations and empowered teams to sustain QI interventions for routine performance in the absence of external financing. Very few illustrate successful national integration of these models.

22. Performance Metrics Lord Kelvin “You cannot manage what you cannot measure” Albert Einstein “Not everything that can be counted counts and not everything that counts can be counted”

23. Essential Public Health FunctionsDavid Bishai

24. Primary Care Assessment Tool – Leiyu Shi PCAT – Consumer/client PCAT – Facility Survey