In the sections on leadership/governance, service delivery and information systems, composite indices, derived
from a selection of system indicators, are presented. These cover both core and additional indicators, reflecting
the scope and the complexity involved in trying to measure multiple subsystem components. Issues related
to improving data availability and quality, with consideration of the investments that may be needed, are also
presented in the service delivery and health workforce sections.
Core principles guiding the use of this handbook
When working with countries to measure and compare health systems functioning, it is important to strike a
good balance between avoiding blueprints that do not allow for country contexts and specificities while also
encouraging a degree of standardization that enables comparisons within and between countries as well as over
time. Standardized indicators allow comparisons between countries and can help mutual learning, including
the identification of bottlenecks and the sharing of lessons learnt. In general, however, measurement should be
attuned to a country’s health strategy objectives. Each section has proposed core indicators that all countries are
encouraged to collect, plus a wider set of indicators that users can choose or modify as needed. It is anticipated
that the core indicators will enable the production of country “dashboards” that contain the instruments
by which health systems trends can be regularly monitored and compared. Countries should integrate new
indicators with existing indicators of their health sector and statistical strategies and plans. Health systems
monitoring should also be seen in the context of the indicators’ impact on access to priority health services and
their contribution to reaching the Millennium Development Goals (MDGs).
A number of the proposed indicators require disaggregation by sub-populations or units, e.g. by sex, age
or location. Often such sub-analyses are country specific. Continued research and knowledge generation is
needed to inform and generate evidence that would help in understanding the actual meaning of trends in an
indicator’s value.
Strategies and investments for improving data availability and quality
Responsibilities for effective data generation go beyond that of ministries of health and involve other bodies,
such as departments and agencies that handle health-related data, including national statistics offices, ministries
of education, among others. There is a need for a strong coordinating body that brings together the various
stakeholders and helps ensure the development of a comprehensive and integrated plan for health information and
statistical system development. Such a plan should provide the basis for enhanced alignment and harmonization of
technical and financial support from the development partners. The Health Metrics Network (HMN) framework
has set out standards for information system components and data management (5).
Having poor or unreliable data creates long-term costs and unforeseen effects that are high compared with the
costs and benefits of having good data. Practical and generally affordable strategies exist for generating timely
and reliable data on health systems, but appropriate investment is needed to develop the capacity to collect,
manage, analyse, disseminate and use the obtained information. Further work on the costs of generating data
required for monitoring health systems strengthening is needed.