Monitoring and Evaluation Frameworks for Primary Health Care

Monitoring and Evaluation Frameworks for Primary Health Care
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Monitoring and Evaluation Frameworks for Primary Health Care
Primary health care forms the foundation for effective healthcare systems and facilitates the provision of healthcare to all. According to the World Health Organization (WHO) (2020), PHC is the most cost-effective approach in meeting the comprehensive healthcare needs of communities around the world and the gateway to universal healthcare. As such, it is important to continuously assess the effectiveness of PHC projects and programs through monitoring and evaluation (M&E). As Rifkin (2018) reveals, the implementation of PHC programs and projects requires continuous monitoring and evaluation of what works, how it works, and why it works. Therefore, using effective assessment frameworks that not only continually monitor and evaluate PHC but also address some of its complex issues is paramount. The purpose of this paper is to develop indicators of PHC, namely inputs, activities, outputs, outcomes, as well as the impact of the indicators. In addition, this paper will comprehensively describe the roles of international agencies involved in PHC.
Part One: Indicators of Elements of PHC
           Following the Alma Ata Declaration, several key components of PHC were identified. They include health education on existing health issues and the methods for preventing and controlling them, prevention and control of locally endemic diseases, nutritional promotion through an adequate food supply and nutrition, sufficient supply of safe water and sanitation, maternal and child health care, immunization against major infectious diseases, supply of vital drugs, and proper treatment of common illnesses and diseases (Du et al., 2019). These core components are important in promoting health, preventing and curing diseases, and rehabilitating communities through PHC. Also, effective referral systems, albeit not part of the Alma Ata components, play an essential role in enhancing the effectiveness of PHC. Below is a presentation of all the indicators of these PHC components. These indicators are developed based on the M&E components, namely inputs, activities, outputs, outcomes, and impacts.
E: Education on existing health problems and methods for preventing and controlling them 
Inputs
           Health education is instrumental in improving the health of individuals as it gives them an understanding of diseases and how to prevent and control illnesses (Pueyo-Garrigues et al., 2019). Effective health education requires significant resources to facilitate learning, absorption, and dissemination of information to promote behavioral change. The input indicators for the education of health problems include:
* Health educators
* Health education materials/curricula
* Mass media platforms
* Written standards to guide the education process
Activities
           Health education involves a learning process that is person-centered, multidimensional, and collaborative (Pueyo-Garrigues et al., 2019). The activities involved in education on prevailing health issues should be broad enough to meet the population’s unique needs. As such, different activities and approaches should be employed to facilitate person-centered health education. The activities/process indicators for education on health problems include:
* Community group discussions
* Workshops
* Seminars
* Classes
* Health talks in community spaces
* Dissemination of information through mass media platforms
Outputs
           The effects of health education are immense and can range from changes in health behaviors of the target population to health literacy among the target population (Pueyo-Garrigues et al., 2019). As such, the output indicators include:
* The proportion of adults with adequate health literacy levels
* Number of adults adopting health-promoting behavior
* The proportion of adults reached through health education activities
* Number of people aware of the existing health problems and how to control and prevent the problems
Outcomes
           According to Pueyo-Garrigues et al. (2019), education on health issues enhances health literacy and encourages more people to make changes in their health behavior to prevent the development of an illness or manage an existing illness. The outcome indicators for education on existing health issues can include:
* Improved adult health literacy levels
* Improved adoption of health-promoting behaviors
* An increase in the number of adults reached through health education activities
* Increased awareness about existing health problems and approaches to preventing and controlling
Impacts
           According to Pueyo-Garrigues et al. (2019), education can impact individuals beyond health. It can also have a social and economic impact through reduced use of medication and other health services to treat existing health conditions. As such, the impact indicators for education on existing health issues include:
* Lower rates of medication use
* Lower disease prevalence rates
* Higher rates of awareness about existing health issues
* Higher rates of adoption of health-promoting behaviors
* Lower rates of mortality from lifestyle-related diseases
 L: Prevention and control of locally endemic diseases 
Input
           According to Perry (2018), preventing and controlling disease, including endemic diseases, requires access to preventative services, health products, and tools. These preventative services also have to be offered or administered by trained personnel to enhance their effectiveness. The input indicators include:
* A skilled healthcare workforce
* Vaccines and preventative drugs
* Personal protective equipment for healthcare workers
* Screening tools for various endemic diseases
* Training and education materials on preventative measures
Activities
           Perry (2018) indicates that diseases prevention and control involve a range of activities such as offering preventative services, including immunization and screening services to prevent and detect infectious diseases early on for proper disease control and management. Thus, the activities indicators would involve activities aimed at providing such services. They include: 
* Distribution of vaccines and preventative drugs
* Immunization outreach to create awareness and enhance utilization
* Conducting training sessions with local/target population
* Performing routine screening for endemic diseases 
* Offering treatments services to affected individual
Output
           The prevention and control of locally endemic diseases play an instrumental role in reducing the occurrence of the diseases (Perry, 2018). The output of the prevention and control of endemic diseases can be assessed through the occurrence of the endemic diseases as well as the utilization of preventative services, products, and tools. The output indicators include:
* The proportion of the population with the endemic disease
* The proportion of the population receiving preventative services/products
* Number of people receiving routine screening services
Outcome
           Through prevention and control, endemic diseases can reduce. Prevention and control have significant outcomes such as the slower transmission of disease, increased demand for routine screening, increased demand and use of preventative services, as well as reduced diseases occurrence. The outcome indicators for the prevention and control of locally endemic diseases include:
* Decreased occurrence of the endemic disease
* Decreased disease transmission
* Increased utilization of preventative services
* Increased routine screening of specific endemic diseases
Impact
           The overall impact of prevention and control of locally endemic diseases can be assessed by examining their prevalence, endemic disease-specific deaths, and the burden of specific endemic diseases. The impact indicators include:
* Lower rates of mortality from specific endemic diseases
* Reduction of endemic diseases burden for selected diseases
* Lower prevalence rates of specific endemic diseases
* Reduction in morbidity for specific endemic diseases
 E: Expanded program on immunization against major infectious diseases 
Input
           Through immunization, the healthcare system has been able to fight against infectious diseases and save many lives (Piot et al., 2019). Yet, immunization coverage continues to be a challenge in many parts of the world. Some of the factors that affect immunization coverage include resource scarcity. As Piot et al. (2019) reveals, the introduction and maintenance of immunization programs require adequate financial and human resources. The input indicators of immunization, thus, include:
* Skilled vaccine providers
* Vaccines
* Syringes
* Vaccines storage units (refrigerators, freezers)
* Immunization cards
* Immunization registers/monitoring charts
* Funds to support immunization programs
Activities
           Various activities must be carried out to enhance and improve immunization efforts. These include activities that ensure there are enough vaccines in healthcare facilities, reduce reluctance towards immunization, and increase coverage, especially in hard-to-reach areas (Piot et al., 2019). Thus, the activity indicators include:
* Vaccine procurement
* Facilitating outreach sessions to increase immunization in the community
* Planning immunization sessions
* Provision of immunization services in healthcare facilities
* Updating immunization registers/monitoring charts
Output
           The immediate effects of immunization would include an increase in procurement of vaccines, immunization services, improved utilization, as well as changes in attitudes towards vaccines among both healthcare providers and the public. The output indicators include:
* The proportion of healthcare facilities reporting vaccines stock-out
* Number of fully immunized children
* The proportion of pregnant women receiving recommended vaccines
* Number of healthcare facilities with planned immunization sessions
Outcome
           Some of the challenges encountered in immunization include issues with acceptance of vaccines, accessibility of immunization services, as well as the availability of vaccines and immunization services (Piot et al., 2019). As such, the intermediate effects of immunization would be on acceptance, availability, and accessibility, which would involve alteration of behaviors among healthcare providers and the public. Thus, the outcome indicators for immunization include:
* Improved public acceptance of immunization based on current reports
* Improved satisfaction with immunization services
* Increased immunization coverage
* Enhanced access to immunization services
* Increased planned immunization sessions in healthcare facilities
Impact
           The primary long-term impact of immunization is enhanced survival among human beings. According to Piot et al. (2019), immunization programs have enhanced human survival by preventing infectious diseases and, ultimately, death from such diseases. To this end, immunization rates have increased when effective immunization programs have been implemented. Thus, the impact indicators for immunization and immunization programs include:
* Lower rates of immunization drop-outs
* Higher rates of immunization among women and children
* Reduction in specific infectious diseases morbidity
* Lower rates of child mortality from vaccine-preventable infectious diseases
M: Maternal and child health care, including family planning 
Input
           The improvement of maternal and child care requires access to several resources. According to the WHO (2019), maternal and child health is affected by a lack of skilled health workers, poor road infrastructure and long distances, and a lack of information. All these require funds to not only finance the programs but also ensure enhanced access. As such, the input indicators for maternal and child health care includes:
* Skilled healthcare workers
* Funds for maternal and child health programs
* Sufficient information, infrastructure, and facilities
Activities
           Maternal and child health care activities include services such as family planning, antenatal care, immunization, and postnatal care, among others (Shetty, 2016). Thus, the process or activities indicators include:
* Provision of family planning services, antenatal care, immunization, and postnatal care in healthcare facilities
* Education, such as sex education among adolescents 
* Provision of education to mothers on the need for exclusive breastfeeding, immunization, and prompt medical attention
Output
           The output of maternal and child healthcare can be assessed based on the proportion or percentages of maternal and child health services provided/received. The output indicators include:
* The number of women seeking and receiving maternal and child health services
* The proportion of women using family planning services provided
* The number of children completely immunized
Outcome
           As Shetty (2016) reveals, key maternal and child health interventions should reduce unintended pregnancies, improve immunization, prevent childhood illnesses, and increase the number of births attended by skilled attendants. Thus, the outcome indicators of maternal and child health include:
* Reduced cases of maternal and child morbidity
* Reduced cases of unwanted pregnancy
* Increased uptake of immunization and family planning services
* Increased access and utilization to skilled birth attendants
Impact
           The impact indicators for maternal and child health include the reduction of maternal and child morbidity and mortality and enhanced nutrition among mothers and children. Specifically, the ultimate impact indicator of all the efforts and resources put in place to address maternal and child care, including family planning, reduced mortality ratio, or rate. The impact of maternal and child healthcare should be aligned with the sustainable development goal of reducing the maternal mortality ratio to below 70 per 100,000 live births by 2030 (WHO, 2017).
 E: Provision of Essential drugs and Laboratory Investigations
Input
           According to Dong et al. (2020), the accessibility and availability of essential drugs are critical to public health because these drugs facilitate the prevention and treatment of illnesses. As such, the provision of essential drugs should be a top priority. Yet, at least one out of three people in the world has no access to essential drugs, which puts them at a health disadvantage. Dong et al. (2020) indicate that a lot of people lack access to essential drugs because of the high cost of healthcare services as well as drugs. There is also a drug shortage where the available drugs do not match the needs of the population. To ensure adequate provision of essential drugs and laboratory investigations, it is important to invest adequate and relevant resources to increase the supply of essential drugs and reduce the costs of drugs. The primary input in providing essential drugs and laboratory investigations is policies. According to Dong et al. (2020), implementing the right policies will address the cost associated with medication. The input indicators include:
* Effective drug price policies
* Trained healthcare workers on effective prescribing practices
Activities
           Provision of essential drugs and laboratory investigations requires healthcare workers to also be responsible while handling drugs. The activity indicators that apply in this case include:
* Adequate handling and conservation of essential drugs
* Appropriate prescribing and dispensing of essential drugs
* Tracking of drug stock-out in healthcare facilities
* Health education to enhance medication adherence
Output
           The indicators for the immediate effects of the provision of essential drugs and laboratory investigations include:
* The proportion of healthcare reporting essential drugs stock-out
* The proportion of prescribed essential drugs and laboratory investigations
* The proportion of dispensed essential drugs compared to prescribed drugs
* Amount of essential drugs available and affordable
Outcome
           The indicators for the intermediate effects of the provision of essential drugs and laboratory investigations include:
* Increased accessibility of essential drugs and laboratory investigations
* Improved availability and affordability of essential drugs and laboratory investigations
* A decreased gap between dispensed and prescribed medicine
* Improved handling and conservation of essential drugs
* Improved prescribing practices and rational use of drugs
Impact
           In ensuring adequate provision of essential drugs and laboratory investigation, more people will have access to these essential health products. This facilitates the treatment of major illnesses and ensures that people are not dying from a lack of medication. Ultimately, this has a huge impact, and the impact indicators include:
* Higher accessibility rates of essential drugs and laboratory investigations
* Lower costs of healthcare
* Lower rates of mortality arising from lack of essential medicine
 N: Provision of food supply and adequate nutrition 
           The provision of adequate food and nutrition is of great importance in health promotion, especially among mothers and children under five years old (Perry, 2018). As such, access to adequate food supplies and nutrition, even in times of crisis, is a top global priority to improve population health outcomes.
Input
           The primary inputs to facilitate the provision of food supply and adequate nutrition include:
* Micronutrient supplementation
* Food and nutrition programs
* Growth monitoring charts
* Human resources
Activities
           According to the WHO (2018), nutrition covers areas such as growth monitoring, nutrition counseling, supplements, breastfeeding, and complementary feeding practices. As such, the activities involved in the provision of adequate food and nutrition include:
* Nutrition health education
* Growth monitoring
* Malnutrition screening
* Promotion of exclusive breastfeeding
* Provision of supplements to people with malnutrition
Output
           The indicators for the immediate effects of the provision of adequate food and nutrition include:
* Number of children less than five years with a lower value of weight-for-age
* The proportion of children receiving malnutrition treatment
* Number of women breastfeeding exclusively for the first six months
* Number of PHC providers offering nutrition health education
Outcome
           The indicators for the intermediate effects of the provision of adequate food and nutrition include:
* Decreased proportion of women with underweight children
* Decreased proportion of children with malnutrition issues
* Enhanced exclusive breastfeeding
* Improved nutritional health literacy
Impact
           Adequate food and nutrition play an important role in improving health and preventing diseases and death. As such, the impact indicators of the provision of adequate food and nutrition include:
* Lower rates of childhood morbidity
* Lower rates of mortality from illness caused by poor nutrition
* Higher nutritional status of children below the age of five years
 T: Appropriate treatment of common diseases and injuries
           Appropriate treatment of common diseases and injuries refers to the provision of treatment services that match and meet the population’s needs. According to Perry (2018), appropriate treatment to common diseases and injuries involve the provision of 
timely first aid, effective management of chronic and acute illnesses, mental illness services, pain management, timely referrals in cases of life-threatening health issues, and treatment of infections such as respiratory and eye infections, among others. It also involves the treatment of childhood illnesses such as diarrhea and malnutrition. This is supported by the use of essential drugs and laboratory investigations as well as effective referral systems. 
Input
           The input indicators for appropriate treatment of common diseases and injuries include:
* An adequate PHC workforce that matches and meets the health needs of the population
* Treatment drugs, products, and technologies to match the demand
Activities
           Based on Perry’s (2018) description of appropriate treatment of common illnesses and injuries, the core activity indicators include:
* Provision of prompt first aid for accidents and other injuries
* Use of appropriate pain medication to manage pain in chronic illnesses
* Making timely referrals for cases that actually need referrals to specialists
* Prescription of drugs based on the patients need for drugs
* Assessment of illnesses and injuries through laboratory investigations for cases that actually require further investigation
Output
           The indicators for the immediate effects of appropriate treatment of common illnesses and injuries include:
* Number of accident patients who received prompt first aid
* Number of malnutrition cases receiving nutritional supplements
* The proportion of bacterial infections treated with antibiotics
* The proportion of patients accessing healthcare services
Outcome
           The indicators for the intermediate effects of appropriate treatment of common illnesses and injuries include: 
* Improved management of chronic disease among the elderly
* Improved management of children with malnutrition through adequate food supplements
* Improved management of bacterial infections using appropriate antibiotics
Impact
           Appropriate treatment of common illnesses and injuries has long-term effects on the survival and well-being of people. The impact indicators for this element include:
* Lower rates of mortality from common diseases and injuries
* Enhanced quality of life
 S: Sufficient supply of safe water and basic sanitation
Input
           Sufficient supply of safe water and sanitation is an important aspect of PHC because, as the WHO (2019) reveals, a lack of access to adequate water and sanitation services exposes the public to preventable diseases. The input indicators for sufficient supply of safe water and sanitation include:
* Waste management and disposal systems/services
* Safe drinking water facilities and services
* Sanitary toilets in communities
* Sewerage systems
Activities
As the WHO (2019) reveals, about 2 billion people in the world lack access to basic sanitation facilities and drink water from sources with fecal contamination. This points to a need for improved systems and services to support access to safe water and sanitation. The activities indicators include:
* Construction of waste management and disposal systems
* Provision of safe piped water
* Construction of sanitary toilets in communities
* Development/improvement of sewerage systems
Output
           The goal of ensuring a sufficient supply of safe water and sanitation is to ensure there is access and sustainable management of water and sanitation for every person (WHO, 2019). Thus, the output for safe water and sanitation should be the number of safe water and sanitation systems as well as the number of people accessing such services. The output indicators are:
* The number of safe water and sanitation systems constructed/improved compared to the number needed for a sufficient supply of safe water and sanitation
* The proportion of people accessing such services
Outcome
           The overall outcome of an adequate supply of safe water and sanitation is to increase access to safe water and basic sanitation in the world (WHO, 2019). The outcome indicators include:
* Increased access to safe drinking water
* Improved access to waste management and disposal systems
* Increase in the number of sanitary toilets in communities
* Enhanced development/improvement of sewerage systems
Impact
           A lack of access to safe water and sanitation is associated with several diseases, including cholera and diarrhea (WHO, 2019). The ultimate goal is to ensure people have access to safe water and sanitation. The impact indicators include;
* Higher rates of access to safe drinking water
* Higher rates of access to basic sanitation
* Reduction in the incidence rates of diseases caused by poor water and sanitation practices
 R: Referral systems
Input
           According to Bashar et al. (2019), referral systems fail to function because of a lack of resources such as an adequate...