Indicator Library

System

  • Per capita current primary health care expenditure (PPP)

    Total primary health care spending per person is measured in purchasing power parity (PPP) and contributes to the understanding of the priority and importance a country and population places on primary health care.

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    Per capita current primary health care expenditure (Purchasing Power Parity)

    Rationale

    This indicator measures the overall investment in PHC in a country in relation to population. It is an important input for PHC service delivery and an important factor affecting the performance of PHC. This is a core indicator of health financing systems. This indicator contributes to the understanding of the current expenditure on primary health care relative to the beneficiary population.

    Construction

    • Numerator: Total current primary health care expenditure expressed in PPP international dollars
    • Denominator: Total population

    Current expenditure on PHC is defined as Expenditure on health care providers providing PHC services + Expenditure on PHC preventive services + Proportion of administrative expenditure (based on ratio of PHC services expenditure and non-PHC service expenditure).

    Data are presented in purchasing power parity (PPP int. $) to enable international comparison.

    Notes

    The PHC Vital Signs indicators rely on third party data. To learn more about our data click here, or e-mail us at info@phcperformanceinitiative.org to provide feedback. Visit the Indicator Library for detailed descriptions of the rationale, construction, and limitations of indicators.

    Data Source Notes

    Data are collected using the System of Health Accounts (SHA2011) standards, which were jointly developed by WHO, OECD, and USAID. A working definition for primary health care expenditure has been developed which includes (1) all expenditures for PHC service providers; (2) expenditures for PHC preventive services; and (3) a proportion of administrative expenditures (based on ratio of PHC services expenditure and non-PHC service expenditure).

    Limitations

    The SHA2011 standards were not designed to collect PHC expenditure information, and there is no explicit PHC expenditure category in its data set. Thus, the estimates are based on a “working definition” for PHC expenditure based on SHA2011 expenditure codes of health care providers and health care functions. The PHC expenditures may be underestimated due to inability to identify the PHC curative services provided by higher-level facilities, such as secondary or tertiary hospitals.

  • Percent of current government health spending dedicated to PHC

    Percent of government health spending dedicated to primary health care (PHC) measures the percent of government health spending that is specifically dedicated to primary health care. This core health financing indicator reflects government investment in and commitment to primary health care and enables increased accountability of governments on their primary health care investments.

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    Percent of current government health spending dedicated to primary health care (CPHCE/CHE)

    Rationale

    This is a core primary health care systems financing indicator that directly measures the current investment in primary health care by a country’s government. In most low- and middle-income countries there is a need to increase public investments in primary health care. This indicator enables increased accountability and transparency of those investments.  

    Construction

    • Numerator: Total current government primary health care expenditure  (CPHCE)
    • Denominator: Total current government health expenditure (CHE)

    Notes

    The PHC Vital Signs indicators rely on third party data. To learn more about our data click here, or e-mail us at info@phcperformanceinitiative.org to provide feedback. Visit the Indicator Library for detailed descriptions of the rationale, construction, and limitations of indicators.

    Data Source Notes

    Data are collected using the System of Health Accounts (SHA2011) standards, which were jointly developed by WHO, OECD, and USAID. A working definition for primary health care expenditure has been developed which includes (1) all expenditures for PHC service providers; (2) expenditures for PHC preventive services; and (3) a proportion of administrative expenditures (based on ratio of PHC services expenditure and non-PHC service expenditure).

    Limitations

    The SHA2011 standards were not designed to collect PHC expenditure information, and there is no explicit PHC expenditure category in its data set. Thus, the estimates are based on a “working definition” for PHC expenditure based on SHA2011 expenditure codes of health care providers and health care functions. The PHC expenditures may be underestimated due to inability to identify the PHC curative services provided by higher-level facilities, such as secondary or tertiary hospitals.

Inputs

  • Basic equipment availability

    Minimum equipment availability is the percent of pieces of essential equipment that are available and functioning at a health facility. These pieces of equipment are typically required to provide effective and safe essential health services.

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    Availability of basic equipment

    Rationale

    To effectively provide essential health services, health facilities must have available minimum levels of equipment, including a weighing scale, stethoscope, sphygmomanometer, and thermometer. In addition, health centers and hospitals should have available sterilizing equipment and a refrigerator.

    Construction

    • Numerator: Number of pieces of equipment on the defined list available and functioning at a facility
    • Denominator: Total number of pieces of equipment on the defined list

    The specific list of equipment facilities are assessed against varies depending on the data source. We chose to include values from SARA and SDI facility assessments where available, recognizing that there are slight definitional differences.

    • SDI includes the following items: thermometer, stethoscope, weighing scale, blood pressure apparatus, refrigerator, and sterilization equipment. For additional details, click here.
    • SARA includes the following items: thermometer, stethoscope, adult scale, child scale, blood pressure apparatus, and a light source. For additional details, click here.

    Notes

    The PHC Vital Signs indicators rely on third party data. To learn more about our data click here, or e-mail us at info@phcperformanceinitiative.org to provide feedback. Visit the Indicator Library for detailed descriptions of the rationale, construction, and limitations of indicators.

    Data Source Notes

    Data for this indicator are collected in 15 countries. 

    Service Delivery Indicators (SDI) includes the following items in its assessment: thermometer, stethoscope, weighing scale, blood pressure apparatus, refrigerator, and sterilization equipment.

    Service Availability and Readiness Assessment (SARA) includes the folllowing items in its assessment: thermometer, stethoscope, adult scale, child scale, blood pressure apparatus, and a light source. 

    Limitations

    Different health facility assessments note the availability of different sets of equipment, making this indicator more complicated to standardize across methods. The availability of minimum equipment is a point-in-time indicator and thus does not reflect whether facilities have the resources and capacity required to maintain minimum equipment levels over time. Further, it does not reflect provider ability or knowledge to use the equipment appropriately.

  • Community health worker, nurse, and midwife density (per 1,000 population)

    Community health worker, nurse, and midwife density is the sum of the number of community health workers, nurses, and midwives relative to the size of a country’s population (per 1,000 population). Having a sufficient number of primary health workers is critical to service delivery.

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    Community health worker, nurse, and midwife density (per 1,000 population)

    Rationale

    Preparing the health workforce to work towards the attainment of a country's health objectives represents one of the most important challenges for its health system. Methodologically, there are no gold standards for assessing the sufficiency of the health workforce to address the health care needs of a given population. It has been estimated however, in the World Health Report 2006, that countries with fewer than 23 physicians, nurses and midwives per 1,000 population generally fail to achieve adequate coverage rates for selected primary health care interventions as prioritized by the Millennium Development Goals framework (GHO, accessed August 2015). 

    Construction

    Numerator: Total number of community health workers, nurses and midwifery personnel

    Denominator: Total population of country

     

    Expressed as density of workforce per 1,000 population.

    Notes

    The PHC Vital Signs indicators rely on third party data. To learn more about our data click here, or e-mail us at info@phcperformanceinitiative.org to provide feedback. Visit the Indicator Library for detailed descriptions of the rationale, construction, and limitations of indicators.

    Data Source Notes

    Global Health Observatory (GHO). This indicator is derived from two separate indicators (community health worker density and nurse and midwife density). Population is derived from United Nations Population Division's World Population Prospects database. Community health worker counts are derived from: population censuses, labor force and employment surveys, health facility assessments and routine administrative information systems (including reports on public expenditure, staffing and payroll as well as professional training, registration and licensure).

    Limitations

    The classification of health workers is based on criteria for vocational education and training, regulation of health occupations, and the activities and tasks involved in carrying out a job, i.e. a framework for categorizing key workforce variables according to shared characteristics. While much effort has been made to harmonize the data to enhance comparability, the diversity of health worker roles and information sources means that considerable variability remains across countries and over time in the coverage and quality of the original data. Some figures may be underestimated or overestimated when it is not possible to distinguish whether the data include health workers in the private sector, double counts of health workers holding two or more jobs at different locations, workers who are unpaid or unregulated but performing health care tasks, or people with a health-related education working outside the health care sector (e.g. at a research or teaching institution) or who are not currently engaged in the national health labour market (e.g. unemployed, migrated, retired or withdrawn from the labour force for personal reasons). (GHO, accessed August 2015)

  • Essential drug availability

    Essential drug availability measures the number of unexpired drugs in a health facility compared to the total expected number of drugs on the list defined by the World Health Organization. To effectively provide essential health services, facilities must have available a minimum level of essential drugs.

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    Availability of essential drugs

    Rationale

    To effectively provide essential health services, health facilities must have available minimum levels of essential drugs.

    Construction

    • Numerator: Number of unexpired drugs on the defined list of which a facility has at least one available
    • Denominator: Total number of drugs on the defined list, which includes tracer medicines for children and mothers identified by the World Health Organization

    The specific list of drugs facilities are assessed against varies depending on the data source. We chose to include values from SARA and SPA facility assessments where available, recognizing that there are slight definitional differences.

    Details on the items included in the SARA and SPA surveys can be found here (SARA) and here (SPA). The list of essential drugs is derived from the WHO Model List of Essential Medicines.

    Notes

    The PHC Vital Signs indicators rely on third party data. To learn more about our data click here, or e-mail at info@phcperformanceinitiative.org us to provide feedback. Visit the Indicator Library for detailed descriptions of the rationale, construction, and limitations of indicators.

    Data Source Notes

    Data for this indicator are collected in less than 15 countries. 

    Service Availability and Readiness Assessment (SARA) - Click here for the detailed list of drugs. 

    Service Provision Assessment (SPA) -  Click here for the detailed list of drugs. 

    The list of essential drugs is derived from the WHO Model List of Essential Medicines.

    Limitations

    Different health facility assessments note the availability of different sets of essential drugs, making this indicator more complicated to standardize across methods. In addition, the list must reflect the national standards. The availability of essential drugs is a point-in-time indicator and thus does not reflect whether facilities have the resources and capacity required to maintain essential drugs stock levels over time, nor does it measure frequency of stock-outs. Further, it does not reflect provider ability or knowledge to administer drugs appropriately. 

  • Health center and health post density (per 100,000 population)

    Health center and health post density reflects the total number of health centers and health posts relative to population size (per 100,000 population). Health center and health post density helps measure physical access to outpatient health care services.

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    Health center and health post density (per 100,000 population)

    Rationale

    Facility density is primarily an indicator of outpatient service access, and may indicate the accessibility of primary health care facilities. Health centers and health posts were selected because they are often the first contact point that many individuals have with the PHC system. 

    Construction

    • Numerator: Total number of health centers and health posts from the public and private sectors
    • Denominator: Total population of country (expressed per 100,000 population)

    Health posts are either community centers or health environments with a very limited number of beds with limited curative and preventive care resources normally assisted by health workers or nurses (GHO, accessed August 2015). 

    Notes

    The PHC Vital Signs indicators rely on third party data. To learn more about our data click here, or e-mail us at info@phcperformanceinitiative.org to provide feedback. Visit the Indicator Library for detailed descriptions of the rationale, construction, and limitations of indicators.

    Data Source Notes

    Global Health Observatory (GHO). This indicator is derived from two separate indicators (density of health centers and density of health posts). Information is collected directly from country focal points from ministries of health through the baseline country survey on medical devices 2013 update, conducted by HQ/HIS/EMP/PAU. The population data was obtained from World Population Prospects 2012 Revision (2013 medium estimates) (GHO, accessed August 2015).

    Limitations

    This indicator does not take into account the size or capacity of the facilities.  More developed health systems may not utilize health posts as a primary point of contact. As a result, those systems may have low density on this measure. Additionally, the density of health centers and health posts is often reported as an average and therefore doesn’t reflect the equity of distribution of health centers and health posts throughout the country. 

  • Vaccine availability

    Vaccine availability measures the total number of unexpired vaccines available in a facility relative to the vaccines on a defined list. To effectively provide essential health services, health facilities must have available a minimum level of vaccines, including but not limited to measles, DTP, oral polio, and pneumococcal.

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    Availability of vaccines

    Rationale

    To effectively provide essential health services, health facilities must have available minimum levels of vaccines, including but not limited to measles, DPT, oral polio, and pneumococcal. 

    Construction

    • Numerator: Number of unexpired vaccines from the defined list available in a facility
    • Denominator: Total number of vaccines on the defined list

    The specific list of vaccines facilities are assessed against varies depending on the data source. We chose to include values from SARA, SDI, and SPA facility assessments where available, recognizing that there are slight definitional differences.

    • Details on the SDI survey can be found here.
    • Details on the items included in the SARA survey can be found here.

    Notes

    The PHC Vital Signs indicators rely on third party data. To learn more about our data click here, or e-mail us at info@phcperformanceinitiative.org to provide feedback. Visit the Indicator Library for detailed descriptions of the rationale, construction, and limitations of indicators.

    Data Source Notes

    Service Delivery Indicators (SDI): SDI values reported for Mozambique, Nigeria, Senegal, Tanzania, Togo, and Uganda.

    Service Availability and Readiness Assessment (SARA): SARA value reported for Kenya.

    Limitations

    Different health facility assessments note the availability of different sets of essential vaccines, making this indicator more complicated to standardize across methods. In addition, the list must reflect the national standards. The availability of vaccines is a point-in-time indicator and thus does not reflect whether facilities have the resources and capacity required to maintain vaccine stock levels over time, nor does it measure frequency of stock-outs.

Service Delivery

  • Access barriers due to treatment cost

    Access barriers due to treatment cost measures the percent of women who self-report problems in accessing health care due to cost of treatment. Financial access is a critical component of health service access, and access barriers can have a detrimental effect on utilization of health services.

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    Percent of women who report barriers in care access due to cost of treatment

    Rationale

    Financial access is a critical component of health services access. This indicator reflects user-reported access barriers and is a complement to measurement of overall out-of-pocket expenditures on health. Access barriers due to cost can have detrimental effects on the utilization of health services.

    Construction

    Numerator: Number of women who report specific problems in accessing health care when they are sick due to issues related to getting money for treatment

    Denominator: Number of women interviewed

    Notes

    The PHC Vital Signs indicators rely on third party data. To learn more about our data click here, or e-mail us at info@phcperformanceinitiative.org to provide feedback. Visit the Indicator Library for detailed descriptions of the rationale, construction, and limitations of indicators.

    Data Source Notes

    Demographic and Health Survey (DHS) is a nationally-representative household survey that provides data for a wide range of monitoring and impact evaluation indicators in the areas of population, health, and nutrition. Standard DHS surveys have large sample sizes (usually between 5,000 and 30,000 households) and typically are conducted about every 5 years, to allow comparisons over time. Read more here

    Limitations

    This indicator captures access barriers due to treatment costs, but it may not capture financial barriers to access that are related to transport or medicines required following diagnosis. 

  • Caseload per provider (daily)

    Caseload per provider is the average number of outpatient visits seen by a provider per day. Provider caseload can have critical impacts on service quality - a shortage of providers may cause caseload to rise and potentially compromise service quality and lead to provider burnout. Conversely, low caseloads may impact provider motivation, absenteeism, and the practice of skills and procedures.

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    Number of outpatient visits per clinician per day

    Rationale

    From the perspective of a patient visiting a health facility, caseload is a critically important measure impacting wait time and access to providers. From a provider perspective, caseload is a central component of total workload and measure of efficiency and productivity. A shortage of providers may cause patient caseload to rise and potentially compromise service quality and reduce provider motivation. 

    Construction

    • Numerator: Number of outpatient visits recorded in outpatient records in the health facility three months prior to the survey
    • Denominator: Number of days the facility was open during the three-month period and the number of health workers who conduct patient consultations (i.e. excluding cadre-types such as public health nurses and out-reach workers) 

    Notes

    The PHC Vital Signs indicators rely on third party data. To learn more about our data click here, or e-mail us at info@phcperformanceinitiative.org to provide feedback. Visit the Indicator Library for detailed descriptions of the rationale, construction, and limitations of indicators.

    Data Source Notes

    Data for this indicator are collected in less than 15 countries.

    Service Delivery Indicators (SDI): Caseload is measured by dividing the number of outpatient visits in outpatient records in the health facility three months prior to the survey by the number of days the facility was open during the three-month period and the number of health workers who conduct patient consultations (i.e. excluding cadre-types such as public health nurses and out-reach workers).

    Limitations

    Caseload does not measure the full workload experienced by a provider, which includes administrative work and other non-clinical activities. It also does not capture the quality of care. 

  • Continuity of care: DTP3 dropout rate

    Diptheria-tetanus-pertussis (DTP) dropout rate is the percent of children who do not receive three doses of DTP after receiving an initial dose. Measuring this gap reflects health system continuity, including the system’s ability to capture and follow up with patients.

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    Dropout rate between 1st and 3rd diphtheria-tetanus-pertussis vaccination

    Rationale

    Immunization is an essential component for reducing under-five mortality. Immunization coverage estimates are used to monitor coverage of immunization services and to guide disease eradication and elimination efforts. Measuring the gap between DTP1 and DTP3 reflects continuity within a health system, including the system’s ability to capture and follow up with patients.

    Construction

    This indicator is constructed from two separate measures. 

    DTP1-3 drop-out rate (%) = [DTP1 Immunization Coverage - DTP3 Immunization Coverage]/[DTP1 Immunization Coverage]

    Notes

    Benchmark: 10% from UNICEF, which reports "when drop-out rate is less than 10%, children who receive an initial DTP dose are highly likely to receive all three required doses, indicating a high level of health care assistance and performance.”

    The PHC Vital Signs indicators rely on third party data. To learn more about our data click here, or e-mail us at info@phcperformanceinitiative.org to provide feedback. Visit the Indicator Library for detailed descriptions of the rationale, construction, and limitations of indicators.

    Data Source Notes

    WHO/UNICEF. The WHO and UNICEF regularly report and release updated immunization coverage data related to the Global Vaccine Action Plan. 

    Limitations

    Given the prevalence of global support for immunization efforts, a high coverage rate of DTP3 immunization may be reflective of strong support from vertical programming in some countries. As such, DTP3 coverage alone is not necessarily a proxy for primary care health system performance. 

  • Continuity of care: Antenatal care dropout rate

    Antenatal care (ANC) dropout rate reflects the difference in the percent of women who do not receive four ANC visits after receiving an initial visit. Measuring this gap reflects health system continuity, including the system’s ability to capture and follow up with patients.

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    Dropout rate between 1st and 4th antenatal care visits

    Rationale

    Antenatal care coverage is an indicator of access and use of health care during pregnancy. The antenatal period presents opportunities for reaching pregnant women with interventions that may be vital to their health and wellbeing and that of their infants. Receiving antenatal care at least four times, as recommended by WHO, increases the likelihood of receiving effective maternal health interventions during antenatal visits. Measuring the gap between ANC1 and ANC4 reflects continuity within a health system, including the system’s ability to capture and follow up with patients.

    Construction

    This indicator is constructed from two separate measures. 

    ANC drop-out rate (%) = [Antenatal care coverage-at least one visit (%)] – [Antenatal care coverage-at least four visits (%)]/[Antenatal care coverage-at least one visit (%)]

    Antenatal care coverage (at least one visit) is the percentage of women aged 15 to 49 with a live birth in a given time period that received antenatal care provided by skilled health personnel (doctor, nurse or midwife) at least once during pregnancy.

    Antenatal care coverage (at least four visits) is the percentage of women aged 15 to 49 with a live birth in a given time period that received antenatal care four or more times. Available survey data on this indicator usually do not specify the type of the provider; therefore, in general, receipt of care by any provider is measured. 

    Notes

    The PHC Vital Signs indicators rely on third party data. To learn more about our data click here, or e-mail us to provide feedback. Visit the Indicator Library for detailed descriptions of the rationale, construction, and limitations of indicators.

    Data Source Notes

    UNICEF. UNICEF compiles empirical data from DHS, MICS and other national household surveys. Available survey data on this indicator usually do not specify the type of the provider; therefore, in general, receipt of care by any provider is measured. At the global level, data from facility reporting are not used. Before data are included into the global databases, UNICEF undertakes a process of data verification that includes correspondence with field offices to clarify any questions regarding estimates.

    Limitations

    Receiving antenatal care during pregnancy does not guarantee the receipt of interventions that are effective in improving maternal health (effective coverage). Although the indicator for “at least one visit” refers to visits with skilled health providers (doctor, nurse, midwife), “four or more visits” usually measures visits with any provider because national-level household surveys do not collect provider data for each visit. In addition, standardization of the definition of skilled health personnel is sometimes difficult because of differences in training of health personnel in different countries (UNICEF). Recall error is a potential source of bias in the data. 

  • Continuity of care: TB treatment success rate

    Tuberculosis (TB) treatment success rate is the percent of all TB cases that successfully complete treatment. The cure rate of complex conditions like TB is a proxy for a number of aspects of successful service delivery within a health system, including diagnostic and treatment accuracy and the system’s ability to capture and follow up with patients over time.

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    Continuity of care: Tuberculosis treatment success rate

    Rationale

    Treatment success is an indicator of the performance of national TB programs. It also serves as a proxy for a number of aspects of successful service delivery within a health system, including diagnostic and treatment accuracy and the system’s ability to capture and follow up with patients. Further, this serves as an indicator of patient continuity within a health care system. 

    Construction

    Numerator: Number of new TB cases registered in a given year (excluding cases placed on a second-line drug regimen) that successfully completed treatment whether with or without bacteriological evidence of success (GHO, accessed August 2015)

    Denominator: Number of TB cases registered in a given year

    Notes

    Benchmark: 85%, as adopted at the 44th World Health Assembly through resolution 44.8.

    The PHC Vital Signs indicators rely on third party data. To learn more about our data click here, or e-mail us at info@phcperformanceinitiative.org to provide feedback. Visit the Indicator Library for detailed descriptions of the rationale, construction, and limitations of indicators.

    Data Source Notes

    Global Health Observatory (GHO). Preferred data sources include patient record and surveillance systems.

    Limitations

    This indicator measures only public-sector TB programs and does not include results from private-sector treatment programs or facilities. Therefore, in countries with strong private-sector TB programs, these results do not reflect the totality of the TB treatment success rate. Further, this indicator does not capture the system’s ability to identify new TB patients. As a result, a country could perform well on this indicator, but poorly on the identification of new TB cases. 

  • Diagnostic accuracy

    Diagnostic accuracy measures the number of cases that are correctly diagnosed out of the number of patients examined, as observed through clinical vignettes on multiple common conditions. This indicator is a proxy for provider competence, impacting the clinical quality of care that is delivered to patients.

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    Diagnostic accuracy

    Rationale

    Having health professionals present in facilities is a necessary but not sufficient condition for delivering quality health services. This indicator is a proxy for the clinical quality of care that is delivered to patients.

    Construction

    Numerator: For each clinical case, a score of one is assigned for each clinical case if the diagnosis is mentioned. The numerator is the sum of the total number of correct diagnoses identified. Where multiple diagnoses were provided by the clinician, the diagnosis is coded as correct as long as it is mentioned, irrespective of what other alternative diagnoses were given.

    Denominator: Total number of clinical cases tested

    Data are collected for the following clinical vignettes: (i) acute diarrhea; (ii) pneumonia; (iii) diabetes mellitus; (iv) pulmonary tuberculosis; (v) malaria with anemia.

    Notes

    The PHC Vital Signs indicators rely on third party data. To learn more about our data click here, or e-mail us at info@phcperformanceinitiative.org to provide feedback. Visit the Indicator Library for detailed descriptions of the rationale, construction, and limitations of indicators.

    Data Source Notes

    Data for this indicator are collected in less than 15 countries.

    Service Delivery Indicators (SDI). Diagnostic accuracy is measured by assessing providers' ability to correctly diagnose the following conditions: pulmonary tuberculosis, pneumonia, acute diarrhea, diabetes, malaria with anemia.

    Limitations

    The limitation of clinical vignettes is that they measure a provider’s abilities in a theoretical scenario, but do not capture “real world” phenomena. They are designed to approximate and isolate aspects of the decision-making process that occur in real world settings. However, making the correct diagnosis does not ensure the provision of appropriate care (the “know-do” gap). Other approaches to evaluate adherence to guidelines include use of standardized patients, patient reporting, and observations of clinical encounters.

  • Provider absence rate

    Provider absence rate measures the number of clinical staff actually present at a facility compared to the expected number of staff at a given time. Not only is having health professionals present in primary health care facilities a necessary condition for delivering health services, staff absenteeism is also a reflection of the quality of organization and management processes within a health facility.

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    Provider absence rate

    Rationale

    Having health professionals present in facilities is a necessary condition for delivering health services. Staff absenteeism is also a reflection of the quality of organization and management processes within a health facility.

    Construction

    Numerator: Number of health professionals that are not off duty who are absent from the facility on an unannounced visit

     

    Denominator: Ten randomly sampled workers who are supposed to be on duty at the facility on the day of the assessment. Health workers doing fieldwork (mainly community and public health workers) were counted as present. 

    Notes

    The PHC Vital Signs indicators rely on third party data. To learn more about our data click here, or e-mail us at info@phcperformanceinitiative.org to provide feedback. Visit the Indicator Library for detailed descriptions of the rationale, construction, and limitations of indicators.

    Data Source Notes

    This indicator is collected in less than 15 countries.

    Service Delivery Indicators (SDI)

    Limitations

    Having providers present in facilities is necessary but not sufficient for delivery of quality health services, which is dependent on other aspects of service delivery including provider competence and motivation, and availability of equipment. 

Outputs

  • Antenatal care coverage (4+ visits)

    Antenatal care coverage (4+) visits is the percent of women with a live birth who received antenatal care (ANC) 4 or more times. It indicates both women’s access to and use of primary health care services, and also represents opportunities for pregnant women to receive essential services vital to their health and wellbeing and that of their infants. ANC coverage was a Millennium Development Goal target and is incorporated into the Sustainable Development Goals. 

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    ANC coverage (4+ visits)

    Rationale

    Antenatal care coverage is an indicator of access and use of health care during pregnancy. The antenatal period presents opportunities for reaching pregnant women with interventions that may be vital to their health and wellbeing and that of their infants. Receiving antenatal care at least four times, as recommended by WHO, increases the likelihood of receiving effective maternal health interventions during antenatal visits. This is an MDG indicator.

    Construction

    • Numerator: The number of women aged 15-49 surveyed with a live birth in a given time period that received antenatal care four or more times
    • Denominator: Total number of women aged 15-49 with a live birth in the same period surveyed

    Notes

    Benchmark: 100% (universal coverage) by 2030, per the current Sustainable Development Goal (SDG) targets. This benchmark will be updated if SDG targets change.

    The PHC Vital Signs indicators rely on third party data. To learn more about our data click here, or e-mail us at info@phcperformanceinitiative.org to provide feedback. Visit the Indicator Library for detailed descriptions of the rationale, construction, and limitations of indicators.

    Data Source Notes

    UNICEF. UNICEF compiles empirical data from DHS, MICS and other national household surveys. Available survey data on this indicator usually do not specify the type of the provider; therefore, in general, receipt of care by any provider is measured. At the global level, data from facility reporting are not used. Before data are included into the global databases, UNICEF undertakes a process of data verification that includes correspondence with field offices to clarify any questions regarding estimates.

    Limitations

    Receiving antenatal care during pregnancy does not guarantee the receipt of interventions that are effective in improving maternal health (effective coverage). Although the indicator for “at least one visit” refers to visits with skilled health providers (doctor, nurse, midwife), “four or more visits” usually measures visits with any provider because national-level household surveys do not collect provider data for each visit. In addition, standardization of the definition of skilled health personnel is sometimes difficult because of differences in training of health personnel in different countries (UNICEF). Recall error is a potential source of bias in the data.

  • Children with diarrhea receiving appropriate treatment

    Children with diarrhea receiving appropriate treatment is the percent of children with diarrhea, a leading cause of death in children under five, who received appropriate treatment with oral rehydration and continued feeding. This indicator reflects trust in the primary health care system, access to facilities, availability of common home treatments, and health knowledge and behavior.

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    Percent of children under 5 with diarrhea receiving oral rehydration and continued feeding

    Rationale

    The percentage of children under five with diarrhea receiving oral rehydration and continued feeding is an important indicator of access to health commodities and effective treatment of a common cause of child mortality. 

    Construction

    Numerator: Number of children aged 0–59 months with diarrhea in the two weeks prior to the survey receiving oral rehydration therapy or increased fluids, and continued feeding during the time the child had diarrhea

    Denominator: Total number of children aged 0–59 months with diarrhea in the two weeks prior to the survey.

    Notes

    The PHC Vital Signs indicators rely on third party data. To learn more about our data click here, or e-mail us at info@phcperformanceinitiative.org to provide feedback. Visit the Indicator Library for detailed descriptions of the rationale, construction, and limitations of indicators.

    Data Source Notes

    World Development Indicators (World Bank). Data are sourced from UNICEF, State of the World’s Children, Childinfo, and Demographic and Health Surveys. 

    Limitations

    This indicator does not reflect whether oral rehydration salts and continued feeding were given appropriately. Most diarrhea-related deaths are due to dehydration, and many of these deaths can be prevented with the use of oral rehydration salts at home. However, recommendations for the use of oral rehydration therapy have changed over time based on scientific progress, so it is difficult to accurately compare use rates across countries. Until the current recommended method for home management of diarrhea is adopted and applied in all countries, the data should be used with caution. Also, the prevalence of diarrhea may vary by season. Since country surveys are administered at different times, data comparability is further affected (World Development Indicators (World Bank), accessed September 2015.

  • Contraceptive prevalence rate

    Contraceptive prevalence rate measures the percent of women of reproductive age who are using any modern method of contraception. The contraceptive prevalence rate serves as a proxy for population access to reproductive health services, particularly women’s access, which are frequently delivered through the primary health care system and are essential for meeting many health targets.

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    Contraceptive prevalence rate (modern methods)

    Rationale

    Use of modern contraception is a critical component of women’s, maternal, and population health.

    Construction

    Numerator: Number of currently married women aged 15-49 who use a modern method of contraception except for the lactational amenorrhea method (LAM). Modern methods include female sterilization, male sterilization, oral contraceptive pill, intra-uterine device, injectables, implants, male condom, female condom, diaphragm, and foam or jelly.

    Denominator: Number of women ages 15-49 surveyed

    Notes

    The PHC Vital Signs indicators rely on third party data. To learn more about our data click here, or e-mail us at info@phcperformanceinitiative.org to provide feedback. Visit the Indicator Library for detailed descriptions of the rationale, construction, and limitations of indicators.

    Data Source Notes

    Demographic and Health Survey (DHS) is a nationally-representative household survey that provides data for a wide range of monitoring and impact evaluation indicators in the areas of population, health, and nutrition. Standard DHS surveys have large sample sizes (usually between 5,000 and 30,000 households) and typically are conducted about every 5 years, to allow comparisons over time. Read more here

    Limitations

    In some surveys, the lack of probing questions, asked to ensure that the respondent understands the meaning of the different contraceptive methods, can result in an underestimation of contraceptive prevalence. Sampling variability may be an issue, particularly when contraceptive prevalence, modern methods is measured for a specific subgroup (according to method, age-group, level of educational attainment, place of residence, etc.) or when analyzing trends over time. This indicator is a measure of both service coverage and fertility preferences and, as such, no target exists. 

  • Coverage Index

    The Coverage Index acts as a tracer for a country’s performance on PHC service coverage. It is based off a country’s performance on antenatal care coverage (4+ visits), children with diarrhea receiving appropriate treatment, and DTP3 coverage. For more information about how the Coverage Index is constructed, click here.

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    Coverage Index

    Rationale

    The purpose of the coverage index is to act as a tracer for a country’s performance on PHC services. It is an intial attempt to summarize performance on PHC coverage. 

    Construction

    The coverage index is a work in progress and expert feedback is being sought in order to strengthen this measure. If you have specific ideas, please share them by emailing us at info@PHCperformanceinitiative.org

    The composite score is derived from the following underlying indicators: (1) ANC 4+ visits (2) Percentage of children under 5 with diarrhea receiving oral rehydration and continued feeding and (3) DTP3 immunization coverage. The composite is created as a scaled residual to address the variation across the number of observations for each indicator. Countries with population of at least 1 million were used to calculate the sample mean and standard deviation for each indicator, but the coverage score was calculated for all countries. The residual is divided by the standard deviation of the indicator. This gives each country a score that reflects the number of standard deviations they are from the mean. The composite score for each country is the sum of input indicators divided by the number of indicators reported for that country. This use of mean (rather than sum) ensures that we are not introducing a bias towards countries reporting on more indicators. These values were re-scaled to range from 0-1. Only countries reporting on at least two indicators are reported.

    Notes

    The PHC Vital Signs indicators rely on third party data. To learn more about our data click here, or e-mail us at info@phcperformanceinitiative.org to provide feedback. Visit the Indicator Library for detailed descriptions of the rationale, construction, and limitations of indicators.

    Data Source Notes

    UNICEF, WHO, World Bank – World Development Indicators

    Limitations

    The coverage index was limited to those indicators that are part of the Vital Signs indicator set. As a result, there are only five potential coverage indicators that could form the metric, and only three of which are measured on a true 0-100% scale.

  • DTP3 coverage

    Diptheria-tetanus-pertussis (DTP) coverage measures the percent of one-year-olds who have received three doses of the combined diphtheria, tetanus toxoid and pertussis vaccine in a given year. Not only is immunization an essential component of reducing under-five mortality and controlling the spread of communicable diseases, but it also represents the primary health care system’s ability to reach and serve children multiple times during the first year of life.

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    Diphtheria-tetanus-pertussis (DTP3) immunization coverage

    Rationale

    Immunization is an essential component for reducing under-five mortality. Immunization coverage estimates are used to monitor coverage of immunization services and to guide disease eradication and elimination efforts. 

    Construction

    Numerator: Number of children of aged 12 months surveyed who have received three doses of the combined diphtheria, tetanus toxoid and pertussis vaccine in a given year

    Denominator: Total population of children aged 12 months surveyed

    Notes

    Benchmark: 90%, as adopted by the United Nations as a resolution during the 27th session.

    The PHC Vital Signs indicators rely on third party data. To learn more about our data click here, or e-mail us at info@phcperformanceinitiative.org to provide feedback. Visit the Indicator Library for detailed descriptions of the rationale, construction, and limitations of indicators.

    Data Source Notes

    WHO/UNICEF. The WHO and UNICEF regularly report and release updated immunization coverage data related to the Global Vaccine Action Plan. 

    Limitations

    Given the prevalence of global support for immunization efforts, a high coverage rate of DTP3 immunization may be reflective of strong support from vertical programming in some countries. As such, DTP3 coverage alone is not necessarily a proxy for health system performance.

  • Facility-based deliveries

    Facility-based deliveries measures the percent of live births that take place in a public or private health facility. Deliveries in health facilities can reduce maternal and neonatal mortality and morbidity by increasing the likelihood that women deliver with a skilled birth attendant and are connected to a referral system.

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    Percent of births taking place in a health care facility

    Rationale

    Increasing the proportion of women who deliver in a health facility can be an important component in reducing maternal and neonatal mortality in low-income settings. Deliveries in health facilities can increase the likelihood that women deliver with a skilled birth attendant and are connected to a referral system in the case of delivery complications.

    Construction

    Numerator: Number of interviewed women who had one or more live births in a public or private health facility in the five years preceding the survey

    Denominator: Total number of interviewed women who had one or more live births in the five years preceding the survey

    Notes

    The PHC Vital Signs indicators rely on third party data. To learn more about our data click here, or e-mail us at info@phcperformanceinitiative.org to provide feedback. Visit the Indicator Library for detailed descriptions of the rationale, construction, and limitations of indicators.

    Data Source Notes

    UNICEF aggregates data from the Demographic and Health Survey and Multiple Indicator Cluster Survey.

    Limitations

    Delivery in a health facility does not necessarily ensure that high quality health services are received, as this is dependent on the presence and competence of providers and the availability of essential drugs, equipment, and infrastructure.

Outcomes

  • Adult mortality from non-communicable diseases

    Adult mortality from non-communicable diseases measures the probability that adults under the age of 70 will die from a non-communicable disease (NCD). The NCD burden among adults is increasing due to aging and health transitions worldwide, but many NCDs can be prevented or effectively managed by strong primary health care.

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    Probability (%) of dying between ages 30 and 70 from cardiovascular disease, cancer, diabetes, or chronic respiratory disease

    Rationale

    Disease burden from non-communicable diseases (NCDs) among adults - the most economically productive age span - is rapidly increasing in developing countries due to aging and health transitions. Measuring the risk of dying from target NCDs is important to assess the extent of burden from mortality due NCDs in a population. This indicator has been selected to measure NCD mortality for the "25 by 25" NCD mortality target (GHO, accessed August 2015).

    Construction

    Numerator: Number of 30-year-old-people who would die before the age of 70 years from cardiovascular disease, cancer, diabetes, or chronic respiratory disease, assuming that s/he would experience current mortality rates at every age and s/he would not die from any other cause of death (e.g., injuries or HIV/AIDS).

    Denominator: Population aged 30-70

    Expressed as a percent 

    Notes

    The PHC Vital Signs indicators rely on third party data. To learn more about our data click here, or e-mail us at info@phcperformanceinitiative.org to provide feedback. Visit the Indicator Library for detailed descriptions of the rationale, construction, and limitations of indicators.

    Data Source Notes

    Global Health Observatory (GHO). Preferred data source: civil registration with complete coverage and medical certification of cause of death.

    Life tables specifying all-cause mortality rates by age and sex for WHO Member States are developed from available death registration data, sample registration systems (India, China) and data on child and adult mortality from censuses and surveys.
    Cause-of-death distributions are estimated from death registration data, and data from population-based epidemiological studies, disease registers and notifications systems for selected specific causes of death. Causes of death for populations without useable death-registration data are estimated using cause-of-death models together with data from population-based epidemiological studies, disease registers and notifications systems. 

    Probability of death between exact age 30 and exact age 70 was calculated using cause-specific mortality rates in each 5-year age group and standard life table methods (GHO, accessed August 2015).

    Limitations

    Data on adult mortality, particularly in low-income countries, is often limited. Methods to estimate adult mortality from censuses and surveys are retrospective and possibly subject to measurement error (GHO, accessed August 2015). They also rely on accurate cause of death.

  • Efficiency: under-five mortality rate relative to per capita PHC expenditure

    This efficiency indicator measures how well countries achieve a key PHC outcome—low under five mortality (U5M)—relative to their spending on PHC. It is a proxy for how effective a country’s allocation of resources is. It is derived by taking the difference between a country’s predicted U5M and its actual U5M, and is scored relative to other countries. This measure is currently available only for countries with data on PHC spending. For more details on how efficiency is constructed, click here.   

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    Efficiency: Under-five mortality relative to primary health care spending per capita

    Rationale

    Under-five mortality relative to primary health care spending is an important measure of the efficiency of the health system in converting inputs (such as financing) into desired health outcomes. By comparing countries against peers with similar levels of spending, one can assess whether they are achieving more/less value for money. This can indicate whether or not the current allocation of resources is as effective as possible.

    Construction

    The efficiency measure is a work in progress and expert feedback is being sought in order to strengthen this measure. If you have specific ideas, please share them by emailing us at info@PHCperformanceinitiative.org.

    We first estimate a regression equation between under-five mortality rate (U5MR), the dependent variable, and PHC per capita spending, the independent variable. We then use the estimated equation to predict what the U5MR would be for any particular country, on the assumption that the country's U5MR performance is as efficient as the global average. We then compare the actual U5MR of the country in question to the predicted U5MR to determine if its U5MR performance is relatively more (or less) efficient than the global average. 

    Given the wide range in observed under-five mortality rate, the final efficiency measure is reported as a percentage of observed deaths and is standardized on a 0-1 scale, relative to other country performance. 

    Notes

    The PHC Vital Signs indicators rely on third party data. To learn more about our data click here, or e-mail us at info@phcperformanceinitiative.org to provide feedback. Visit the Indicator Library for detailed descriptions of the rationale, construction, and limitations of indicators.

    Data Source Notes

    Global Health Observatory (GHO), SHA2011. Predicted under five mortality is determined by PHC spending per capita from SHA2011. 

     

     

  • Equity: under-five mortality wealth differential

    This equity indicator measures equity through the difference in the under-five mortality rate between the fifth (highest) and first (lowest) wealth quintile, and represents equity in primary health care outcomes across wealth quintiles. 

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    Under-five mortality equity: difference between 1st and 5th wealth quintiles

    Rationale

    Equity is an important dimension of PHC systems, but is often masked by national level statistics. Large differences in under-five mortality between wealth quintiles may indicate disparities in access to child health care services.

    Construction

    Under-five wealth differential = [Wealth Q5 U5 mortality rate] – [Wealth Q1 U5 mortality rate]

    Notes

    The PHC Vital Signs indicators rely on third party data. To learn more about our data click here, or e-mail us at info@phcperformanceinitiative.org to provide feedback. Visit the Indicator Library for detailed descriptions of the rationale, construction, and limitations of indicators.

    Data Source Notes

    Global Health Observatory (GHO) Equity Monitor: The Inter-agency Group for Child Mortality of Estimation, which includes representatives from UNICEF, WHO, the World Bank and the United Nations Population Division, produces trends of under-five mortality with standardized methodology by group of countries depending on the type and quality of source of data available. For countries with adequate trend of data from civil registration, the calculations of under-five and infant mortality rates are derived from a standard period abridged life table. For countries with survey data, under-five mortality rates are estimated using the Bayesian B-splines bias-adjusted model.

    These under-five mortality rates have been estimated by applying methods to all Member States to the available data from Member States that aim to ensure comparability of across countries and time; hence they are not necessarily the same as the official national data (GHO, accessed August 2015).

    Limitations

    The reliability of estimates of under-five mortality depends on the accuracy and completeness of reporting and recording of births and deaths. Underreporting and misclassification are common. This indicator reports only socioeconomic quintile differences, and there does not capture other aspects of equity.

  • Maternal mortality ratio (per 100,000 live births)

    Maternal mortality ratio (MMR) measures the annual number of maternal deaths from any cause related to or aggravated by pregnancy or its management, relative to the total number of births. The indicator is reported as deaths per 100,000 live births. Maternal mortality indicates the ability of a system to deliver care at critical moments, including preventing and addressing pregnancy complications, and is one of the Sustainable Development Goal targets. It may also highlight access to and delivery of care, as well as the presence of a functioning referral system to treat complications that cannot be addressed at the primary health care level.  

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    Maternal mortality ratio (per 100,000 live births)

    Rationale

    Complications during pregnancy and childbirth are a leading cause of death and disability among women of reproductive age in developing countries. The maternal mortality ratio represents the obstetric risk associated with each pregnancy, i.e. the obstetric risk. It is also a Millennium Development Goal Indicator for monitoring Goal 5, improving maternal health.

    The indicator monitors deaths related to pregnancy and childbirth. It reflects the capacity of the health systems to provide effective health care in preventing and addressing the complications occurring during pregnancy and childbirth (GHO, accessed August 2015).

    Construction

    Numerator: Annual number of female deaths from any cause related to or aggravated by pregnancy or its management (excluding accidental or incidental causes) during pregnancy and childbirth or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy

    Denominator: 100,000 live births for a specified year

    Notes

    Benchmark: <70 per 100,000 live births by 2030, per the current Sustainable Development Goal (SDG) targets. This benchmark will be updated if SDG targets change.

    The PHC Vital Signs indicators rely on third party data. To learn more about our data click here, or e-mail us at info@phcperformanceinitiative.org to provide feedback. Visit the Indicator Library for detailed descriptions of the rationale, construction, and limitations of indicators.

     

    Data Source Notes

    Global Health Observatory (GHO). Data on maternal mortality and other relevant variables are obtained through databases maintained by WHO, UNPD, UNICEF, and the World Bank. Data available from countries vary in terms of the source and methods. Given the variability of the sources of data, different methods are used for each data source in order to arrive at country estimates that are comparable and permit regional and global aggregation.

    Limitations

    Vital registration and health information systems in most developing countries are weak, and thus, cannot provide an accurate assessment of maternal mortality. Even estimates derived from complete vital registration systems, such as those in developed countries, suffer from misclassification and underreporting of maternal deaths (GHO, accessed August 2015).

  • Under-five mortality rate (per 1,000 live births)

    Under-five mortality rate is the probability that a child will die before reaching age five. The indicator is reported as the number of deaths per 1000 live births. Child mortality includes infant and neonatal deaths and reflects the effectiveness of numerous essential services that children receive during their first years of life through primary health care systems, including but not limited to vaccinations, breastfeeding promotion, and nutrition counseling for mothers. This indicator captures more than 90% of global mortality among children under age 18.

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    Under-five mortality rate (per 1,000 live births)

    Rationale

    Under-five mortality rate measures child survival. It also reflects the social, economic and environmental conditions in which children (and others in society) live, including their health care. Because data on the incidences and prevalence of diseases (morbidity data) frequently are unavailable, mortality rates are often used to identify vulnerable populations. Under-five mortality rate is an MDG indicator (GHO, accessed August 2015).

    Construction

    Under-five mortality rate measures child survival. It also reflects the social, economic and environmental conditions in which children (and others in society) live, including their health care. Because data on the incidences and prevalence of diseases (morbidity data) frequently are unavailable, mortality rates are often used to identify vulnerable populations. Under-five mortality rate is an MDG indicator (GHO, accessed August 2015).

    Notes

    Benchmark: <25 per 1,000 live births by 2030, per the current Sustainable Development Goal (SDG) targets. This benchmark will be updated if SDG targets change.

    The PHC Vital Signs indicators rely on third party data. To learn more about our data click here, or e-mail us at info@phcperformanceinitiative.org to provide feedback. Visit the Indicator Library for detailed descriptions of the rationale, construction, and limitations of indicators.

    Data Source Notes

    Global Health Observatory (GHO). The Inter-agency Group for Child Mortality of Estimation which includes representatives from UNICEF, WHO, the World Bank and the United Nations Population Division, produces trends of under-five mortality with standardized methodology by group of countries depending on the type and quality of source of data available. For countries with adequate trend of data from civil registration, the calculations of under-five and infant mortality rates are derived from a standard period abridged life table. For countries with survey data, under-five mortality rates are estimated using the Bayesian B-splines bias-adjusted model.

    These under-five mortality rates have been estimated by applying methods to all Member States to the available data from Member States that aim to ensure comparability of across countries and time; hence they are not necessarily the same as the official national data (GHO, accessed August 2015).

    Limitations

    The reliability of estimates of under-five mortality depends on the accuracy and completeness of reporting and recording of births and deaths. Underreporting and misclassification are common.