Achieving universal health coverage (UHC) requires resilient health systems that utilize timely country-generated data to monitor health reforms, respond to disruptions in health service utilization, and inform how the health system adapts to changing needs. During the COVID-19 pandemic, the GFF supported Ministries of Health in 22 low- and middle-income countries to quantify the extent of disruptions to essential health services with rapid-cycle monitoring approaches. This support demonstrated that reductions in essential health services were a major contributor to the pandemic's overall impact on mortality and set back the global effort to reduce child and maternal deaths in most countries1. A range of events beyond COVID-19 contributed to service disruptions, including political instability, prolonged and acute insecurity, health worker strikes, supply chain shortages, economic shortages, and infectious disease outbreaks. Though many countries are no longer in the acute phase of the pandemic, these events continue to threaten service delivery and progress towards UHC.
There are opportunities to strengthen country-led processes to collect and use real-time data for decision-making to strengthen health systems. Countries can benefit from more frequent evidence to make course corrections in health reforms and respond to acute changes in the supply or demand of health services. Until now, country health management information system (HMIS) data may not be analyzed promptly or are too low quality to inform real-time decision making. In-person household and facility-based surveys are expensive and take years to complete and analyze. Approaches to improve the rigor of HMIS analysis and implement rapid-cycle, phone-based facility and household surveys during the COVID-19 pandemic can be institutionalized to improve country-led routine health systems monitoring. Rapid-cycle approaches and reliable in-country data systems detect service disruptions and empower frequent assessments of locally defined priorities. Rapid approaches are designed and validated alongside gold-standard evaluations to empower a more agile platform for continuous monitoring and evaluation that approximates surveillance of health system performance in a way that compliments periodic in-person surveys. Such platforms can routinely analyze health information data, contextualize results with rapid-cycle phone surveys, and regularly provide input into short-term planning, long-term health sector strategy development, and emergency response operations.
Through Frequent Assessment & Surveillance Tools for Resilience (FASTR), the GFF provides support to country-led efforts to build infrastructure for rapid-cycle service delivery data collection, analysis, and interpretation to inform actions to strengthen resilient health systems with a four-pillar approach. In all partner countries, the GFF offers technical assistance to assess acute constraints in EHS service delivery through a package of rapid-cycle analytics (Pillar 1). In partner countries with demand for additional services, a broader package of activities are available to strengthen the capacity and policy pathways required for evidence-based policy to improve the delivery of essential health services (Pillars 2-4). These mutually reinforcing program pillars provide demand-driven support to GFF partner countries to strengthen the resilience of health systems and ultimately reduce morbidity and mortality for women, children, and adolescents (Figure 1). Descriptions of the program pillars are as follows:
- Pillar 1: Analyze
The GFF will provide rapid cycle analytics supporting countries to monitor service volumes, understand reasons for changes in service delivery, and diagnose health inequities through:
- HMIS-based data analysis monitors changes in service volumes in key indicators and across equity dimensions (i.e., geography, gender, age). On a country-by-country basis and in collaboration with the Ministry of Health, analysis is routinely conducted on priority service indicators. The analysis is conducted sub nationally from health facility-level data and includes detailed feedback on data quality. Results are shared, and changes in service volume due to health shocks or programs are identified for further investigation.
- Rapid-cycle surveys are administered by phone to a sample of health facilities and households. They aim to rapidly identify key constraints in service delivery, identify inequities in service utilization, and contextualize disruptions identified in the analysis of HMIS data. The surveys collect information on facility service availability and readiness quarterly and estimate the magnitude and reasons for foregone care among households. Surveys are designed to minimize the burden on respondents and inform real-time decision-making.
- Pillar 2: Learn
Country stakeholders develop a contextualized and data-driven understanding of the challenges and opportunities in improving health system resilience and program effectiveness through:
- Learning studies leverage Pillar 1 data platforms to conduct in-depth research on local health system priorities. These studies respond to country-defined questions, including process/impact evaluations of health reforms or implementation research on the characteristics of high-performing local health systems.
- Data use workshops convene monitoring and evaluation and programmatic staff to discuss results from HMIS analysis, rapid-cycle surveys, and learning studies. Workshops are catalysts for data-influenced policymaking as participants discuss data trends, identify weaknesses and strengths in service delivery, and propose action plans to strengthen health systems. Workshops are used to tailor the analysis approach, generate demand for analyses, and kick off capacity-building activities.
- A community of practice encourages the continual use of analysis results, strengthening a country's data use culture. Opening a line of communication between data use workshop participants and other colleagues increases demand for analysis results while also reducing the feedback loop between analysis and policy action.
- Pillar 3: Strengthen
Capacity building and technical assistance are offered to countries to integrate rapid-cycle service delivery HMIS analysis and surveys into routine monitoring and evaluation activities through:
- Capacity building of health information data managers and analysts to manage the automatic extraction and cleaning of HMIS data, and conduct various analytical approaches. Ultimately, Ministry of Health staff will be able to identify and quantify service disruptions and translate the results for policymakers.
- Data use strengthening based on country-specific needs. For example, support for data use platforms, including supporting routine meetings, development of a country profile to monitor progress, and support for developing policy pathways. Potential policy pathways include integration into facility supervision activities and recommendations to development partners and senior management within the Ministry of Health.
- Pillar 4: Act
Countries are supported in data-informed policy development for routine short-term planning, long-term health sector strategies, and emergency response through:
- Action plans are developed through a structured review and interpretation of essential health service data. These plans can target either short/long-term priorities, planning or emergency response, or respond to specific concerns such as inequities in service delivery or poor data quality in priority indicators.
- Partner alignment around the gaps identified in a government-led national investment case. Results from these rapid cycle analytics can inform the progress of these national investment cases and realign priorities to the short- and long-term recommendations developed through the data use platform.
These activities can be adjusted based on country priorities, existing capacities, and stated needs. All requests can be directed to the GFF country liaison officer and focal person.
Shortfall in Service Delivery Compared to Pre-Pandemic Trends
The GFF supports routine monitoring of disruptions to essential health services. The essential health services data included in the graph below are sourced from country routine health information systems and shown monthly starting at the beginning of 2020. For all countries, the number of monthly deaths from Covid-19 is reported as a measure of the pandemic’s reach. The data on deaths from the Covid-19 pandemic were sourced from Johns Hopkins University (JHU) dashboards and compiled into monthly aggregates. The data used in this report were sourced 8/24/2021.