Background Paper:
Mainstreaming Adolescent Girls
into
Indicators of Health Systems Strengthening
James E. Rosen
Ruth Levine
February 26, 2010
Center for Global Development
Washington, DC
Background Paper: Adolescent Girls’ Indicators for Health Systems Strengthening
February 26, 2010
i
Contents
List of Acronyms ............................................................................................................... iv
Acknowledgements ............................................................................................................. v
Abstract .............................................................................................................................. vi
1 Introduction ................................................................................................................. 1
1.1
Objectives and audiences for the background paper........................................... 1
1.2
About health systems and health systems strengthening .................................... 2
1.2.1
Defining health systems .............................................................................. 2
1.2.2
Components of a health system .................................................................. 3
1.2.3
Shortcomings in WHO‘s Framework ......................................................... 4
2 A framework for incorporating adolescent-specific indicators into measurement of
health systems strengthening .............................................................................................. 5
2.1.1
Entry points for adolescent girl-specific indicators of health systems
strengthening ............................................................................................................... 5
2.2
Indicator evaluation criteria ................................................................................ 6
3 A Suggested Set of Adolescent Health Indicators ...................................................... 7
3.1
Summary of performance of the indicators ........................................................ 8
3.2
Suggested indicators ......................................................................................... 11
3.2.1
Building block 1: service delivery ............................................................ 11
3.2.1.1 Indicator: Percent of districts that are delivering adolescent-friendly
health services ....................................................................................................... 11
3.2.1.2 Indicator: Number and distribution of health facilities with basic
adolescent-friendly service capacity per 10,000 adolescent girls ......................... 12
3.2.2
Building block 2: health workforce .......................................................... 15
3.2.2.1 Indicator: Availability of a service provider trained in adolescent health
15
3.2.2.2 Indicator: Percent of health professions schools including adolescent
health topics in health worker training.................................................................. 16
3.2.2.3 Indicator: Annual number of graduates of health professions educational
institutions who receive training in adolescent health per 100,000 adolescents
girls – by level and field of education ................................................................... 18
3.2.3
Building block 3: information ................................................................... 19
3.2.3.1 Indicator: Availability of age & sex disaggregated data through the
national health management information system ................................................. 19
3.2.4
Building block 4: medical products, vaccines, and technologies ............. 20
3.2.5
Building block 5: financing ...................................................................... 21
3.2.5.1 Indicator: Coverage of the most vulnerable adolescent girls with health
insurance schemes ................................................................................................. 21
3.2.5.2 Indicator: Country has a policy that exempts adolescent girls from
paying user fees for preventive/FP services.......................................................... 22
3.2.6
Building block 6: leadership/governance.................................................. 23
3.2.6.1 Indicator: The country has a national situation analysis on adolescent
health
23
Background Paper: Adolescent Girls’ Indicators for Health Systems Strengthening
February 26, 2010
ii
3.2.6.2 Indicator: The country has national standards for the delivery of health
services to young people ....................................................................................... 25
3.2.6.3 Indicator: Provisions are made in laws or regulations allowing legal
minors to consent to key medical interventions .................................................... 26
4 Discussion and Recommendations ........................................................................... 27
Appendices ........................................................................................................................ 30
References ......................................................................................................................... 44
Appendices
Appendix 1: Key Considerations in Measuring Health Systems Strengthening .............. 30
Appendix 2: Criterion scoring used to rank indicators ..................................................... 34
Appendix 3: Full list of indicators .................................................................................... 36
Appendix 4: Statement by President Barack Obama on the Global Health Initiative ...... 40
Appendix 5: GHI programmatic focus areas .................................................................... 42
Appendix 6: U.S. Global Health Initiative operating principles ....................................... 43
Tables
Table 1: Health system building block aims, desirable attributes, and priorities ............... 4
Table 2: Suggested adolescent girl-specific indicators, by health systems building block 9
Figures
Figure 1: The WHO health system framework ................................................................... 3
Figure 2: Entry points for incorporating adolescent girl-relevant indicators of health
systems strengthening ......................................................................................................... 6
Boxes
Box 1: Why adolescent girls? ............................................................................................. 1
Box 2: Elements of adolescent-friendly health services ................................................... 13
Background Paper: Adolescent Girls’ Indicators for Health Systems Strengthening
February 26, 2010
iii
List of Acronyms
CHeSS
GHI
HMIS
HPV
IHP+
MDG
USAID
SAM
SPA
WHO
Country Health Systems Surveillance
Global Health Initiative
Health management information system
Human papillomavirus
International Health Partnership
Millennium Development Goals
U.S. Agency for International Development
Service availability mapping
Service provision assessment
World Health Organization
Background Paper: Adolescent Girls’ Indicators for Health Systems Strengthening
February 26, 2010
iv
Acknowledgements
The authors thank Miriam Temin, co-author of Start With A Girl: A New Agenda for
Global Health, and Sandy Stonesifer of the Center for Global Development. We are also
grateful for the valuable insights and time given by reviewers who offered comments on
several versions of the document, and provided input in two teleconferences. Reviewers
included:
Carla Abou-Zahr, Coordinator, Statistics, Monitoring and Analysis (STM), World Health
Organization
Stan Bernstein, Senior Researcher and Policy Advisor, UN Population Fund
Jane Bertrand, Professor, Tulane University
Ann Biddlecom, Chief, Population Policy Section, United National Population Division
Ann Blanc, Director, Maternal Health Task Force, Engender Health
Ties Boerma, Director, Department of Measurement and Health Information Systems, World
Health Organization
Ed Bos, Lead Specialist, World Bank
Vicky Camacho, Adolescent Health and Development, Medical Officer- Sexual and Reproductive
Health, World Health Organization
Jane Ferguson, Scientist, Adolescent Health and Development, World Health Organization
Margaret Greene, Independent Consultant
Sara Pacque Margolis, Director, Monitoring and Evaluation, Elizabeth Glaser Pediatric AIDS
Foundation
Sean McBride, Program and Research Coordinator, Khulisa Management Services
Catherine Michaud, Harvard University
Priya Nanda, Director, Social and Economic Development, International Center for Research on
Women
Mead Over, Senior Fellow, Center for Global Development
Ritu Sadana, World Health Organization
Lale Say, Reproductive Health Research Department, World Health Organization
Ilene Speizer, Research Associate Professor, U. of North Carolina
Note: Reviewers advised the authors in a personal capacity and on a voluntary basis. The report reflects the
views of the authors only and not of the reviewers, the organizations with which the reviewers are
affiliated, the Center for Global Development‘s funders, or its Board of Directors.
Background Paper: Adolescent Girls’ Indicators for Health Systems Strengthening
February 26, 2010
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Abstract
This background paper provides planners with adolescent girl-specific indicators that are
candidates to measure progress towards health systems strengthening. The analysis
focused on input, process, and outcomes indicators of health systems strengthening. The
paper recommends eleven indicators covering five of the six health systems building
blocks proposed by the World Health Organization. Those who are designing the U.S.
Global Health Initiative, as well as other donor-supported efforts to strengthen the
function of the health sector in developing countries, should consider including these
indicators in their monitoring and evaluation plans. Efforts also should be aimed at
enhancing country capacity to collect and analyze the information required for these and
other indicators of health systems strengthening.
Background Paper: Adolescent Girls’ Indicators for Health Systems Strengthening
February 26, 2010
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1 Introduction
1.1 Objectives and audiences for the background paper
This paper proposes a set of indicators for measuring progress toward health sector
strengthening that reflect attention to adolescent girls. It is offered as a contribution to
those who are engaged in the design of the U.S. Global Health Initiative, as well as others
who are seeking to monitor health system strengthening.
There are multiple reasons for using girl-specific indicators as one aspect of monitoring
how well health systems function, including:
-
As articulated in the recent report Start with a Girl: A New Agenda for Global
Health (Temin and Levine, 2009), adolescent girls comprise a priority population
for health services to reach. The health of adolescent girls, important in its own
right, is a major determinant of the health of future generations and contributes in
direct ways to the attainment of a range of global development goals. Therefore,
a special emphasis on adolescent girls is warranted in virtually any health system
investment.
-
Adolescent girls are among the populations most likely to be ―missed‖ by health
systems, except through the provision of antenatal and delivery care if and when
girls become pregnant. Unlike preventive and curative care for children under 5,
or family planning and other reproductive health services targeted at older,
married women, very few health services are aimed at adolescent girls and to date
there have been few efforts to ensure that health services are accessible and
appropriate for them. Therefore, the extent to which health services are
successful at reaching girls is indicative of the system‘s accessibility to key
populations that have traditionally been excluded from care.
-
As donors focus increasing attention on health systems, it may be tempting to use
generic process-related measures, such as the number of personnel being trained,
rather than on the provision of essential services to important segments of the
population. Given a growing recognition of the need to address adolescents‘
health concerns, there is value in examining how well the health system is
enhancing its capacity to reach girls ages 10-19.
Box 1: Why adolescent girls?
When adolescent girls win, everyone wins. The primary motivation to improve the health
of and health care for adolescent girls must always be the wellbeing of girls themselves.
But girls are also agents of positive change for their future families and communities.
Improving the health of adolescent girls happens to be one of the most direct means to
Background Paper: Adolescent Girls’ Indicators for Health Systems Strengthening
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accelerate and sustain progress toward improving maternal and child health, halting the
HIV/AIDS pandemic, mitigating the looming burden of chronic disease, and achieving a
range of economic and social development goals at the top of the international agenda.
Specific health measures taken for girls also will benefit boys and, indeed, virtually all
users of health systems. Strategic investments in girls‘ health today also pay off through
lower demands on public health dollars tomorrow, for girls themselves as they grow into
women, and for their children, who will be born healthier. And finally, they pay off
through reduced childbearing, improving changes for long-term economic growth. In
short, there is near-perfect convergence between protecting the rights of adolescent girls
and making the right public policy choices to establish a sound foundation for
development.
Source: Start with a Girl: A New Agenda for Global Health
The indicators proposed here do not reflect the breadth of indicators of girls‘ health, nor
do they venture into outcome or impact measures. Rather, they seek to answer the
question, ―How can we measure the extent to which, as health systems are strengthened,
they are responsive to the needs of adolescent girls?‖
1.2 About health systems and health systems strengthening
This section defines what we mean by health systems and health systems strengthening.
1.2.1 Defining health systems
Among the most commonly used recent definitions of health systems is one from the
World Health Organization, first outlined in its World Health Report 2000:
…all organizations, people and actions whose primary intent is to promote,
restore or maintain health. This includes efforts to influence determinants of
health as well as more direct health-improving activities. A health system is
therefore more than the pyramid of publicly owned facilities that deliver personal
health services. It includes, for example, a mother caring for a sick child at home;
private providers; behaviour change programmes; vector-control campaigns;
health insurance organizations; occupational health and safety legislation. It
includes inter-sectoral action by health staff, for example, encouraging the
ministry of education to promote female education, as well known determinants
of better health (WHO 2007).
We will use this definition of health system in the discussion below, with particular
attention to the dimensions that are most closely related to adolescent girls and the health
challenges they face. Like many others, we narrow the frame to focus on features of the
Background Paper: Adolescent Girls’ Indicators for Health Systems Strengthening
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health sector itself, and attend less to the characteristics outside of the health sector, such
as education or community empowerment.
1.2.2 Components of a health system
To make it easier to grasp the functioning of a health system and how countries can
strengthen it, there have been attempts to organize the health system into a framework of
more easily understandable components. Although complete agreement on these
frameworks and components is lacking, among the most widely accepted and used is the
WHO framework first widely disseminated in the World Health Report 2000, and which
follows from the definition described above.
WHO‘s framework defines six building blocks around which health systems can be
strengthened, including service delivery, health workforce, information, medical
products, vaccines and technologies, financing, and leadership and governance. Working
through these building blocks, health systems aim to achieve multiple goals, including
improved health outcomes and equity (see Figure 1).
Figure 1: The WHO health system framework
Source: WHO 2007
Each building block has corresponding aims, desirable attributes, and priorities (Table 1).
The building block approach will help frame our discussion of indicators below.
Background Paper: Adolescent Girls’ Indicators for Health Systems Strengthening
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Table 1: Health system building block aims, desirable attributes, and priorities
The six building blocks of a health system: aims and desirable attributes
• Good health services are those which deliver effective, safe, quality personal and nonpersonal health interventions to those who need them, when and where needed, with
minimum waste of resources.
• A well-performing health workforce is one which works in ways that are responsive,
fair and efficient to achieve the best health outcomes possible, given available resources
and circumstances, i.e., there are sufficient numbers and mix of staff, fairly distributed;
they are competent, responsive and productive.
• A well-functioning health information system is one that ensures the production,
analysis, dissemination and use of reliable and timely information on health determinants,
health systems performance and health status.
• A well-functioning health system ensures equitable access to essential medical
products, vaccines and technologies of assured quality, safety, efficacy and costeffectiveness, and their scientifically sound and cost-effective use.
• A good health financing system raises adequate funds for health, in ways that ensure
people can use needed services, and are protected from financial catastrophe or
impoverishment associated with having to pay for them.
• Leadership and governance involves ensuring strategic policy frameworks exist and are
combined with effective oversight, coalition building, the provision of appropriate
regulations and incentives, attention to system-design, and accountability.
Priorities by Health System Building Block
1 Service delivery: packages; delivery models; infrastructure; management; safety &
quality; demand for care
2 Health workforce: national workforce policies and investment plans; advocacy;
norms, standards and data
3 Information: facility and population based information & surveillance systems; global
standards, tools
4 Medical products, vaccines & technologies: norms, standards, policies; reliable
procurement; equitable access; quality
5 Financing: national health financing policies; tools and data on health expenditures;
costing
6 Leadership and governance: health sector policies; harmonization and alignment;
oversight and regulation
Source: WHO 2007
1.2.3 Shortcomings in WHO’s Framework
The WHO building blocks framework has the merit of being understandable, but has
several shortcomings. Importantly, the framework shortchanges the importance of
Background Paper: Adolescent Girls’ Indicators for Health Systems Strengthening
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demand-side actions, including those interventions that work on the changing behavior of
health consumers. This is critical for adolescents—indeed one of the oft-cited difficulties
with efforts to improve services for adolescents is the weakness (in definition and
execution) of demand-creation activities. In addition, adolescent girls often need
―permission‖ to act, granted by parents or other guardians. In addition, although the
definition of health system encompasses private health providers, in practice the actions
that have come out of efforts to strengthen health systems have disproportionately
focused on the public sector. However, many adolescent girls, like many older women,
use private health care. Another of the shortcomings of the WHO framework is that it
fails to capture the dimension of dynamic interaction among the various components—
the very interaction that makes it a system and not simply the sum of its parts.
Despite these limitations, the WHO framework is currently the mostly widely used means
of conceptualizing the elements of a health system and, by extension, the functions that
need to be strengthened with additional resources, technical content, manpower and other
inputs. It has been useful in an operational sense for those engaged in design of the
Global Health Initiative and we will use it as the framework for the indicators proposed
below.
2 A framework for incorporating adolescent-specific
indicators into measurement of health systems
strengthening
The U.S. Global Health Initiative seeks simultaneously to strengthen health systems and
to focus on girls and women as the gatekeepers for family health (―women-centered
care‖). Therefore, within the GHI, there is an opportunity to incorporate measures of
responsiveness to adolescent girls as it seeks to monitor progress toward stronger health
systems.
2.1.1 Entry points for adolescent girl-specific indicators of
health systems strengthening
The conceptual framework in Figure 2 shows the possible entry points for incorporating
adolescent girl-specific indicators into measurement of health systems strengthening (for
more on general considerations related to HSS see Appendix 1).
For each of the six building blocks, we can define indicators of inputs, processes, and
outputs that measure performance specific to one of the six individual system building
blocks. Because most of these efforts can produce changes in the health system in a
relatively short period of time (two years or less), we call these ―short-term measures‖ of
health systems strengthening. These short-term measures are in the service of the
outcome and impact indicators further to right on the conceptual framework and are not
tied to specific building blocks (but rather measure overall health systems strengthening).
Background Paper: Adolescent Girls’ Indicators for Health Systems Strengthening
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It often takes years to see changes work their way through to health outcomes and
impacts, we call these ―long-term measures‖ of health systems strengthening (see Figure
2). These long-term measures of health systems strengthening are important to evaluate,
but this paper does not focus on them. Also included in the framework are indicators
measuring key social determinants of health. Again, these are important to measure, but
this paper does not focus on them. Other groups interested in measuring progress on
adolescent health in the other Global Health Initiative focal areas could look separately at
these outcomes and social determinants indicators.
Figure 2: Entry points for incorporating adolescent girl-relevant indicators of health systems
strengthening
Entry points for incorporating adolescent girl-relevant indicators of
health system strengthening
Health System
Building blocks
Short-term performance measures
that are building block-specific
Long-term
measures that cut
across building
blocks
Financing
Outcome
Governance
Service
delivery
Input
Process
Output
Impact
Workforce
Products
Information
Social determinants of health
Source: the authors
We used this framework to guide identification of indicators, focusing on those input,
process, and output indicators that might be specific to adolescent girls. We discuss this
further in section 3 below.
2.2 Indicator evaluation criteria
To guide us in identifying adolescent girl-specific indicators for inclusion in the list of
indicators for health systems strengthening, we established specific criteria. These criteria
work off general principles of good indicator selection and are adapted to the specific
principles associated with heath sector strengthening and to the context of the Global
Health Initiative. According to these criteria, an indicator should:
Background Paper: Adolescent Girls’ Indicators for Health Systems Strengthening
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1. Utilize objective and high-quality data. Indicators should measure features that do not
rely solely on expert judgment, and the available data should be accurate, complete,
and consistent.
2. Be analytically rigorous and publicly available. In line with the GHI‘s emphasis on
high-quality monitoring and evaluation, the indicators should be grounded in data that
is collected and analyzed in a transparent manner and that is accessible to interested
parties regardless of location or position (i.e. published or available electronically
over the internet).
3. Have broad country-coverage and comparability across countries. Although GHI
planners have yet to define specific focus countries, indicators should be widely
available across developing countries. We should have access to the data for all GHI
countries and use the same or very similar methods for assessing the indicator in all
GHI countries.
4. Have a direct link to country interventions. Indicators should be actionable within the
context of the GHI. That is, the value of an indicator should change when the relevant
country intervention changes. That intervention should be one that the GHI funds
directly.
5. Be easy to interpret. The indicators need to reflect a clear normative judgment. It
should be clear that high (or low) rates of something is good (or bad).
6. Be able to change over the life of the GHI. To give enough time to measure progress,
the indicators should be able to reflect programmatic changes over two to three years,
and should be measured frequently enough to observe that change both midway and
at the end of the GHI.
7. Directly or indirectly reflect attention to equity. One of the principal aims of the GHI
is to focus efforts on serving poor people. Recognizing that public policy choices
determine whether the benefits of public spending are distributed in a progressive or
regressive fashion, indicators should reflect the desire for governments to adopt
health interventions that contribute to poverty reduction and the reduction of health
and income inequities.
8. Reliably measure progress in more than one area of GHI focus and across GHI
principles. Reflecting the desire for a limited set of indicators, indicators that meet the
standard for measuring progress across multiple GHI areas and principles would
potentially qualify as ―super-indicators‖ of health system functioning.
9. Minimize the additional data collection and analysis burden. It is very important to
keep the time and resource burden low—especially on national and sub-national
program officials but also international agencies because of the existing data demands
and associated cost. This applies to program officials at the country level, donors, and
others.
Applying these criteria and ranking potential monitoring and evaluation indicators will
help identity a manageable set of indicators that meet the GHI aim of parsimony.
3 A Suggested Set of Adolescent Health Indicators
To arrive at the suggested set of adolescent health indicators we first consulted a range of
sources on indicators of health systems strengthening and on adolescent girls‘ health.
Background Paper: Adolescent Girls’ Indicators for Health Systems Strengthening
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This yielded a total of 105 indicators. To this we added several more indicators suggested
by our reference group during the early review process.
We eliminated from consideration several population-wide indicators of health systems
strengthening that did not have a directly relevant adolescent girl-specific counterpart.
This includes many of the indicators related to the six health systems building blocks that
reflect actions countries should be taking to improve systems and outcomes for all
people, not only adolescent girls. Next, we eliminated another 16 indicators that were
exact or close duplicates of other indicators under consideration. Upon further discussion
with the reference group, we removed several more indicators that reflected health
outcomes or impacts or that were specific to a particular disease or health condition.
This left 33 indicator candidates for which we applied the criteria listed above in section
2.2. We scored the performance of indicators on each criterion on a scale of 0-4 (see
Appendix 2) and then calculated an un-weighted sum of scores and then ranking the
indicators.1
Starting from this list, we then took a stratified approach in which we identified the top
one to three girl-specific indicators for each of the six WHO building blocks. Each of
these satisfies our criteria and is feasible from a data perspective, at least in a reasonable
subset of countries. This avoids the difficult task of prioritizing across the six building
blocks and allows decision-makers some flexibility in choosing which of the indicators
might be a priority. The top candidates are discussed further below.
3.1 Summary of performance of the indicators
The methodology produced a ranked list of indicators that might qualify as appropriate
for inclusion. These are summarized in Table 2. The full list of indicators considered is
included in Appendix 3.
1
Although we considered weighting the criteria, in the end we decided to use an un-weighted score.
Weighting introduces invisible subjectivity for which there is no strong empirical basis.
Background Paper: Adolescent Girls’ Indicators for Health Systems Strengthening
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Table 2: Suggested adolescent girl-specific indicators, by health systems building block
Adolescent girl-specific
indicator
1. Data
objectivity
& quality
2.a
Analytical
rigor
2.b Public
availability
of data
3. Coverage
and
comparability
(Countries)
4. Clear
intervention
linkage
5. Easy
to
interpret
6. Can
change
over the
life of
the GHI
7.
Embodies
some
measure
of equity
8.
Additional
data
burden on
countries
9.
Measures
progress
across
GHI focus
areas and
principles
Total
score
(max =
40)
Medium
Medium
Yes
Low
Clear
Yes
Yes
Partially
Low
Full
30
Medium
Medium
Yes
Low
Clear
Yes
Yes
Partially
Medium
Full
29
High
Medium
Yes
Low
Clear
Yes
Yes
Partially
Low
Full
32
Medium
Medium
Yes
Low
Clear
Yes
Yes
Partially
Low
Full
30
Medium
Medium
Some
Low
Clear
Yes
Yes
Partially
Medium
Full
27
Medium
Medium
Yes
Low
Clear
Yes
Yes
Partially
Low
Full
30
Building block 1: Service
delivery
% of districts that are
delivering adolescentfriendly health services
Number and distribution of
health facilities with basic
adolescent-friendly service
capacity per 10,000
adolescents
Building block 2: Health
workforce
Availability of a service
provider trained in
adolescent health
% of health professions
schools including adolescent
topics in health worker
training
Annual number of graduates
of health professions
educational institutions who
receive training in adolescent
health per 100 000
adolescents – by level and
field of education
Building block 3: Information
Availability of age & sex
disaggregated data through
the national HMIS
Background Paper: Adolescent Girls’ Indicators for Health Systems Strengthening
February 26, 2010
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Adolescent girl-specific
indicator
1. Data
objectivity
& quality
2.a
Analytical
rigor
2.b Public
availability
of data
3. Coverage
and
comparability
(Countries)
4. Clear
intervention
linkage
5. Easy
to
interpret
6. Can
change
over the
life of
the GHI
7.
Embodies
some
measure
of equity
8.
Additional
data
burden on
countries
9.
Measures
progress
across
GHI focus
areas and
principles
Total
score
(max =
40)
High
High
Some
Low
Clear
Yes
Yes
Fully
Low
Full
34
High
High
Yes
Medium
Clear
Yes
Fully
Low
Partial
35
High
Medium
Yes
Low
Clear
Yes
Yes
Partially
Low
Full
32
Medium
Medium
Yes
Low
Clear
Yes
Yes
Partially
Low
Full
30
Medium
High
Yes
Low
Clear
Yes
Yes
Partially
Medium
Full
31
Building block 4: medical
products, vaccines, and
technologies
No adolescent-specific
indicator recommended
Building block 5: Financing
Coverage of the most
vulnerable adolescent girls
with health insurance
schemes
Country has a policy that
exempts adolescent girls
from paying user fees for
preventive/FP services
Yes
Building block 6: Governance
The country has a national
situation analysis on
adolescent health
The country has national
standards for the delivery of
health services to young
people
Provisions are made in laws
or regulations allowing legal
minors to consent to medical
interventions
Background Paper: Adolescent Girls’ Indicators for Health Systems Strengthening
February 26, 2010
10
3.2 Suggested indicators
The discussion of the indicators is organized according to building block. The ordering
follows the presentation of the building blocks in Figure 1 and does not reflect
prioritization.
3.2.1 Building block 1: service delivery
3.2.1.1
Indicator: Percent of districts that are delivering
adolescent-friendly health services
Score: 30
Source of indicator suggestion
This indicator was developed by the WHO Department of Child and Adolescent Health
and Development.
Definition
This indicator is defined as the percent of districts that have designed and carried out
plans for delivering a nationally defined set of clinical and preventive interventions for
adolescents. Districts have to meet three separate criteria to qualify as fulfilling this
indicator. The first is that the district has an approved plan for carrying out activities; the
second is that the district has secured a budget to implement the plan; the third is that,
during the last year, the district has carried out activities as defined in the plan according
to national standards. The indicator is calculated by dividing the number of districts that
meet the three criteria by the total number of districts in the country. Variants include to
calculate the indicator by region for sub-national analysis, or to use only a subset of target
districts as the denominator.
Rationale for inclusion
Scaling up the implementation of adolescent-friendly health services in countries must be
done at the public health district level. Delivering such services to adolescents has been
shown to be key to improved use, quality, and effectiveness of care for this age group.
Monitoring the number of districts (or other sub-national managerial entities) provides an
indication of the spread of the scaling up.
Data availability and quality
The prime data source for this indicator is district, regional, and national Ministry of
Health documents. Information could be collected yearly as part of routine supervision
Background Paper: Adolescent Girls’ Indicators for Health Systems Strengthening
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11
and monitoring of Ministry of Health activities. In countries with separate adolescent
health departments or offices, such units could carry out the monitoring, data collection,
and reporting. Although this indicator is not currently collected on a consistent basis,
such information gathering and reporting would require little additional effort on the part
of national officials. The value of this indicator can also clearly change over a relatively
short period of time (from year to year) and thus variation in the value of the indicator
can be easily measured over the 6-year lifetime of the Global Health Initiative.
Coverage and comparability
Although this indicator is currently only available for few if any countries, it would be
relatively simple to add to existing data collection efforts and thus available in most
countries where the GHI could conceivably operate. One barrier to cross-country
comparability is that countries may have differing definitions of what constitutes an
―approved plan for carrying out activities‖ as well as the meaning of ―secured a budget‖
and ―carried out activities‖ according to national standards. This problem could be
somewhat mitigated through development of standardized data collection instruments and
detailed scoring instructions.
Interpretability
This indicator is easy to interpret, representing a clear normative judgment that the
greater the percentage of districts delivering health services to adolescents, the better the
health system is functioning.
Relationship to poverty, equity
To the extent that adolescent girls are an especially poor and vulnerable group,
government attention to their needs, as signaled in efforts to provide adolescent-friendly
health services, indicates some desire on the part of government to address inequities in
the way health services are distributed in the country. To make this indicator more
poverty-focused, an alternative formulation would be to examine the percentage of the
poorest districts delivering health services to adolescents.
Measures across GHI focus areas and principles
Because the services delivered to adolescents cover all the GHI focus areas, this indicator
reflects the strength of the GHI effort in multiple focus areas. The indicator also measures
efforts under the GHI principle of integration because in almost all countries services to
adolescents are integrated into existing health infrastructure.
3.2.1.2
Indicator: Number and distribution of health facilities
with basic adolescent-friendly service capacity per 10,000
adolescent girls
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Score: 29
Source of indicator suggestion
This indicator was adapted from a service delivery indicator in the WHO Toolkit. The
original formulation of the indicator in the toolkit was ―number and distribution of health
facilities with basic service capacity per 10,000 population.‖
Definition
This index pertains to functioning facilities that meet national standards for providing
adolescent-friendly services as applicable to their type of facility. To assess the
adolescent-friendliness of a facility, a small set of key components can be assessed
related to staffing, hours, materials, guidelines, etc (see Box 2). The list of components
should be concise so that the adolescent-friendly dimension of the facility can be easily
and quickly monitored along with other program elements, in a single data collection
mechanism. To calculate the indicator, the numerator is the number of facilities that have
the basic service capacity to provide adolescent-friendly services. The denominator is the
total population for the same geographical area to compute the density per 10,000
adolescent girl population. A variant of this indicator is the proportion of health facilities
that meet AFHS service standards.
Box 2: Elements of adolescent-friendly health services
To be considered youth-friendly, services should be equitable—all adolescents, not just
certain groups, are able to obtain the health services they need; accessible—adolescents
are able to obtain the services that are provided; acceptable—services are provided in
ways that meet the expectations of adolescent clients; appropriate—services that
adolescents need are provided; and effective—the right services are provided in the right
way and make a positive contribution to the health of adolescents. Other specific
characteristics make services youth-friendly. These include procedures to facilitate easy
confidential registration, short waiting and referral times, and capacity to see patients
without an appointment. Their providers are non-judgmental, technically competent in
adolescent-specific areas and health promotion, and backed by compassionate support
staff. The facilities should be convenient and allow for privacy. And importantly, they
should be accompanied by community-based outreach and peer-to-peer dialogue to
increase coverage and accessibility
Source: Start with a Girl: A New Agenda for Global Health
Rationale for inclusion
All adolescents need access to adolescent-friendly health services for a range of health
care needs including for prevention of pregnancy, prevention, diagnosis and treatment of
sexually transmitted infections, HIV prevention and testing, contraception, antenatal care,
post-abortion care, general health diagnosis and treatment, and prevention, diagnosis, and
treatment of mental illness. Delivering services to adolescents in a ―friendly‖ way has
been shown to be key to improved use, quality, and effectiveness this age group.
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Data availability and quality
This indicator requires information from facility visits that use a standardized
questionnaire to assess the availability and functioning of the components required to
meet the basic adolescent-friendly service standards. The basic state of facilities could be
monitored annually by focusing on the staffing component (see 3.2.2.1). National
statistics could be updated every 2–3 years, through regular reporting by districts and
sample surveys, and a census once every 3–5 years to validate all information. There is
some additional data burden associated with this indicator because of the extra time
needed for assessment and subsequent analysis. However, any burden could be
minimized by building on existing facility assessment activities, including cross-national
assessments such as the service availability mapping (SAM) and service provision
assessment (SPA).
Coverage and comparability
Definitions and data collection should be standardized as much as possible across
countries, although some allowance should be made for local interpretations of what is
adolescent-friendly. The adolescent-friendly components also should be developed to
closely parallel questions used to gauge service readiness of other programs operating at
the facility.
Interpretability
A higher result for the indicator is unambiguously better in terms of health systems
functioning.
Relationship to poverty, equity
Calculating this indicator for rural and urban areas or for sub-national provinces, regions,
or districts has an implicit equity dimension. An explicit equity dimension could be
introduced by comparing indicator values in poorer versus wealthier districts (or regions)
of a country.
Measures across GHI focus areas and principles
Because the services delivered to adolescents covers the gamut of GHI focus areas, this
indicator reflects the strength of the GHI effort in multiple focus areas. The indicator also
measures efforts under the GHI principle of integration because in almost all countries
services to adolescents would be integrated into existing health infrastructure.
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3.2.2 Building block 2: health workforce
3.2.2.1
Indicator: Availability of a service provider trained in
adolescent health
Score: 32
Source of indicator suggestion
This indicator was developed by the WHO Department of Child and Adolescent Health
and Development.
Definition
This indicator is defined as the percent of facilities with at least one health worker trained
in adolescent health. A variant is facilities per 10,000 adolescent girl population with at
least one health worker trained in adolescent health. Health worker can be a medical
doctor, nurse, or other health professional. Training refers to a curricular based program
approved by the Ministry of Health containing material specifying issues particular to
adolescents and approaches to improve health service delivery to adolescents.
Rationale for inclusion
All initiatives to improve health service delivery to adolescents have included training of
service providers and it has been demonstrated to be one of the key factors in increasing
service use among adolescents. This responds to the aims of having a health workforce
that is competent and responsive to the needs of specific populations, with training in
knowledge about adolescent development; communication skills to deal with adolescent
information needs; and non-judgmental attitudes.
Data availability and quality
Data on this indicator could be obtained from a variety of sources, including yearly
monitoring data from a national adolescent health program or from representative
periodic (every 2-3 years) surveys such service availability mapping (SAM); or service
provision assessment (SPA) Macro Inc survey). The main additional data burden is in
adding a relevant question to existing surveys.
Coverage and comparability
This indicator has been included the SAM protocols, but has not been widely collected to
date. Comparison between countries may be hampered by differing definitions of what it
means to be ―trained in adolescent health,‖ although such concerns could be addressed
through more precise instructions for the data collection.
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Interpretability
A higher percentage or number is unambiguously a better outcome. However, few if any
countries currently have set targets and no standard exists for defining what constitutes
low, medium, or high coverage for this particular indicator.
Relationship to poverty, equity
An equity dimension could be added by calculating the indicator for poorer versus
wealthier districts or regions.
Measures across GHI focus areas and principles
Because the services delivered to adolescents covers the gamut of GHI focus areas, this
indicator reflects the strength of the GHI effort in multiple focus areas. The indicator also
measures efforts under the GHI principle of integration because in almost all countries
services to adolescents would be integrated into existing health infrastructure.
3.2.2.2
Indicator: Percent of health professions schools
including adolescent health topics in health worker
training
Score: 30
Source of suggestion
This indicator is a variant of indicators suggested by the WHO Toolkit.
Definition
This indicator is defined as the percent of health professions schools that include
adolescent health topics in health worker training. The numerator is the number of
schools (including medical, nursing, and midwifery schools) that include adolescent
health topics according to a specific curriculum that addresses the range of adolescent
health needs. The denominator is the total number of health professions schools.
Rationale for inclusion
Providing skills to health professionals in addressing adolescent health needs is important
during their professional formation. Moreover, health care consumers of all ages will
benefit from greater confidentiality, sensitivity, and less judgmental attitudes, which are
some of the topics covered for adolescent health.
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Data availability and quality
The main source of information for this indicator is the health professions institutions.
Information could be collected annually by the Ministry of Health through a survey or
special study. There is a problem in setting standards for what constitutes adequate preservice training, since different schools might have different curricula and standards. This
might be a particular problem with private institutions, which may play a large role in
health worker training. Few Ministries of Health already collect such information, thus
there would be some additional data burden on national officials who would carry out the
data collection and analysis. National surveys and censuses of health worker institutions
may not have 100% coverage of all relevant institutions, particularly of those in the
private sector.
Coverage and comparability
Coverage and comparability present some challenges with regard to this indicator. Few if
any countries currently collect this type of information on a regular basis. Comparability
across countries might also be difficult because of varying standards across countries in
types of health personnel, and what constitutes an adequate pre-service curriculum in
adolescent health. There is also no current standard for what would constitute low,
medium, or high coverage of this indicator. Setting of an international standard would be
required. A more nuanced version of this indicator might examine it relative to the
adolescent girl population. Also, governments may choose to invest in sending health
workers abroad for training rather than building schools in-country.
Interpretability
Clearly, the higher the proportion the better.
Relationship to poverty, equity
By calculating the indicator with respect to particular classes of health workers that are
more likely to serve poor adolescents, an equity dimension could be added.
Measures across GHI focus areas and principles
Because the services delivered to adolescents cover the gamut of GHI focus areas, this
indicator reflects the strength of the GHI effort in multiple focus areas. The indicator also
measures efforts under the GHI principle of integration because in almost all countries
services to adolescents would be integrated into existing health infrastructure.
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3.2.2.3
Indicator: Annual number of graduates of health
professions educational institutions who receive training
in adolescent health per 100,000 adolescents girls – by
level and field of education
Score: 27
Source of indicator suggestion
This is a variant of one of the health workforce indicators from the WHO Toolkit.
Definition
This indicator is defined as the number of graduates of health professions educational
institutions (including schools of medicine, dentistry, pharmacy, nursing, midwifery and
other health services) during the last academic year receiving training in adolescent
health, divided by the total adolescent girl population.
Rationale for inclusion
The number and type of newly trained health workers is relevant everywhere: in
countries that need increased production among all cadres, in countries that need more
workers in rural and underserved areas, and in countries receiving large numbers of
foreign-trained workers that are aiming towards national self-sufficiency of health
workforce regeneration. The number trained in adolescent health is important towards
making health systems more responsive to the needs of adolescent girls.
Data availability and quality
This indicator would be ideally assessed through routine administrative records from
individual training institutions (both public and private) submitted and collated into a
centralized human resource information system or database maintained by the Ministry of
Health or other mandated agency. In some cases, data may be validated against registries
of professional regulatory bodies where certification or licensure is required for practice.
The additional data burden for reporting on training in adolescent health would be
minimal once a generalized reporting system is established.
Coverage and comparability
Similar to the previous indicator (3.2.2.2) several challenges present themselves. Few if
any countries currently collect this type of information on a regular basis, and
comparability may be difficult because of varying standards and definitions across
countries.
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Interpretability
Clearly, the higher the index the better.
Relationship to poverty, equity
By calculating the indicator with respect to particular classes of health workers that are
more likely to serve poor adolescents, an equity dimension could be added.
Measures across GHI focus areas and principles
Because the services delivered to adolescents cover the gamut of GHI focus areas, this
indicator reflects the strength of the GHI effort in multiple focus areas. The indicator also
measures efforts under the GHI principle of integration because in almost all countries
services to adolescents would be integrated into existing health infrastructure.
3.2.3 Building block 3: information
3.2.3.1
Indicator: Availability of age & sex disaggregated data
through the national health management information
system
Score: 30
Source of indicator suggestion
This indicator was developed by the WHO Department of Child and Adolescent Health
and Development.
Definition
This indicator is defined as the extent to which national service statistics data (service use
and health conditions) from the Health Management Information System (HMIS) are
reported and broken down by relevant age groups and sex. The essential criteria for this
indicator include whether reporting is sex disaggregated; and whether reporting is done
by age groups including for 10-14, 15-19 (at a minimum), and 20-24 year-olds.
Optimally, the HMIS would report by ethnicity (if relevant) and by an equity-related
disaggregation (socioeconomic status).
Rationale for inclusion
By facilitating automatic and regular reporting on adolescent health care use and status,
governments can monitor progress and budgeting decisions can be influenced. Age and
sex disaggregation will increase the overall usefulness of information systems.
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Data availability and quality
Primary data sources include the Ministry of Health HMIS. Data could also be obtained
through key informant interviews with national adolescent health program officials. A
yearly assessment could determine the extent to which the HMIS is meeting the criteria
described above, using a standardized scoring scheme. The additional data burden to
national officials is low and would mainly require answering a set of standardized
questions about the availability of disaggregated information from the current system.
Adjustments to the HMIS could be made within the time frame of the Global Health
Initiative, so that the value of this indicator could change over two to three years. One
limitation is that there might be some subjectivity built into any assessment tool, although
this weakness could be addressed by using a standardized instrument with clear
instructions.
Coverage and comparability
Disaggregation of HMIS data by sex is now common, by age group including
adolescents, increasingly, but less common is service utilization data in HMIS.
Comparability across countries may be difficult because of varying standards about what
constitutes adequate disaggregation of HMIS data.
Interpretability
Clearly, the higher the availability of age and sex disaggregated information the better.
Relationship to poverty, equity
If HMIS is able to report data by socioeconomic status or some other measure of equity,
then this indicator displays an equity dimension.
Measures across GHI focus areas and principles
This indicator includes health information from all GHI focus areas.
3.2.4 Building block 4: medical products, vaccines, and
technologies
Generally speaking, the indicators for functioning of the medical products, vaccines, and
technologies building block should be the same for adolescent girls as for adults.
Therefore, we currently do not recommended adolescent girl-specific indicators for this
building block. For a discussion on whether to include an indicator related to availability
of human papillomavirus (HPV) vaccine, see section 4 below.
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3.2.5 Building block 5: financing
3.2.5.1
Indicator: Coverage of the most vulnerable adolescent
girls with health insurance schemes
Score: 34
Source of indicator suggestion
This indicator is adapted from the financing indicators of the WHO Toolkit and also
emerges from recommendations made in Start with a Girl.
Definition
This indicator is defined as the percent of the most vulnerable adolescent girls covered by
health insurance. The most vulnerable adolescent girls are defined as those living on less
than $2 U.S. a day. Health insurance means any type of risk pooling including social
security, private for-profit or non-profit insurers, and community-based insurance
schemes.
Rationale for inclusion
Health financing systems should raise funds in a way that allows people to use needed
services without the risk of severe financial hardship – often called financial catastrophe
– or impoverishment. This implies providing financial risk protection to the population.
For adolescent girls, two elements of insurance have particular salience. First are the
questions about what family members are covered under insurance programs—how, for
example, a community health insurance scheme defines household membership and the
age limits for coverage of children. Second are questions of the benefit package and
whether services of special importance to girls—for example, contraceptive services for
unmarried women—are included.
Data availability and quality
The primary data source for this indicator is health insurance enrollment records. Access
to and analysis of these records may be difficult to obtain, and analyzing them by age and
sex and by whether the enrollee is in a vulnerable group may also be technically difficult.
Some countries that have such national insurance coverage schemes (social security,
private schemes, community-based insurance) may be starting to collect such information
and it might be worthwhile to spend money on an effort to do a better job in collecting
and analyzing this information. This indicator would require some additional data burden
in the collection and analysis of existing health insurance enrollment records.
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Coverage and comparability
This indicator is applicable only in countries with widespread health insurance and may
not be relevant in settings where health care is free at the point of delivery.
Interpretability
Clearly, the higher the insurance coverage the better.
Relationship to poverty, equity
This indicator has a clear poverty dimension.
Measures across GHI focus areas and principles
This indicator reflects all GHI focus areas, assuming insurance covers a wide range of
health conditions.
3.2.5.2
Indicator: Country has a policy that exempts
adolescent girls from paying user fees for preventive/FP
services
Score: 35
Source of indicator suggestion
Emerged from the recommendations of Start with a Girl.
Definition
This indicator is defined as whether a country has a stated law or policy that exempts
girls 10-19 years old from paying user fees for preventive health services, including
family planning. User fees are those payments made by the user at the point of service or
when acquiring drugs or other medical devices (e.g., contraceptives). User fees are just
one of many different ways in which individuals make direct payments in connection
with the use of health services. Others include the opportunity cost of their time, and
food, lodging, and transport costs associated with seeking health care.
Rationale for inclusion
Health financing should ensure that everyone has access to effective public health and
personal health care. User fees have been shown to discourage use of essential preventive
services, especially by poor women. Adolescent girls—even those from relatively welloff families—often lack the power and resources they need to prevent and treat common
health problems.
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Data availability and quality
The primary data source for this indicator is a review of national Ministry of Health
documents. Information could be collected yearly. Although this indicator is not currently
collected on a consistent basis, such information gathering and reporting would require
little additional effort on the part of national officials. The value of this indicator can also
clearly change over a relatively short period of time (from year to year) and thus variation
in the value of the indicator can be easily measured over the 6-year lifetime of the Global
Health Initiative.
Coverage and comparability
This indicator could easily become available in most countries where the GHI operates.
Comparability may be hampered by different country definitions of ―user fees.‖ This
problem could be somewhat mitigated through development of standardized data
collection instruments and detailed scoring instructions.
Interpretability
This indicator is easy to interpret, representing a clear normative judgment.
Relationship to poverty, equity
To the extent that adolescent girls are an especially poor and vulnerable group,
government attention to their needs, as signaled in efforts to provide adolescent-friendly
health services, indicates some desire on the part of government to address inequities in
the way health services are distributed in the country.
Measures across GHI focus areas and principles
The preventive services covered by the user fee exemption cover all the GHI focus areas.
3.2.6 Building block 6: leadership/governance
3.2.6.1
Indicator: The country has a national situation
analysis on adolescent health
Score: 32
Source of indicator suggestion
This indicator was developed by the WHO Department of Child and Adolescent Health
and Development.
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Definition
The indicator measures the extent to which the Ministry of Health (or other relevant
national entity) has (co-) produced a report describing the situation of adolescent health
in the country. The indicator would need to satisfy the following criteria: the analysis has
been undertaken within the past 5 years; the health situation analysis includes
epidemiological data (mortality and morbidity) and health risk behaviors on a variety of
health topics including at a minimum reproductive health and HIV/AIDS; the analysis
intends to cover the situation in the whole country and draws as much as possible on
nationally representative data; the analysis includes consistent attention to sex and age
differences as well as other aspects of the environment or population considered to cause
vulnerability to specific major health issues; and the analysis includes a description of the
current programmatic response and an analysis of the national policy/strategy
environment.
Rationale for inclusion
Quantitative and qualitative information about the health situation of adolescents enables
adjustment of policies, strategies and plans. Health service delivery can be attuned to the
needs of different groups of adolescents. This indicator also links to other recommended
indicators, including ‗Indicator: Percent of districts that are delivering adolescent-friendly
health services‘ and ‗Indicator: The country has national standards for the delivery of
health services to young people‘.
Data availability and quality
The primary source of information for this indicator is a review of Ministry of Health
documents. Most countries do not routinely collect this information, but it would be easy
to measure with little additional data burden. Data could be collected annually. The value
of this indicator could also change relatively quickly.
Coverage and comparability
Most countries do not collect this information. Furthermore, cross-country comparison
could be hampered because of differing definitions of what constitutes an adequate
situation analysis.
Interpretability
Whether a country has a situation analysis or not is easy to interpret. The harder
interpretation relates to the quality of the situation analysis. Countries may be doing a lot
in adolescent health without any national situation analysis, so the lack of one may not be
particularly meaningful. Conversely, a country may have a perfectly wonderful situation
analysis but do nothing to serve adolescent girls‘ health needs. Again, the indicator has
little meaning in this case.
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Relationship to poverty, equity
The indicator could have a poverty dimension by measuring whether the situation
analysis has a specific section dealing with poverty and equity issues.
Measures across GHI focus areas and principles
Because the analysis would presumably cover the range of adolescent girls‘ health
concerns, it would cover all the GHI focus areas and principles.
3.2.6.2
Indicator: The country has national standards for the
delivery of health services to young people
Score: 30
Source of indicator suggestion
This indicator was developed by the WHO Department of Child and Adolescent Health
and Development.
Definition
This indicator is defined as the extent to which the Ministry of Health has official
national standards or norms for the delivery of preventive and curative services to
adolescents. Standards should at a minimum: be based on a national situation analysis
(see 3.2.6.1); clearly define a package of health services; specify the age group to which
those will be delivered, including the mentioning of specific target populations; specify
health workers capacity building needs and required levels of performance; define
managerial responsibilities at various levels of care; and be officially adopted by the
Ministry of Health.
Rationale for inclusion
The existence of clear standards reflects the strength of the governance dimension of the
health system and sets out key aspects of service quality to render the services
adolescent- friendly.
Data availability and quality
The primary data source for this indicator is a review of Ministry of Health documents.
International compilations have captured some of these documents, including sites such
as the USAID-funded youth-policy.com. Additional data burden on national officials
would be low. Existence of standards is something that could change quickly, so changes
in the value of the indicator could occur in a relatively short period.
Coverage and comparability
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Very few countries currently collect this data, but it could conceivably be collected
everywhere. Comparability across countries is a concern because of varying
interpretations of what ―national standards‖ constitute.
Interpretability
Having national standards is unambiguously better than having none at all.
Relationship to poverty, equity
Unless the situation analysis has a specific section dealing with poverty and equity issues,
then the indicator has little relationship to poverty.
Measures across GHI focus areas and principles
Because the analysis would presumably cover the range of adolescent girls‘ health
concerns, it would cover all the GHI focus areas and principles.
3.2.6.3
Indicator: Provisions are made in laws or regulations
allowing legal minors to consent to key medical
interventions
Score: 31
Source of indicator suggestion
This indicator was developed by the WHO Department of Child and Adolescent Health
and Development and also emerges from the analysis and recommendations of Start with
a Girl.
Definition
This indicator reflects the extent to which provisions are made in laws or regulations
specifying that minor adolescents can provide informed consent without the need for
permission of parents, guardians or spouses for specific key medical services including
contraceptive services (except sterilization); condoms for disease prevention; HIV
testing; and harm reduction strategies (needle exchange). A minor, as defined by the
Convention on the Rights of the Child, is a person below 18 years of age and not legally
an adult.
Rationale for inclusion
Legal and regulatory barriers can hamper access to health services, particularly to sexual
and reproductive health services for young people. Removing these legal barriers and
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making providers and clients aware of their rights and duties can contribute to improve
accessibility.
Data availability and quality
Primary data sources include a review of legal and policy documents. Secondary sources
include the country report to the Committee of the Convention on the Rights of the Child.
Because changes to laws and regulation can be made relatively quickly, it is possible to
see changes in the value of this indicator during the life of the GHI.
Coverage and comparability
This indicator could potentially be measured in all countries, although is not being
measured currently in any consistent way. Differing interpretations of consent laws might
complicate comparison across countries.
Interpretability
The greater the freedom of minors to consent to these key medical interventions the
better. This is unambiguous from a public health standpoint. Nonetheless, even if laws
and regulations allow minor consent, service providers may still informally require such
consent from parents or other guardians.
Relationship to poverty, equity
Poor adolescent girls are more likely to benefit from minor consent laws than wealthier
girls, who have greater means to skirt restrictions on their ability to access care.
Measures across GHI focus areas and principles
To the extent that it includes consent for pregnancy prevention and key HIV services, this
indicator cross GHI focus areas.
4 Discussion and Recommendations
Start with a Girl recommends that, ―Across the board, girls‘ health should be an explicit
priority for action within and outside of the health sector. Governments in low- and
middle-income countries should systematically include adolescent girls‘ health as a
development target.‖ By all accounts, the U.S. Government‘s new Global Health
Initiative will take on this challenge and include many actions to improve girl‘s health.
For greater accountability and to track progress, GHI planners recognize the importance
of incorporating adequate monitoring indicators to measure the impact of GHI-funded
activities on health systems strengthening and on broader outcomes and impact measures
of girls‘ health.
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This background paper used a systematic analysis to help provide planners with
adolescent girl-specific indicator candidates to measure progress towards health systems
strengthening. This analysis focused on input, process, and outcomes indicators of health
systems strengthening, with the assumption that critical outcome and impact indicators of
adolescent girls‘ health will be analyzed through parallel indicator identification
processes underway. The paper recommends 11 indicators covering 5 of the 6 health
systems building blocks. Some important common themes emerge from the findings.
There is no perfect indicator. None of the 11 recommended indicators merited a perfect
score based on the 9 criteria used to rank. In fact, the highest score was 35 out of 40, for
the indicator on user fee exemption. Moreover, although on their own the criteria are
reasonable and appropriate, there are inevitable trade-offs across them. For example, the
criterion of cross-country comparability may clash with timeliness and responsiveness to
policy and program inputs. Despite their flaws, all the recommended indicators are worth
incorporating into monitoring and evaluation of GHI efforts to strengthen health systems.
Data sources for most of the recommended indicators are underdeveloped. For some
indicators it may be necessary to draw on multiple sources and to reconcile conflicting
data. Furthermore, many of the suggested indicators are not currently routinely collected.
These challenges are not insurmountable. First, the additional burden of collecting data
and reporting is relatively low for almost all the suggested indicators. The WHO is
currently actively promoting the collection of information related to many of these
indicators in countries. As noted, almost all the suggested indicators build on existing
data collection and reporting, and are for the most part sex and age-specific variants of
existing indicators. The GHI monitoring and evaluation process represents a unique
opportunity to work towards better collection and reporting of age and sex disaggregated
data—a goal that is essential to better addressing adolescent girls‘ health needs. Second,
the relatively undeveloped state of the data opens the way for opportunities to build local
capacity for data collection, synthesis, and analysis, and for filling critical data gaps. One
area where the GHI can do more is to encourage more frequent collection of data from
facility surveys such as the SAM and the SPA, in coordination with broader health
systems strengthening indicators data needs that GHI planners are currently considering.
Some important gaps remain in identifying indicators for some of the building blocks. No
adolescent girl-specific indicators were recommended for the medical products, vaccines,
and technologies building block. Key products to promote the sexual and reproductive
health of adolescents, such as condoms and other contraceptives and antiretroviral drugs
for AIDS treatment and prevention of mother-to-child-transmission, are already included
in general indicators of product availability. An exception is HPV vaccine availability, a
product that is specifically suited to administering to adolescent girls. It is perhaps
premature to recommend inclusion of HPV vaccine in one of the drug availability
indicators. However, such indicators typically draw on information from health facility
surveys, and planners are still sorting out which are whether health or other non-health
facilities such as schools are the best venue for HPV vaccine delivery. Nonetheless,
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countries should still be tracking overall HPV coverage rates as part of overall adolescent
health outcomes monitoring, particularly as such programs go to scale.
There was also much discussion about whether to recommend inclusion of an indicator
reflecting use of essential health services by adolescent girls. Although very important
with regard to measuring how well health systems are addressing adolescent needs, we
felt for a number of reasons that we should not recommended it within the relatively
narrow framework of this paper. Data availability and quality are a concern. Moreover,
each country might prioritize different coverage indicators, so that choosing a standard
set might prove difficult. Another problem is that the main primary data sources such as
national household surveys are infrequent and in many countries still do not fully survey
unmarried adolescents or those under 15 years of age. We suggest that other groups
addressing indicators to measure progress in GHI should strongly considering inclusion
of adolescent girls‘ use of essential health services in their indicator list.
The suggested indicators clearly have use beyond the GHI. Many other donor
organizations active in the health sector are now struggling to figure out what is meant by
health sector strengthening, and risking a focus on dimensions that may not have real and
measurable health impacts, like ―quality of information systems.‖ This includes the
policymakers in the U.S., Canada, Europe, and multilateral institutions such as the
development banks, Global Fund to Fight AIDS, Tuberculosis, and Malaria, and the
GAVI Alliance. The WHO is already moving forward in a few countries to begin testing
the use of some of the suggested indicators and working on data collection and reporting
protocols. All these groups would benefit from continued discussion and collaboration
and further refinement of these indicators.
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29
Appendices
Appendix 1: Key Considerations in Measuring Health Systems Strengthening
This section looks briefly at some of the frameworks for measuring health systems
strengthening and some of the conceptual and practical challenges. It goes on to discuss
the U.S. Global Health Initiative and its approach to health sector strengthening and
finishes with a framework for incorporating adolescent-specific indicators into
measurement of health systems strengthening. This underlies the discussion of specific
indicators in section 3.
Frameworks for measuring health systems strengthening
Experts have long sought adequate measures for the functioning of health systems, as a
way to track progress and for comparison across countries. As a result, we do not lack for
frameworks and indicators. Reaching consensus on indicators, however, has been slow,
partly because of the lack of agreement on the meaning of health systems strengthening.
Frameworks for measuring health system functioning have typically used the traditional
evaluation continuum of inputs –> processes –> outputs –> outcomes –> impact. At the
impact end are overall measures of health outcomes that countries hope to influence
through their systems strengthening activities. From inputs through outcomes, countries
are examining measures related to specific system strengthening activities.
Building on the framework of the six building blocks, WHO has developed a draft
Toolkit for Monitoring Health Systems Strengthening, which for each of the six building
blocks suggests core indicators and identifies sources of information (WHO 2008). The
country health systems surveillance (CHeSS) approach is another WHO monitoring
initiative under the International Health Partnership (IHP+) effort (IHP+ Working Group
2009). This framework for monitoring performance and evaluation of the scale-up for
better health has been developed under the IHP+ Common Evaluation Framework. The
USAID-sponsored work on measurement of health systems strengthening is encapsulated
in the work of Health Systems 2020 and previous USAID projects that focus on health
systems (Islam 2007), using categories similar to the six building blocks of the WHO
framework.
These frameworks have produced large sets of indicators to measure health systems
strengthening. The following section briefly discusses some of the general conceptual and
practical challenges in measuring these indicators.
Conceptual and practical challenges in measuring health systems strengthening
Conceptual challenges of measurement
The implicit assumption is that if health systems are stronger then health outcomes will
improve, health care will become more efficient and responsive, and the most vulnerable
consumers will see an increase in their protection against the financial and social risks of
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30
poor health. It has been surprisingly difficult, however, to show that specific
interventions to strengthen health systems actually have a positive impact on health
outcomes. For example, if we look at the governance building block, we can all agree that
better governance will improve health outcomes, but we can‘t necessarily show (or have
had great difficulty showing) that a specific intervention to improve governance results in
better health outcomes. This is a larger problem in the measurement of health systems
strengthening that will only be resolved with more operations research-type evaluation
that looks at specific health systems strengthening interventions and their effect on health
outcomes and the other goals of health systems strengthening.
Another measurement problem at the conceptual level has been the absence of indicators
reflecting demand side activities including behavior change, community interventions,
interventions to change social norms, etc. This absence has occurred despite the health
systems definition encompassing the social determinants of health, i.e. those overarching
political, economic and social structural factors such as global agreements and treaties,
distribution of resources, power, and the daily conditions of life that influence health
behaviors and outcomes. This concept does not appear to have translated into an explicit
definition within the six building blocks of health sector strengthening, and thus into
associated indicators of system functioning.
Practical challenges in measurement
Beyond these major conceptual challenges lie several practical challenges in measuring
health systems strengthening.2
Lack of agreement on a common set of indicators. Lack of agreement has led to lack of
data availability.
Choosing from a large selection. Current frameworks tend to include too many indicators
and not enough selectivity, particularly for the information and products building blocks.
Data availability. Data for many of the suggested indicators is not collected routinely –
or has never been collected at all.
Difficulty in making cross-country comparisons. Lack of data has hindered valid crosscountry comparisons.
Over-reliance on indices. Similarly, the use of indices has been overemphasized as a way
to reduce the number of indicators. These tend to be less valid in comparisons over time
and across countries, and incorporate subjective weights across a range of component
measures.
Infrequency of data collection. This is particularly a problem for indicators that rely on
the results of household surveys.
2
Many of these were synthesized in AIM 2009.
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The time dimension. Related to the infrequency of data collection, there is often a
considerable lag time between changes in health system functioning and impact on
health—even when we know or think we know what that impact is likely to be.
Problems in capturing measures of inequality. Resolving inequalities is at the core of
much of health systems strengthening, but rarely measured. Such inequalities affect
adolescent girls even more than older women (Lule, Rosen et al 2006).
Underfocus on the private sector. Indicators tend to ignore private providers and those
more generally outside the formal public sector health system, where many adolescent
girls seek care.
The U.S. government Global Health Initiative and health systems strengthening
Overview of GHI
The United States has long been a leader in funding efforts to improve health in poor
countries. In a May 5, 2009 statement by President Obama (Appendix 4Error!
Reference source not found.), the U.S. government pledged to continue and build on
these long-standing efforts through an enhanced Global Health Initiative (GHI).
By taking a long-term strategic approach to health, the initiative hopes to accelerate
improved access to and use of health care by poor people in developing countries. The
plan is to do so by maintaining funding for fighting infectious disease and enhancing
support for MCH, FP, and nutrition programs.
The GHI identifies the following programmatic focus areas as funding priorities
(Appendix 5):
maternal and child health (MCH), family planning, and nutrition
infectious diseases such as HIV/AIDS, malaria, tuberculosis (TB), and neglected
tropical diseases
The GHI incorporates the following operating principles (Appendix 6):
A women-centered approach
Strengthening health systems
Program integration and coordination
Multilateral coordination
Country ownership and sustainability (Presentation at expert consultation)
The GHI encompasses a 6-year $63 billion commitment for bilateral programs that runs
from fiscal year 2009 through fiscal year 2014 (October 1, 2008 – September 30, 2014).
(Appendix 5). Planning for the GHI is ongoing and being guided by working groups for
each of the focus areas and operating principles, made up of U.S. government officials
and supported by consultations with outside experts.
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Role of health sector strengthening in GHI
By identifying health systems strengthening as one of the operating principles of the GHI,
the U.S. government acknowledges that measuring progress toward achieving GHI goals
will partly depend on how well health systems are functioning, whether they are
improving, and by how much, and whether these improvements are tied to the actions
funded by the GHI.
The U.S. government has long been an advocate of strengthening health systems through
its various global health efforts. The GHI will likely build and expand on its ongoing
efforts to strengthen health systems that have been incorporated in the various U.S.
government-funded initiatives, either via vertical, disease or health-problem specific
programs or via over-arching systems strengthening efforts.
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Appendix 2: Criterion scoring used to rank indicators
Criterion
Data objectivity & quality
Low
Medium
High
Mixed
Scoring
1
2
4
3
Public availability
Yes
No
Some
4
0
2
Coverage and comparability
low
medium
high
1
2
4
Analytical rigor
Low
Medium
High
Mixed
1
2
4
2
Clear intervention linkage
unclear
partially clear
clear
0
2
4
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Easy to interpret
no
yes
somewhat
0
4
2
Change over life of GHI
yes
no
maybe
4
0
2
Embodies attention to equity
No
partially
fully
0
2
4
Additional data burden
none
low
medium
high
4
3
2
1
Degree Crosses GHI Focus
Areas and Principles
none
limited
partial
full
0
1
2
4
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Appendix 3: Full list of indicators
RECOMMENDED INDICATORS
Building block 1: Service delivery
% of districts that are delivering adolescent-friendly health services
Number and distribution of health facilities with basic adolescent-friendly service
capacity per 10,000 adolescents
Building block 2: Health workforce
Availability of a service provider trained in adolescent health
% of health professions schools including adolescent topics in health worker training
Annual number of graduates of health professions educational institutions who
receive training in adolescent health per 100 000 adolescents – by level and field of
education
Building block 3: Information
Availability of age & sex disaggregated data through the national health management
information system
Building block 4: Medical products, vaccines, and technologies
No adolescent-specific indicator recommended
Building block 5: Financing
Coverage of the most vulnerable adolescent girls with health insurance schemes
Country has a policy that exempts adolescent girls from paying user fees for
preventive/FP services
Building block 6: Governance
The country has a national situation analysis on adolescent health
The country has national standards for the delivery of health services to young people
Provisions are made in laws or regulations allowing legal minors to consent to
medical interventions
OTHER INDICATORS CONSIDERED BUT NOT RECOMMENDED
Building block 1: Service delivery
Health services utilization by young people
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Disparity in use of essential health services by adolescent girls3
% of adolescent population with access to adolescent-friendly health services
Proportion of health facilities that meet basic adolescent-friendly service standards
Building block 2: Health workforce
Number of health workers trained in adolescent health per 10,000 adolescents
Number and distribution of health facilities with a service provider trained in
adolescent health per 10 000 adolescents
Number of health workers trained in adolescent health per 10,000 adolescents
Building block 3: Information
Use of M&E findings in revising plans, strategies and budgets related to adolescent
girls' health
Building block 4: Medical products, vaccines, and technologies
Percent of facilities that have HPV vaccine in stock
Building block 5: Financing
Health spending per adolescent with government as source
Total Health Expenditure (THE) per adolescent in international and US$
General government health expenditure on adolescents as a proportion of total
government expenditure on adolescents (GGHE/GGE).
Building block 6: Governance
The health of adolescent features in national policies/strategies.
The health of adolescent features in national policies/strategies
The country has a functional national adolescent health program
Engagement of youth and youth-serving organizations
Existence of effective civil society organizations working on behalf of adolescents
DISEASE OR CONDITION-SPECIFIC INDICATORS
Adolescent Contraceptive Prevalence Rate
Unmet need for contraception amongst sexually active adolescent girls
% of births to adolescent mothers with a skilled attendant
% of adolescent girls vaccinated with HPV vaccine
Abortion rates in adolescents
3
This indicator, as well as other measures of service utilization, should be reconsidered in the future after
there exists a technical consensus regarding the appropriate type and amount of service utilization by
adolescent girls.
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Prevalence of current tobacco use in 15-19 year old girls
% of adolescent girls receiving iron supplementation
Adolescent girl-specific elements of a national TB plan exist
Adolescent girl-specific elements of a national malaria plan exist
National index on policy related to young people and HIV/AIDS showing the
progress in the development of national-level HIV/AIDS policies and strategies in six
key areas
Adolescent girl-specific elements of a national maternal health plan exist
Adolescent girl-specific elements of a national child health plan exist
OUTCOME OR IMPACT INDICATOR NOT DIRECTLY ASSOCIATED WITH THE HEALTH
SYSTEM
Adolescent fertility rate
Neonatal Mortality Rate for babies born to adolescents <20
Mortality of girls 10-19
HIV prevalence in adolescent girls
Age disaggregated maternal mortality ratio
INDICATORS OF SOCIAL DETERMINANTS OF ADOLESCENT GIRLS’ HEALTH
Presence of policies to protect girls‘ rights
Presence of policies related to early marriage
Extent to which gender norms exist that disadvantage adolescent girls
Proportion of adolescent girls in school
Proportion of girls married
GENERAL HEALTH SYSTEMS STRENGTHENING INDICATORS LACKING A CLEAR
ADOLESCENT-SPECIFIC VARIANT
Availability of essential supplies and drugs
Number and Distribution of Inpatient Beds Per 10,000 Population
Worldwide Governance Indicators–Control of Corruption
Existence of an essential medicines list updated within the last five years and
disseminated annually:
Existence of policies on drug procurement which specify: (i) procurement of the most
cost-effective drugs in the right quantities; and (ii) open, competitive bidding of
suppliers of quality products.
Health worker absenteeism in public health facilities
Proportion of government funds which reach district-level facilities
Stock-out rates (absence) of essential drugs in health facilities
Proportion of informal payments within the public health care system
Proportion of pharmaceutical sales that consist of counterfeit drugs
Costed, prioritized human resources management/development plan exists
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Number of national data points on the stock and distribution of health workers
produced within the last three years
Number of entrants into community health training programs (with nationally
approved curriculum) in the past 12 months, e.g. by sex
Number of students in medical, nursing and midwifery (pre-service) education
programs per qualified instructor
Number of health workers newly recruited at primary health-care facilities in the past
12 months, e.g. expressed as percentage of planned recruitment target
Private provider registration system is up to date and accurate
Rate of retention of health service providers at primary health-care facilities in the
past 12 months
Number of senior staff at primary healthcare facilities who received in-service
management training (with nationally approved curriculum) in the past 12 months
Percentage of health service providers at primary health-care facilities who received
personal supervision in the past six months
Number of days of health worker absenteeism relative to the total number of
scheduled working days over a given period among staff at primary health-care
facilities
Proportion of nationally trained health workers (e.g. with distribution of foreign
trained workers by country of origin)
Percent of facilities that have all tracer medicines and commodities in stock: on the
day of visit, and in the last three months Supplemented by: median proportion of
tracer drugs that are in stock: on the day of visit, and in the last three months
Ratio of median local medicine price to MPR for core list of drugs
Number and distribution of in-patient beds per 10 000 population
Improved coordination among agencies
Changes introduced by H8 agencies to streamline procedures and operations,
harmonize, and align
GFATM funds country health plans
Increasing efficiency of aid use; shown by more flexible funding for health systems
and more predictable funding
Strong mutual accountability process that holds agencies to account for their incountry behavior and funding
Appraisal of health plan – does it build systems? Does it have a good M&E plan? Is
the costing and budget realistic?
Proportion of donor funds that are on budget and support the health plan; proportion
that use national procurement systems
Proportion of Population with Access to Affordable Essential Drugs on a Sustainable
Basis
Overall Country Policy and Institutional Assessment (CPIA)
Availability and Price of Essential Medicines
Health-specific CPIA
Health information system performance index (HISPIX),
HIS Performance Index (HISPIX)
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Appendix 4: Statement by President Barack Obama on the Global Health Initiative
STATEMENT BY THE PRESIDENT ON GLOBAL HEALTH
INITIATIVE
May 5, 2009
In the 21st century, disease flows freely across borders and oceans, and, in recent days, the 2009
H1N1 virus has reminded us of the urgent need for action. We cannot wall ourselves off from the
world and hope for the best, nor ignore the public health challenges beyond our borders. An
outbreak in Indonesia can reach Indiana within days, and public health crises abroad can cause
widespread suffering, conflict, and economic contraction. That is why I am asking Congress to
approve my Fiscal Year 2010 Budget request of $8.6 billion -- and $63 billion over six years -- to
shape a new, comprehensive global health strategy. We cannot simply confront individual
preventable illnesses in isolation. The world is interconnected, and that demands an integrated
approach to global health.
As a U.S. Senator, I joined a bipartisan majority in supporting the Bush Administration‘s
effective President‘s Emergency Plan for AIDS Relief (PEPFAR). That plan has provided
lifesaving medicines and prevention efforts to millions of people living in some of the world‘s
most extreme conditions. Last summer, the Congress approved the Lantos-Hyde US Global
Leadership Against HIV/AIDS Act -- legislation that I was proud to cosponsor as a U.S. Senator
and now carry out as President. But I also recognize that we will not be successful in our efforts
to end deaths from AIDS, malaria, and tuberculosis unless we do more to improve health systems
around the world, focus our efforts on child and maternal health, and ensure that best practices
drive the funding for these programs.
My budget makes critical investments in a new, comprehensive global health strategy. We
support the promise of PEPFAR while increasing and enhancing our efforts to combat diseases
that claim the lives of 26,000 children each day. We cannot fix every problem. But we have a
responsibility to protect the health of our people, while saving lives, reducing suffering, and
supporting the health and dignity of people everywhere. America can make a significant
difference in meeting these challenges, and that is why my Administration is committed to act.
FACT SHEET: American Leadership on Global Health
President Obama believes that it is in keeping with America‘s values and our history of
compassion to lead an effort to solve some of the most serious problems facing the world‘s
poorest people. Already, American leadership, sparked in large part by President George W. Bush
and a bipartisan majority in Congress, has helped to save millions of lives from HIV/AIDS,
malaria, and tuberculosis. Yet, even with that monumental progress, 26,000 children around the
world die every day from extreme poverty and preventable diseases.
In response, the President‘s 2010 Budget begins to focus attention on broader global health
challenges, including child and maternal health, family planning, and neglected tropical diseases,
with cost effective intervention. It also provides robust funding for HIV/AIDS. The initiative
adopts a more integrated approach to fighting diseases, improving health, and strengthening
health systems.
The U.S. global health investment is an important component of the national security "smart
power" strategy, where the power of America‘s development tools -- especially proven, costBackground Paper: Adolescent Girls’ Indicators for Health Systems Strengthening
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40
effective health care initiatives -- can build the capacity of government institutions and reduce the
risk of conflict before it gathers strength. In addition, the Administration‘s funding plan can
leverage support from other nations and multilateral partners so that the world can come closer to
achieving the health Millennium Development Goals. Discussions are underway with the G-8
partners on fulfilling all of the commitments. This comprehensive global health approach can
yield significant returns by investing in efforts to:
Prevent millions of new HIV infections;
Reduce mortality of mothers and children under five, saving millions of lives;
Avert millions of unintended pregnancies; and
Eliminate some neglected tropical diseases.
To reach these goals, the Budget invests $63 billion cumulatively over six years (2009-2014) for
global health programs. PEPFAR (the President‘s Emergency Plan for AIDS Relief) will
constitute more than 70 percent of global health funding.
GLOBAL HEALTH FUNDING (2009 TO 2014)
($ in billions)
FY 2009 Enacted FY 2010 Budget
Change FY10
from FY09
Six-Year Total
(FY09 – FY14)
PEPFAR (Global
HIV/AIDS & TB)
$6.490
$6.655
+$.165
Malaria
$.561
$.762
+$.201
PEPFAR &
Malaria Subtotal
$7.051
$7.417
+$.366
$51
Global Health
$1.135
Priorities Subtotal
$1.228
+$.093
$12
GLOBAL HEALTH
INITIATIVE
$8.186
TOTAL
$8.645
+$.459
$63
Moving forward, the Obama Administration will work with key stakeholders to deliver
new congressionally mandated strategic plans for HIV/AIDS, tuberculosis, and malaria.
These plans will be coordinated as part of the comprehensive global health strategy to
identify specific initiatives, quantitative goals, and appropriate funding levels beginning
in 2011.
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Appendix 5: GHI programmatic focus areas
Maternal-child health, Family Planning, Nutrition
Maternal-child health
Family planning
Nutrition
Infectious disease:
HIV/AIDS
Tuberculosis
Malaria
Influenza and non-tropical diseases
Source: AIM 2009
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Appendix 6: U.S. Global Health Initiative operating principles
Women-centered programming
• Women must be at the center of any global health strategy. Research shows that where
women are valued, protected, educated, and healthy, there are long-term benefits for their
families and communities.
Program integration and coordination and multilateral engagement
• The GHI must ensure integration and coordination, including integration among U.S.
government health programs, integration with other U.S. government initiatives outside
of health (e.g., food security, water supply and sanitation, etc.), and collaboration with
other donors and multilateral organizations.
Country ownership and sustainability
• The GHI must ensure that host countries are at the center of decision making and
leading health and development programs. A global health strategy must focus on
sustainability.
Health systems strengthening
• Sustainability encompasses both building and strengthening health systems with the
eventual goal of responsible transfer of ownership to sustain such initiatives.
Monitoring and evaluation
• The GHI must be continuously and effectively monitored and evaluated to ensure
measurable results are achieved.
Source: AIM 2009
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