Measuring the success of health sector reforms requires the monitoring of a range of areas, including staff performance and the development of evidence-based decision making by management at operational level. Can evidence-gathering systems be created in Sri Lanka to strengthen policy making at the national level?  Researchers from Keele University examine what support might be needed to build the required capacities - institutional and technical - to tackle performance management in developing country health systems?

Many countries, like Sri Lanka, are not accustomed to utilising routine performance assessment to inform health policy at a national level.  The introduction of Sector Wide Approaches (SWAps) makes it necessary for countries to assess both policy and implementation.  The introduction of a monitoring system using key indicators has practical implications for health service processes. 

In 2000 the World Health Organisation launched an initiative to encourage countries to shift the focus away from monitoring implementation of programmes and towards assessing the development of their health systems. In 1997, earlier WHO field trials in Sri Lanka to examine the potential for human resource performance indicators had shown that their use was feasible and could potentially influence decision-making.  The trials also suggested the requirement for organisational change, increased understanding and incentives, all of which are common to many developing country health systems.

The researchers found that:

• New organisational structures are emerging out of health sector reform.  Applying monitoring mechanisms to these new structures can be difficult.
• A comprehensive health service information management system often does not exist in developing countries.  To engage with policy management requires the development of several interconnected initiatives to develop the necessary technical and organisational capacities.
• Operational data is not sufficient to inform policy making.  A sound understanding of policy objectives is the basis for identifying the relevant questions to be addressed and what performance indicators are needed.  Often the technical skill to drive this process is not available within ministries of health.
• Selection of appropriate performance indicators is a dynamic, cyclical process, based on the reformulation of policy questions over time. However, the creation of new indicators during this process is not feasible.  This raises issues of necessary but difficult changes in organisational culture and the need for research to identify the generic, ‘core’ issues of policy review.
• The adoption and use of performance indicators is dependent on the existence of a ‘perceived need’, motivation to use them and understanding of their purpose, as well as the technical competence to lead the process, effective means of collecting data and power to take action based on the resulting policy analysis.

From these finding, implications for policy include:

• The benefits of introducing performance indicators depend on the existence of adequate structures, processes and skills within health systems.
• Policy decisions are not made on the basis of quantitative evidence alone.  Qualitative data, observation and intuition still have a part to play.
• Development of performance management at policy level takes place within the wider national economic, political, demographic and epidemiological context.  This is outside the control of any Ministry of Health.
• Health ministries need to be flexible in response to changes in their situation and on the basis of evidence and experience.

Source(s):
‘A development framework for promoting evidence-based policy action: drawing on experiences in Sri Lanka’ International Journal of Health Planning and Management 17: 165-183, by P. Hornby and H.S.R. Perera, 2002

id21 Research Highlight: 4 March 2004

Further Information:
Peter Hornby
Centre for Health Planning and Management
Keele University
Keele
Staffordshire ST5 5BG
UK

Tel: +44 (0) 1782 583 191
Fax: +44 (0) 1782 711 737
Contact the contributor: hma28@keele.ac.uk

Centre for Health Planning and Management, Keele University, UK

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