Primary Health Care Monitoring Defined
Monitoring ensures interventions are implemented as planned, identifies specific
problems as they arise, and allows continuous feedback (Baker, 2000). Monitoring
primary health care interventions means using participatory approach to methodically
ensure that activities are carried out according as to achieve objectives of the
intervention. Implementers use information generated to make necessary changes for
greater effectiveness and efficiency.
It is therefore not monitoring when health officials, and politicians visit PHC projects in
communities long after commencement; courtesy calls are paid on community leaders,
and the project visited without clear plan of what is being monitored. Decision to monitor
PHC interventions, what is monitored, when and how must be part of primary health care
programme planning, and contained in the plan. Although, Green, (1992) suggests
monitoring of health intervention is important function of a health planner during
implementation. Indeed, methodical monitoring of PHC interventions begins even before
implementation, once project or intervention is decided monitoring follows at the
planning stage, and through the life of the intervention. Essentially, monitoring pervades
all segments of the primary health care intervention, project and programme in the
community or health facility, to address gaps at three main stages planning,
implementation, and post implementation. Primary health care planners, managers,
policy makers, health workers, beneficiaries, and sponsors are all responsible for
monitoring interventions.
Participatory Primary Health Care Monitoring
1. Participatory PHC monitoring starts with constituting monitoring teams, carefully
selected based on agreed criteria to ensure competence. Ensure the team is include
women, men, and when necessary youths depending on what is being monitored.
Integrating beneficiaries of health interventions in PHC monitoring enhances credibility,
transparency, and accountability. Beneficiaries can certify claims by implementers.
2. Clear objectives and indicators facilitate monitoring. Those involved in implementing,
and monitoring activities must understand objectives, indicators, expected outputs,
outcomes, and their linkages. Specific, measurable, achievable, and time bound
(SMART) objectives are easier to measure. Review indicators to ensure viability in
measuring objectives, different people using the same indicators should be able to obtain
the same results, particularly on quantitative measures, valid and reliable indicators are
likely to give credible results. Validity means the indicator measures what it is supposed
to measure based on stated objective. Reliability implies different people using indicators
at different times get similar results.
3. The team collectively develops monitoring plan guided by objectives, and resources.
The plan addresses highlights and objectives of the primary health care project;
monitoring objectives, activities, schedule, persons, and budget. The monitoring schedule
has about eight items objectives, indicators, activities, time, monitoring method, progress,
problems, and solutions. PHC monitoring objectives could include to: determine if
project is being implemented according to plan, specifications, standards, and on time;
understand the quality and quantity of money, and materials reaching implementers;
ensure outputs are consistent with agreed targets; identify any unexpected constraints
and problems and where; identify where changes are necessary and actions needed; and
determine if the project plan should be reviewed.
4. Structured, consistent, user-friendly tools are necessary for collecting relevant,
accurate, and timely data. Monitoring team tailors tools to match activity, objectives,
information needed, data collectors, and the environment. Tools for monitoring depend
on what is being reviewed and include: worksheet for the review, interview checklist and
guidelines, discussion guidelines, observation guidelines. Techniques depend on
reviewers and what is being reviewed. These could include: interview and observation,
formal and informal discussion, review records and reports, and review minutes of
meeting. Sources of data include health workers, policy makers, community leaders,
related agencies, organisations, and ordinary men and women affected by the
intervention.
The team agrees appropriate tools and techniques for collecting data on each aspect of the
intervention for monitoring. Key questions are: What information is needed and what are
the sources? Who should be involved in monitoring? When should monitoring be
conducted?
What tools and techniques should be used? What materials are needed? How should the
information be analysed? How would results be presented? How would results be used?
5. The team monitors and submits report. Monitoring must be conducted in accordance
with specifications, and report submitted at agreed time. The health officers, consultants,
and monitoring team agree reporting format during planning.
Planning and Conducting Participatory Primary Health Care Evaluation
Evaluation is systematic examination of intervention, project, or programme to determine
degree to which objectives are achieved (Gajanayake, & Gajanayake, 1993). Evaluation
responds to specific management decision-making needs and describes the intended
programme; what was actually implemented; participant characteristics; and
demonstrates impact of the programme (Poreteous, Sheldrick, and Stewart, 1997). In this
context, participatory primary health care evaluation involves an inclusive team that
methodically gather data using scientific and reliable tools and techniques to determine
outputs and outcomes of interventions in order to improve them. Reliable evidence
generated facilitates planning, and determining relevance, progress, efficiency,
effectiveness, impact, and sustainability of interventions.
In primary health care monitoring and evaluation are inextricable. Monitoring ensures
that primary health care programmes are on track while evaluation ensures they are on
the right track with the desired effect, and impact. Judgement of activities at every stage
is hence based on valid, accurate, and relevant information generated through monitoring
and evaluation ( Adindu, 2007). Evaluation in primary health care provides reliable
information to guide present and future decisions and actions, hence part of planning, and
implementation processes rather than the activity that may or may not be carried out.
Characteristics of Participatory Evaluation in Primary Health Care
Adindu (2008) suggests evaluation of health care interventions is more technical than
monitoring, uses scientific research methodologies, quantitative and qualitative for data
gathering and analysis. It requires specialist skills, but does not preclude none specialist
stakeholders. However, adopting participatory approach in PHC evaluation has the
following advantages:
i. ensures everyone involved or affected by the programme or providing resources
has opportunity to participate in the evaluation process;
ii. shared interests and different concerns are recognised;
iii. all stakeholders have access to results of evaluation;
iv. enhances acceptability and support for the intervention and evaluation process;
v. Builds capacities, promotes partnership among beneficiaries, implementers, and
sponsors;
vi. community experience, and expertise are recognised and utilised; and
vii. enhances accuracy and reliability of results, and promotes sustainability of health
intervention;
What to Evaluate in Primary Health Care
Effective primary health care evaluation helps in determining current health realities,
priorities, objectives, and indicators, if project objectives are achieved using agreed
indicators, extent to which results satisfy resource investment, quality of intervention,
things that went right and wrong, how not to repeat mistakes, and measures to improve
intervention.
Assess relevance of primary health services at the planning stage to understand current health situation, determine rationale, and appropriateness of each intervention in meeting identified health needs of the community. Changes proposed to the delivery and organisation of health services should be evaluated before they are widely implemented (McDonnell, Wilson and Goodacre, 2006). On the same note, evaluation should precede
implementation and follow a staged approach (Cambell, Fitzpatrick, Kinmouth, et. al, 2000). Information from desk monitoring of PHC activities are utilised to assess relevance of planned intervention to the context, people, health needs, available resources, technologies, and capacities. Relevance evaluation helps in deciding what activities must take place before actual implementation, and indeed how to break down the intervention.
Assess progress of primary health intervention during implementation to periodically
measure actual achievement against planned activities, identify gaps, and their causes.
Actions are then taken to keep the process, and activities on course. Data and information
derived from monitoring are utilised to measure progress. Effective monitoring using
the right tools, asking the right questions, and examining the right things, against the
intervention plan, time, and budget to provide credible information for measuring
progress of the primary health intervention. To assess progress means that the planning
process was properly conducted with clear objectives, indicators, time, budget, and
people properly selected and trained for various activities. Materials, and equipment are
available on time in agreed quality and quantity. Objective assessment of progress is
difficult when needed inputs agreed at the planning stage are not consistently coming on
schedule.
Assess efficiency of PHC intervention to determine the relationship between results, and
resources utilised. The aim is to improve implementation, and enhance progress by using
results of monitoring. Efficiency evaluation of PHC ensures that the right people are
assigned tasks, and properly trained; workers are well supervised, and remunerated.
Assess effectiveness to determine immediate outputs and outcomes of the primary health
care intervention, and degree to which predetermined objectives, and targets are
achieved. In addition, effectiveness addresses satisfaction or dissatisfaction expressed by
the different health beneficiaries, communities, health workers, donors, and other
stakeholders. Effectiveness requires application of scientific methodologies to measure
outputs, and some degree of outcomes of the PHC intervention.
Assess impact after implementation to understand overall outcome of primary health
acre intervention on the health and social well being of the people. Impact evaluation
typically conducted years after assesses causality, depending on initial plan determines if
the intervention had desired effect on individuals, households, and institutions, whether
the effect is attributable to the intervention, also exposes unintended consequences,
positive or negative, on beneficiaries (Baker 2000). Impact evaluation of primary health
care interventions helps in understanding positive, negative, foreseen and unforeseen
status of beneficiaries due to health programme.
Assess sustainability to determine continuity of intervention after exit of external
stakeholders, a litmus test for the success of PHC interventions. This is critical and forte
of approach advocated in primary health care, and indeed all health and development
interventions. It means the community is properly trained manage the intervention,
understands the PHC intervention, actively involved in all the processes, has adequate
local capacity to continue or maintain the intervention. Sustaining the PHC intervention
means community values it, and ready to mobilise necessary resources to continue the
intervention for long-term health improvement of the people. Sustainability is assessed
years after external agents have left the community.
Basic steps are in participatory PHC evaluation start with constituting an inclusive
evaluation team; review programme plan, objectives, and indicators; prepare evaluation
plan; design data collection tools; and collect credible data, analyse and produce report.
In terms of when to evaluate, Turnock (2004) argues that establishing measurable
checkpoints in time and direction is key to any evaluation strategy. PHC evaluation is
continual but results are summarised and reported at agreed times or intervals. During
planning those involved collectively decide when, what to evaluate, and when to report.
Typically, quarterly evaluation is good practice, brings reports from all points, units or
departments involved, often preceded by monthly review at each point. The quarterly
review helps to track activities, and allows changes to take place if necessary. Evaluate
at the beginning of the primary health care intervention to determine relevance and
feasibility of issues being addressed, the objectives, indicators, and work plan.
Continuously evaluate at the middle of PHC intervention to assess outputs, effect,
progress, and efficiency. Compare results with objectives planned, identify gaps and
problems, and take corrective action. Evaluate at the end of PHC intervention to
determine extent to which objectives are achieved as planned, then three years after to
assess impact.
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