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The development of a national policy and strategy for health system quality is a prerequisite to country-led measurement and is discussed further in the next section.212 Assessing measurement approaches against the standards defined in the national strategy will provide insight on gaps and inefficiencies in measuring quality. Another responsibility of a national institution for health system measurement is the development of the quality measurement toolkit. The toolkit can differ by context and resource availability, but should include three tiers: foundational systems, routine data, and targeted studies. The first tier consists of vital registries to track population births and deaths, supply chain management, and human resources information systems, including provider payment tracking. These elements are fundamental for a sound understanding of the population and the capacity of the health system. The second tier is routine data collection through electronic health records or health information systems; many measures for effective coverage and system competence can be derived from routine health information systems. Accuracy and parsimony are essential to these measurements, because of not only their importance, but also their high potential burden. The third tier consists of targeted health system studies, which include health facility and population surveys and patient registries to probe more deeply into health needs and system performance. Facility assessments must be more agile and responsive to national priorities, with increased emphasis on measures that might be hard to capture in a routine system, including timeliness and accuracy of care delivery and patient experience. Patient registries can be developed as a subset of facility assessments to provide information on health outcomes and patient perspectives over time for priority groups or conditions. Quality of care can be assessed, using measures derived from facility assessments or provider payment tracking to elicit exit data and proxy measures, as well as direct patient, provider or clinical staff accountability measures for quality of services (provider performance measurement). Patient surveys can be linked to these experiences with the aim of understanding drivers of service delivery and assessing the quality of services for the user. These studies can provide insight on health needs, based on the conditions that demand priority. These studies will continue to be instrumental in providing data for equity assessment, particularly in lower-income countries. When optimised, the combination of these data sources has powerful potential to advance the quality of health systems. The matrix of tools will differ by context, because one of the aims of the SDG era is for all countries to own their data systems and to define their data needs within a common framework. National ownership of tools at all tiers is important for the results to be integrated and used. d2c66b5586
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