Evaluation of health

services +NHP2002

by
Dr Sanjeev Gupta
 Presentation Outline
Monitoring and Evaluation
of health services

NHP 2002

Evaluation

Monitoring
Definition and
Concept
Types Definition and
Designs concept
Methods Process: Evaluation
FIVE phases of challenges Monitoring
Evaluation versus evaluation
 Monitoring and Evaluation (M&E)
• Monitoring progress and evaluating results are key functions
to improve the performance of those responsible for
implementing health services.

• M&E show whether a service/program is accomplishing its

goals. It identifies program weaknesses and strengths, areas
of the program that need revision, and areas of the program
that meet or exceed expectations.

• To do this, analysis of any or all of a program’s domains is

required
Where does M&E fit?
 Monitoring versus Evaluation
Monitoring Evaluation

A planned, systematic process A process that assesses an

of observation that closely achievement against preset
follows a course of criteria.
activities, and compares Has a variety of purposes, and
what is happening with follow distinct
what is expected to happen methodologies (process,
outcome, performance,
etc).
 Evaluation Monitoring

• The periodic collection and

• A systematic process to
review of information on
determine the extent to which
programme implementation,
service needs and results have
coverage and use for
been or are being achieved
comparison with
and analyse the reasons for
implementation plans.
any discrepancy.
• Open to modifying original
• Attempts to measure service’s
plans during implementation
relevance, efficiency and
effectiveness. It measures • Identifies shortcomings before
whether and to what extent it is too late.
the programme’s inputs and • Provides elements of analysis
services are improving the as to why progress fell short of
quality of people’s lives. expectations
Comparison between Monitoring and Evaluation
Evaluation
 Evaluation can focus on:
• Projects
normally consist of a set of activities undertaken to achieve specific
objectives within a given budget and time period. Processes
• Programs
are organized sets of projects or services concerned with a particular
sector or geographic region
Services
• Services
are based on a permanent structure, and, have the goal of becoming,
national in coverage, e.g. Health services, whereas programmes are
usually limited in time or area.
Projects
• Processes
are organizational operations of a continuous and supporting nature
(e.g. personnel procedures, administrative support for projects,
distribution systems, information systems, management operations).
Conditions
• Conditions
are particular characteristics or states of being of persons or things (e.g.
disease, nutritional status, literacy, income level).

Programs
 So what do you think?
• When is evaluation desirable?
 Evaluation:
It is the final step of planning cycle. It should be both concurrent and
terminal.

The purpose of evolution is to assess the achievements of stated

objectives, its adequacy, efficiency and its acceptance by the people.

Evaluation measures the degree to which objectives and targets are

fulfilled and the quality of the results obtained.

It measures the productivity of the available resource in achieving

measured output.

Evaluation makes it possible the reallocation of priorities and of

resources on the basis of changing health needs.
Components of the evaluation process:

Relevance: Relevance relates to the rationale for

adopting health policies in terms of

Their response to social and economic policy; and to

having programmes, activities, or services,

 Their response to essential human needs. For example

vaccination against small pox is now irrelevant because the
disease is eradicated.
Adequacy: Adequacy implies that sufficient attention has been
paid to certain previously determined course of action, such as
the various issues to be considered during broad
programming.

Progress; Progress is concerned with the comparison of actual

with schedule activities, the identification of reason for
achievements or shortcomings and indications for remedies
for any shortcomings.
•Progress evaluation track of ongoing activities,
milestones achieved, personnel matters, supplies and
equipment, money spent in relation to budgets
allocated.
 Efficiency: Efficiency is an expression of the relationship
between the results obtained from a health programme or
activity and the efforts expended in terms of human, financial
and other resources, health processes and technology and time.

Effectiveness; effectiveness is an expression of the desired effect

of a programme, services, institution or support activity in
reducing a health problem or improving an unsatisfactory health
situation. Thus effectiveness measures the degree of attainment
of the predetermined objectives and targets of the programme,
services or institution.
Efficacy is "the extent to which a drug has the ability to bring
about its intended effect under ideal circumstances, such as in
a randomized clinical trial“

Effectiveness is "the extent to which a drug achieves its intended

effect in the usual clinical setting/non controlled situations.

Efficiency: Efficiency measures whether healthcare resources

are being used to get the best value for money.

Health care can be seen an intermediate product, in the sense of

being a means to the end of improved health.

Efficiency is concerned with the relation between resource inputs

(costs, in the form of labour, capital, or equipment) and either
intermediate outputs (numbers treated, waiting time, etc) or final
health outcomes (lives saved, life years gained, quality adjusted
life years (QALYs)).
Impact: Impact is an expression of overall effect
of a programme, service or institution on health
and related socioeconomic development.

Aimed at identifying any necessary change in the

direction of health programmes so as to increase
their contribution to overall health and
socioeconomic development
Basic steps of evaluation
Determine what is to beevaluated

Establish standards andcriteria

P l a n the methodology

Co l l e c t information

Analysis and interpretation of the results

Taking action

Re-evaluation
 Determine what is to be evaluated:
There are types of evaluation
• Structure evaluation- evaluation of the resources used
in the programme like personnel, money, materials or
buildings etc.
• Process evaluation- the way in various activities of the
programme is carried out is evaluated by comparing with
the predetermined standard. How the inputs are utilized
to produce an output of a service.
• Outcome evaluation – this is concerned with the end
result of the programme. The types and quantities of
goals and services produced by the programme.
Evaluation can also be classified as
a) terminal evaluation
b) continuous evaluation
c) periodic evaluation
based whether evaluation is planned at the
end of the programme or along with the
programme continuously or periodically.
 Establishment of standards and criteria:
Establishment of standards and criteria are
necessary to determine how well objectives have
to be attained.
Structure criteria: physical facilities, personnel and
equipments
Process criteria: no. of antenatal visits to be made, no.
of blood smear to be collected.
Outcome criteria: no. of death to be prevented no of
patients cured.
Methodology: methodology of evaluation should
be based on the purpose of evaluation.

Gathering information: evaluation requires

collection of data or information. The amount of
data required will depend on the purpose and
the use of the evaluation.
Analysis of results: analysis of the data and
interpretation of data and feedback to all individuals
concerned should take place which will provide
opportunity for discussing the evaluation results.

Taking action: Based on the evolution results actions

are taken to strengthen or modify the programme,
which may call for shifting priorities, revising the
objectives etc.

Re-evaluation: Evaluation is an ongoing process

which is needed to make health programmes more
relevant, efficient and effective
NATIONAL HEALTH POLICY- 2002
 INTRODUCTION
• Policy is a system, which provides the logical
framework for the achievement of intended
objectives.

• Policy sets priorities and guide resource

allocations.

• Public health policy improves conditions

under which people live
 National Health Policy:
• The Ministry Of Health And Family Welfare, Govt. of
India formulated the First formal NHP in 1983 with
the goal of health for all by 2000.

• Since then there has been significant changes in

the determinants of health necessitating the
revision of NHP and a new NHP 2002 evolved.
 National Health Policy 2002
Objectives:
•Achieving an acceptable standard of good
health of Indian Population

•Decentralizing public health system by

upgrading infrastructure in existing
institutions.

•Ensuring a more equitable access to health

service across the social and geographical
expanse of India.
 NHP 2002, Objectives……..
• Enhancing the contribution of private sector in
providing health service for people who can afford to
pay.

• Giving primacy for prevention and first line curative

initiative.
• Emphasizing rational use of drugs.

• Increasing access to tried systems of Traditional

Medicine
Goals – NHP 2002

1. Eradication of Polio & Yaws 2005

2. Elimination of Leprosy 2005

3. Elimination of Kala-azar 2010

4. Elimination of lymphatic Filariasis 2015
of HIV/AIDS
5. Achieve of Zero level growth of HIV I AIDS 2007
 Goals – NHP 2002……

6.Reduction of mortality by 50% 2010

on account of Tuberculosis, Malaria,
other vector and water borne Diseases

7.Reduce prevalence of blindness 2010

to 0.5%
 Goals – NHP 2002……
8. Reduction of IMR to 30/1000 2010
& MMR to 100/lakh

9. Increase utilization of public 2010

health facilities from current
level of <20% to > 75%

10.Establishment of an integrated 2007

system of surveillance,
National Health Accounts
and Health Statistics
 Goals – NHP 2002……

11. Increase health expenditure by 2010

government as a % of GDP
from the existing 0.9% to 2.0%

12. Increase share of Central 2010

grants to constitute at least
25% of total health spending
 Goals – NHP 2002……
13. Increase State Sector
Health spending from 2005
5.5% to 7% of the budget

14. Further increase of

2010
State sector Health
spending from 7% to 8%
 Suggested norms for health personnel
Category of Norms
personnel suggested
1 . Doctors 1 per 3,500 population
2. Nurses 1 per 5,000 population
3. Health worker female 1 per 5,000 population in plain area
and male and 3000 population in tribal
and hilly areas.
4. Trained dai 1per village
5. Health assistant (male 1 per 30,000 population in plain area
and female and 20000 population in tribal
and hilly areas.
6. Health assistant provides supportive super-
(male and female) vision to 6 health workers
(male /female).
7. Pharmacists 1 per 10,000
population
8. Lab. 1 per 10,000
technicians population
 Five Year Plan
• Formulated by Planning Commission.
• To re-build rural India, to secure balanced development of all
parts of India.

BROAD OBJECTIVES:
• Control or eradication of major communicable diseases
• Strengthening of basic health services through establishment
of PHC & SCs.
• Population control
• Development of health manpower resources
 Five year Plan

Planning Commission of India – 1950

Assessment of Material, capital, Human Resource
 Draft Development plans for effective utilization of
resources.
 Different Planning divisions with Program advisors,
Technical Divisions of Planning Commission.
 First Five Year Plan 1951 – 56.
 Health Sector Planning includes
following sectors.

– Water supply and sanitation

– Control of Communicable disease

– Medical Education Training and Research

– Medical Care including Hospitals, Dispensaries

and PHCs
– Public Health Services

– Family Planning

– Indigenous system of Medicine

 Eleventh Five Year Plan (2007- 2012)
Goals :-
a) MMR – 1 per 1000 live births, IMR – 28 per 1000
live births, Total Fertility Rate – 2.1

b) Providing clean Drinking Water for all by 2009

c) Reducing Malnutrition (0 – 3 yrs) by half.

d) Reducing Anaemia (women and girls) by 50%

e) Raising sex ratio  0 – 6 yrs – 935 by 11 – 12,
-- 950 by 16 – 17
 Thrust Areas during Eleventh Plan

• Improving Health Equity (NRHM, NUHM)

• Adopting system-centric approach then disease
centric.
• Increasing survival by improving maternal and child
health

• Taking advantage of local enterprise for solving

health problems
• Protecting poor from health expenditure
• Decentralizing governance
Thrust Areas during Eleventh Plan (Contd…..

• Establishing E-health
• Improving access to and utilization of
essential and quality health care.
• Focus on health human resources
• Focus on excluded/ neglected areas
• Enhancing efforts at disease reduction
• Health system and Bio-medical research
 Achievements during the plan periods
ACHIEVEMENTS 1st plan (1951-56) 12th plan (2012-17)

PHCs 725 25,020

Subcentres NA 152,326
CHCs - 5,363
Total beds (2002) 125,000 914,543

Medical colleges 42 356

Annual admissions in MCs 3,500 41,569

Dental Colleges 7 297

Allopathic doctors 65,000 9,18,303
Nurses 18,500 1,237,964

ANMs 12,780 602,919

Health Visitors 578 52,653

Health workers(F) - 217,780

Health workers(M) - 55,445
BEE - 2,904
Thank you