Health System Indicators

Health system
resilience indicators
an integrated package for measuring
and monitoring health system
resilience in countries
Health system
an integrated package for measuring
and monitoring health system
Health system resilience indicators: an integrated package for measuring and monitoring health system
ISBN 978-92-4-008898-6 (electronic version)
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iii
Contents
Acknowledgements v
Abbreviations vi
1 Introduction 1
1.1 Scope and objectives 3
1.2 Target audience 3
1.3 Approach and guiding principles 4
2 Using the package of HSR indicators 5

2.1 Step-by-step process 7
2.2 Using the technical specifications or metadata 13
3 Health system resilience indicators 14

3.1 Overview 15
3.2 Summary list 16
4 Health system resilience indicators with metadata 21

4.1 Service delivery 23
4.2 Health workforce 39
4.3 Health information 45
4.4 Access to medicines and other health products and technologies 58
4.5 Health financing 70
4.6 Governance and leadership 80
4.7 General/composite indicators 119

Health system resilience indicators: an integrated package for measuring and monitoring health system resilience in countries iv
5 Supplementary indicators of relevance to

health system resilience 121
6 Resources of indicator sets and monitoring and evaluation

frameworks as sources 140
References 146
Annex. Methodological approach to HSR indicator development 148

Defining health system resilience capacities 148
Data collection 149
Data analysis and indicator selection 150
References: Annex 151

v
Acknowledgements
This development of this work was led by the Special Gratitude also goes to the Korea International
Programme on Primary Health Care, Health System Cooperation Agency (KOICA) Global Disease
Resilience and Essential Public Health Functions Eradication Fund (GDEF) (within the scope of the
Team: Sohel Saikat (Team Lead), Saqif Mustafa, project on “Making Health Services Resilient with
Redda Seifeldin, Yu Zhang, and Geraldine McDarby, Quality and Emergency Preparedness for Response
in collaboration with the Integrated Health Services in Ethiopia and Liberia”) and the Universal Health
Department, Health Service Assessment Unit: Coverage Partnership for the funding support for the
Kathryn O’Neill (Unit Head), Dirk Horemans, Kavitha development of this package.
Viswanathan, and Briana Rivas-Morello.
Appreciation goes to Gerard Schmets (Deputy
Director, Special Programme on Primary Health
Care), Suraya Dalil (Director, Special Programme
on Primary Health Care), Rudi Eggers (Director,
Integrated Health Services Department) and other
expert technical colleagues in WHO headquarters
and regional offices for their support and technical
contributions to the development of this package.
vi
Abbreviations
DHS Program Demographic and Health Surveys Program

EPHF essential public health functions
HHFA Harmonized Health Facility Assessment
HSR indicator health system resilience indicator
IHR International Health Regulations
JEE joint external evaluations
M&E monitoring and evaluation
PAHO Pan American Health Organization
PHC primary health care
PHCMFI Primary Health Care Measurement Framework and Indicators
SARA Service Availability and Readiness Assessment
SDG Sustainable Development Goal
SPA Service Provision Assessment
UHC universal health coverage
WHO World Health Organization
1
Introduction
Health system resilience indicators: an integrated package for measuring and monitoring health system resilience in countries 2
be seen as a continuum, with the same capabilities

Health system resilience means that health actors required to ensure the delivery of quality essential
(including institutions and populations) are able to health services in the face of chronic stressors
effectively anticipate, prevent, prepare for, absorb also providing the base required to support the
and adapt in response to, and recover from a wide maintenance of those services in the midst of
variety of shocks and stressors while delivering high- responding to a large-scale shock event.
quality individual and population health services as
needed, utilizing lessons from experiences within While the concept of health system resilience is
and outside their settings to continuously improve supported by a rapidly growing knowledge base,
on their baseline capacities and performance in all there remains an unmet need and demand for its
contexts (1–3). measurement and monitoring as part of sustainably
strengthening health systems and building resilience
Global experiences with public health emergencies, at country level (6, 7). This package of health system
such as Ebola virus disease outbreaks and the resilience indicators (HSR indicators) addresses
COVID-19 pandemic, have reinforced the need for this gap, complementing the body of experiences
strengthening health system resilience, as reflected and resources identified in the Health Systems
in the proceedings of the World Health Assembly (4), Resilience Toolkit (2) and supporting implementation
the Intergovernmental Negotiating Body (5), the World of the recommendations in WHO’s position paper
Health Organization (WHO) and other global partners. on building health system resilience for universal
While health system resilience is typically a response health coverage and health security (8). The added
to disruptive shocks such as infectious disease value of this package includes bringing together
outbreaks, acute climate change-related events, what health systems require to be functional during
and war and conflict, health system resilience is periods of relative normalcy, in the face of day-to-
equally important in the face of everyday stressors day challenges and stressors, sometimes referred
such as evolving population health needs, resource to as “everyday resilience” (Box 1), as well as what is
and infrastructure challenges, and staff shortages. needed when there are small or large shocks.
In fact, the development of resilience capacities can
Box 1. Resilience against different types of stressors

Health systems must be resilient against a range of shocks and stressors, from acute external events
such as natural disasters or infectious disease outbreaks to more chronic internal challenges such as
insufficient funding or a chronic shortage of human resources. In academic literature, this differentiation
is sometimes reflected in the definition of different types of resilience, such as event-based resilience
related to acute events, and everyday resilience for more chronic challenges. Regardless of the cause,
acute and chronic shocks and stressors share the underlying principle of disruption, which varies in
size and onset. It is important that efforts to build resilience do not focus on a specific type of shock
or stressor but rather develop the baseline capacities required to ensure the delivery of quality health
services in all contexts. This is in recognition of the fact that it is the same capabilities required to ensure
the delivery of quality essential services in the face of chronic challenges that provide the foundation for
the provision of services during more acute events.
1. Introduction 3
• to provide a consolidated reference of indicators

1.1 Scope and objectives that can be adapted and utilized to support
measuring and building health system resilience,
The package of HSR indicators serves as a dedicated complementary to and integrated with routine
resource for those who wish to measure and monitor national health information systems and existing
health system resilience on a routine basis and in WHO and other authoritative guidance and tools;
the context of disruptive shocks as well as everyday
• to promote an integrated approach to
stressors, and to expand their capacity to do so as
strengthening existing measuring and monitoring
their population health needs and health system
of health and allied systems in countries by
and monitoring capabilities evolve. It promotes and
including considerations for making health systems
supports building health system resilience through an
more resilient, thus advancing progress towards
integrated approach to health system strengthening1
universal health coverage and health security;
that embeds essential public health functions,
including health security capacities, within health • to support countries in identifying targeted
systems to comprehensively address population interventions for building health system resilience
health needs. The HSR indicators can be adapted for across policy, planning and operational levels
use based on population health needs, country or within an integrated, whole-of-system approach.
regional risk profiles, specific health system stressors,
disease burden, epidemiological and demographic 1.2 Target audience
profile, and income level, and can be applied in a The primary target audience for this package is
range of contexts, including fragile, conflict-affected national and subnational health authorities (including
and vulnerable settings, humanitarian disasters, planners and managers) and service providers, as well
and specific country contexts, such as Small Island as local, regional, and global technical organizations
Developing States (SIDS). and partners working on health system strengthening,
The package is not intended to be prescriptive or to including WHO, United Nations country teams, donors,
serve as a separate assessment tool or framework, nongovernment organizations, development and
but rather to act as a feasible, contextualised humanitarian agencies, and other health-related
and pragmatic resource tool for measuring and technical agencies.
monitoring health system resilience. The indicators
should therefore be integrated with and complement
existing health information systems, for example, by
being included in national health sector monitoring
and evaluation frameworks – though it is recognized
that this kind of integration may take time.
The overall aim of this package is to support
countries to progressively expand their capabilities
to measure, monitor and build health system
resilience from national level to health facilities and
other service delivery platforms in order to enable
the delivery of individual- and population-focused
health services in all contexts. The specific
objectives include:
1 Health system strengthening comprises the means (for example, policy instruments) to achieve health goals. It can be understood as (a) the process
of identifying and implementing the changes in policy and practice in a country’s health system, so that the country can respond better to its health and
health system challenges; and (b) any array of initiatives and strategies that improves one or more of the functions of the health system and that leads to
better health through improvements in access, coverage, quality or efficiency.
system, health security, and disease-, program- and

1.3 Approach and guiding principles life course-specific indicator sets and measurement
tools (see section 6). It has been aligned with and
A multipronged strategy was employed to inform
is complementary to the Primary Health Care
the development of this package. Literature
Measurement Framework and Indicators (PHCMFI).
reviews underpinned by systematic methods and
While not comprehensive, the PHCMFI includes a list
technical consultations with selected experts at the
of resilience-relevant indicators highlighted within
national (ministries of health, national public health
the associated technical annex (15). Both documents
institutes, WHO country offices and academia),
will remain as “live” documents to allow the
regional (WHO regional offices) and global (WHO
incorporation of evolving evidence and knowledge.
headquarters and technical partners) levels,
were conducted to identify, adapt, and develop Throughout the development of this package,
indicators and technical specifications (metadata) contextualization and utility for end users, and
and accompanying guidance (see Annex for detailed integration with existing health system measuring
methodological approach). and monitoring mechanisms, have been considered
as guiding principles. It was recognized that
The set of HSR indicators was also informed by
feasibility in terms of technical and financial
and builds on existing monitoring and evaluation
resources required to measure and monitor
frameworks, guidance, and indicator sets, including
each indicator would vary by context. Therefore,
Monitoring the building blocks of health systems:
suggested criteria for assessing feasibility were
a handbook of indicators and their measurement
defined and those indicators categorized as having
strategies (9); Primary health care measurement
“high” or “medium” feasibility by consultees and end
framework and indicators (10); Continuity of essential
users were incorporated into this package (Box 2).
health services: facility assessment tools (11);
The same principles guiding the development of this
International Health Regulations (2005) monitoring
package equally apply in its application as end users
and evaluation framework (12); Universal health
select, adapt, and adopt the HSR indicators based on
and preparedness review (UHPR) (13); health system
their contexts and needs.
performance assessments (14); and other health
Box 2. Feasibility criteria

It was recognized that feasibility in terms of technical and financial resources required to monitor each
indicator would vary by health system. Therefore, the following criteria for assessing feasibility were
defined to guide the selection of HSR indicators.
• “High” feasibility was defined as: the necessary resources to measure the indicator are already
available or the data are already being collected.
• “Medium” feasibility was defined as: one or two of the necessary resources to measure the indicator
are currently missing; or, with ongoing efforts, the necessary resources could be made available in the
next 6 to 12 months to measure the indicator.
• “Low” feasibility was defined as: none or very few of the necessary resources are available to measure
the indicator and the necessary level of technical resources required to measure the indicator is
unlikely to be available in the near future.
2
Using the package
of HSR indicators
represent similar and even overlapping aspects of

In developing this package, it was recognized that resilience, allowing countries to select the indicators
countries have existing mechanisms for monitoring most clearly aligned with their measurement
health system performance and improvements. approaches and goals and most relevant to their
Many of the indicators within these frameworks setting. In addition, the indicators within the package
represent aspects of the health system that can be selected and adapted to align with national
contribute or are even essential to the development priorities, population health needs and health
of health system resilience. Others can be adapted system context.
to measure and monitor resilience with minor The indicators, their technical specifications
alterations or the addition of specific attributes, (metadata), and associated guidance can support
while even more can be progressively adapted as end users in the data collection required for
needed and feasible. The HSR indicators are not measuring and monitoring health system resilience,
meant to replace existing measures but are intended and can inform policy-making, planning and system
to be used alongside existing approaches to health improvements. It is important to note that in the
system monitoring, broadening the scope where context of this package, “health facilities” refers to
necessary, such that resilience is also explicitly all service delivery platforms, including facilities
captured within these mechanisms. and other units of service delivery, where individual
The indicators within the package of HSR indicators or population health services are provided (for
are designed to be applicable across different example, facilities, departments, units and programs
contexts and settings regardless of the level of responsible for health, social care or public health
maturity of the health system. For this reason, some services). In addition, some of the indicators
indicators are high-level composite indicators and contained within the package are also applicable to
others represent specific and foundational aspects the private sector (including for-profit, not-for-profit,
of the health system that may require specific focus informal and other types of service providers).
in the early stages of building resilience or within The package, intended to be a live resource
specific settings, for example in relation to resources, and repository of health system resilience
development stages, health system arrangements indicators, contains:
or priority health needs. Some of the indicators
General guidance on how to use the health system Section

resilience indicators 2
A set of 64 recommended health system resilience Section

indicators with technical specifications 3&4
A supplementary 101 indicators of relevance to Section

health system resilience 5
2. Using the package of HSR indicators 7
2.1 Step-by-step process

There are six steps that end users may consider
while using this package to support measurement,
monitoring and building of health system resilience
(Figure 1).
Figure 1. Suggested steps in using the package of HSR indicators to enhance measurement,
monitoring and building of health system resilience
1. Map HSR indicators
6. Utilize information
2. Select HSR indicators
for improvements
5. Measure and monitor 3. Define targets
4. Build measurement capacity
a. Map HSR indicators against existing national the process of building resilience to be delayed in
monitoring and evaluation framework and order to synchronize with ongoing health sector
indicators and health information system planning or monitoring. Building resilience can
begin alongside existing planning and monitoring,
Within countries, there are various assessments
for example, within the context of recovery from
tools and monitoring and evaluation mechanisms
a public health emergency, with the aim of being
for the health system and allied sectors, including
integrated and aligned over time. The HSR indicators
data collection for routine health, health sector
should ultimately be incorporated into routine health
performance, health emergencies, and disease-,
information system monitoring.
life course-, humanitarian- or disaster-specific
programs. It is unlikely that it will be feasible to
monitor the entire set of HSR indicators at one time
in a given country context. Instead, the indicator
package should be reviewed, and a selection or
suite of indicators chosen to measure and monitor
health system resilience. It is not necessary for
• Specificity. The indicators chosen should be

The first step towards this is to map the HSR granular enough to allow identification of specific
indicators against existing indicators and approaches issues that need to be addressed, as well as
to monitoring and evaluation, including those measurement of those issues in the short to
within routine health information systems. This can medium term. For this reason, some indicators
inform selection of an appropriate suite of indicators in the package measure a single attribute or
by establishing which, if any, aspects of health component of indicators presented in other
system resilience are being captured within existing frameworks. This supports a focus on measuring
measurement mechanisms, as well as any critical and addressing specific deficits. Indicators should
gaps and areas for improvement across health be adapted and adjusted with progress, with the
system building blocks and essential public health ultimate goal of integrating them within existing
functions (Table 1). health system frameworks.
• Relevance and feasibility. The indicators
b. Select and prioritize HSR indicators chosen should be useful to inform planning and
After identifying existing indicators, if any, that are delivery of services in support of building health
currently being collected in relation to resilience, system resilience, and the technical and financial
additional indicators from the package of HSR resources to collect the necessary data should
indicators can be identified to complement these in be available.
order to more comprehensively monitor and build • Integration and duplication. The development of
resilience. Indicators may be selected for inclusion capacities to measure and monitor health system
as they are, or currently collected indicators may resilience should not duplicate or compete with
be adapted to provide a greater focus on resilience. existing assessments, tools and systems; rather,
Adaptation may include tailoring existing data they should build on existing data collection, as
collection tools, such as national-, subnational- or available. There should be a plan to integrate, over
facility-level surveys, or embedding new indicators time, the HSR indicators into existing monitoring
within routine health information systems. and evaluation mechanisms, such as national- and
facility-level assessments and tools, and routine
The final suite of indicators chosen to represent
health information systems.
health system resilience will be highly context
specific and should be informed by the following. • Balance. The final suite of indicators chosen
to represent health system resilience in a given
• National population and health system context. context should provide a balanced picture of the
The choice of indicators should be informed by an system, representing all health system building
understanding of current national health priorities, blocks and public health functions as well as
supported by available population and health presenting a balance between indicators with
system data, including population health needs specific relevance to disruptive shock events and
assessment and health system risk profiling. those measuring aspects of everyday resilience.
• Health system foundations. The indicators chosen
should reflect the critical gaps in foundational
elements required to build resilience in a specific
context. Activities or resources dedicated to
strengthening resilience benefit from dedicated
indicators to measure performance and impact.
• People and communities. The involvement
of people and communities is integral to the
development of health system resilience, and
should therefore inform the selection of indicators,
such that people and communities are at the
centre of informing health system priorities and the
development and evaluation of services. This may
require attention to building the capacity of people
and communities to engage with health system
development. A number of indicators with a focus
on community engagement are presented in Box 3.
Box 3. Examples of indicators on community engagement and participation to be

selected across health system building blocks
• % facilities using community voice to inform service planning (service delivery)
• % facilities providing outreach according to community needs (service delivery)
• Mechanism available to assess community trust (health information)
• % subnational health workers trained in community engagement (health workforce)
• Mechanism for multistakeholder participation and community engagement
(governance and leadership)
• Mechanism to ensure community engagement in service planning and organization
(governance and leadership)
c. Define targets for selected HSR indicators needs, health system context and expectations
originally envisioned. This stage allows stakeholders
As resilience is an ongoing and context-specific
to consider and clarify the mechanisms (including the
process, there are no absolute targets or levels
who, where and how) that are required for collecting
universally applicable to the indicators. In the context
the data on set targets. Due to the cross-cutting,
of this package, targets are specific, planned levels
multisectoral and interdisciplinary nature of health
of results that are to be achieved, usually within a
system resilience, targets should be defined and
specified time frame, depending on the indicator type
monitored through a consultative and participatory
and other factors, including administrative level of
process involving a relevant and diverse range of
data collection (national, subnational, community
actors. Box 4 describes principles for defining targets,
or facility). Understanding the baseline and then
while Box 5 provides examples of illustrative targets
defining targets can enable end users such as national
that can enable an understanding of baselines and
and subnational authorities to determine whether
progress made towards attainment of targets.
progress is being made in line with population health
Box 4. Principles for consideration in defining targets for selected HSR indicators
Rational
Targets should be set based on best available evidence. International or national guidance and
recommendations (for example, International Health Regulations (2005) Monitoring and Evaluation
Framework, health system performance assessments) can also inform national and subnational targets
in relation to national identified priorities and lessons.
Measurable and specific

Targets should be described in a way that avoids ambiguity and subjective interpretation.
Achievable
Targets should be determined based on the current baseline of health system resilience, and gaps
between the baseline and goals.
Realistic
Setting realistic targets means being fair to the organizations, agencies or people who are accountable
for reaching them. It is important to ask for improvements in health systems and population health
outcomes in the scope that the government, organizations and health workers can actually influence,
with appropriate resources.
Time-bound
Targets should be achieved within a defined time frame as part of the commitment and accountability
mechanism. Progress towards health goals can be facilitated if organizations and people have a clear
sense of the timeline against which the progress is monitored and evaluated. Depending on the type
of indicator and contextual considerations, the targets can be defined as one off achievements or in a
progressive manner in relation to timelines (for example, a gradual increase in proportions). Examples
are given in Box 5 below.
Box 5. Examples of targets of HSR indicators

Indicator: Percentage of facilities offering services according to a nationally defined essential
health service package
Targets can be defined in terms of percentage of facilities offering a core set of services. For example, if
the baseline is “50% of facilities are offering the core package of services”, then the target can be set as
“75% of facilities are offering the core package of services by the end of the five-year strategy period”.
This can be measured at the national or subnational level. Alternatively, targets can be defined for
specific services or disease areas: for example, the target could be to increase the percentage of facilities
offering services for communicable disease prevention (for example, immunization) from 85% to 100%
by the end of the five-year strategy period.
Indicator: Designated team or focal persons for emergency management and service continuity in
health facility
Targets can be based on consideration of the following levels:
1. No team or focal persons for coordinating emergency management and service continuity available.
2. Team or focal persons for coordinating emergency management and service continuity is available
on an ad hoc basis.
3. Designated team or focal persons for coordinating emergency management and service continuity is
available with terms of reference specifying roles and responsibilities.
4. Designated team or focal persons for coordinating emergency management and service continuity is
available with terms of reference specifying roles and responsibilities, and have been tested through
simulation exercises.
5. Designated team or focal persons for coordinating emergency management and service continuity
is available with terms of reference specifying roles and responsibilities reviewed and updated on a
regular basis.
Indicator: Availability of national and subnational multisectoral structure for emergency
management with participation of all health service levels and health system resilience specified
as a core function
Targets can be based on consideration of the following levels:
1. Multisectoral structure for coordinated emergency management is not in place, under development
or occurs on an ad hoc basis.
2. Multisectoral structure for emergency management with terms of reference specifying participants,
roles and responsibilities is available at the national level.
3. Multisectoral structure for emergency management is available and terms of reference specify
health system resilience as a core function.
4. Multisectoral structure for emergency management with health system resilience as a core function
is available and specifies participation of all relevant stakeholders at all health service levels.
5. Multisectoral structure for emergency management is evaluated and updated on a regular basis.
d. Define and build capacity for measuring e. Collect and analyse information to measure
HSR indicators and monitor HSR indicators
After selecting HSR indicators and setting targets, Once the suite of indicators has been identified
it is necessary to determine whether the required and the capacity to measure indicators is ensured,
data can be collected from existing sources, with data and information can be collected from a
or without adaptation, or whether additional data broad range of sources, such as routine or ad hoc
collection will be required to address any critical data assessments, including facility assessments; clinical
gaps. The adaptation of indicators to measure and reporting systems; population-based surveys;
build resilience can support countries in sustainably national health accounts; health databases and
strengthening existing data monitoring systems, records; human resource, infrastructure or medical
while identifying opportunities to invest in innovative records; policy and planning data; civil registration
methods to collect data for new indicators. Capacity data; and others, depending on national and
building can be achieved by strengthening national subnational contexts. Results of data analysis should
and subnational qualitative key informant surveys, be reported and communicated to stakeholders
facility surveys, routine health information systems at all levels. The reporting process should include
and health management information systems, which clear and accessible visualization of findings, which
are the main recommended data sources for HSR can be utilized for decision-making and action.
indicators and other monitoring and evaluation Analysing data supports the discovery of insights
frameworks for health systems. This should also and transformation into knowledge of health system
involve investment in patient- and community-based performance and utilization. Communication of data
data systems (for example, regular patient surveys and results supports decision-making and action
or interviews, community assessments) to support for strengthening health system resilience to meet
the comprehensive assessment of health system population health needs. Countries could benefit
resilience from the community and population side from a resilience-dedicated dashboard page.
to ensure people-centeredness.
In section 4, data sources and existing data
Information on gaps and what is required should collection tools are suggested for each of the core
be fed into existing processes for strengthening HSR indicators. Data from different sources of data
capacities in data collection and analysis. This will collection can be pooled to formulate targeted
require consideration of data management in terms understanding or give a more comprehensive picture
of how data are created, stored, processed and of the resilience of the health system.
destroyed, as well as their confidentiality (where
applicable), availability and accessibility (that is, f. Utilize information for improvements
the availability of data to those who require and are In order for the chosen HSR indicators to build
authorized to access them). Ensuring the required health system resilience they must be systematically
capacities in data quality, analysis and communication applied to drive performance improvements. To
goes hand in hand with strengthening data support this, the data and information collected
collection mechanisms. Good-quality data enable should be linked with and integrated within wider
better interpretation of the results of analyses and national health sector and allied or related planning
have greater utility for performance improvement, – for example, national action plans for health
thereby strengthening the data capacities of health security or antimicrobial resistance plans – to ensure
ministry officials, public health institutes, national their utility and to guide more targeted interventions
statistics offices, district and facility managers, for building health system resilience and achieving
health professionals, health analysts, and individual universal health coverage, health security and
providers (public and private). healthier populations. Progress towards targets
should be reviewed regularly, making adjustments to
the indicator set as appropriate. These adjustments
may include adding additional resilience indicators
to support a more targeted focus on a specific area
of weakness or deleting indicators that are no longer
useful to inform planning or improvements. This
supports the continual process of building health
system resilience and is reflective of the learning
aspect of resilient health systems.
include information such as the short and long

2.2 Using the technical specifications names of the indicator for ease of identification;
or metadata definitions (including details on the criteria or
attributes needed to measure the indicator); the
To support the step-by-step approach to using
rationale; administrative or service level and
the package of HSR indicators, in section 4,
potential disaggregation of the data; numerator
technical specifications are provided for each
and denominator (if applicable); recommended
of the 64 proposed core HSR indicators. Table 1
data sources; and available data collection tools if
provides a summary overview of the structure of
and where relevant. Explanations for the technical
the technical specifications (or metadata). These
specifications are provided in Table 1.
Table 1. Structure of technical specifications (metadata) for indicators, with explanations of

information provided for each indicator in this package
Metadata Explanation of information provided
Indicator short name Contains the indicator’s short name.
Indicator name Contains the indicator’s full name.
Domain Categorizes the indicator according to the WHO health system

framework; where indicators are considered cross-cutting, the primary
building block or function is in bold.
Definitiona Defines and provides further information and criteria to measure the
indicator.
May include relation with the PHCMFI indicators.
Rationale Provides the reason for and importance of this indicator for
measurement of health system resilience.
Level Designates for which level (facility, subnational or national) the data for
measuring the indicator are predominantly collected.
Disaggregation Describes the possible separation or disaggregation of compiled

information into smaller units.
Numerator If the indicator requires a calculation (common in percentage or

proportion indicators), the recommended numerator is stated.
Denominator If the indicator requires a calculation (common in percentage or

proportion indicators), the recommended denominator is stated.
Recommended data source Provides a recommendation for potential data sources that can be used
to measure the indicator.
Type (M&E domain) Categorizes the indicator on the input/structures–process–output

scale. For example, indicators related to building blocks such as
financing or workforce are typically a part of structures or inputs, and
service delivery indicators are usually processes and outputs.
Additional reading and references Provides recommended additional reading and key references used to
select or develop the indicator.
Existing data collection tools Describes existing data collection tools that can be used to measure
this indicator.
a. For HSR indicators that have close alignment with the PHCMFI, the table includes information on the corresponding PHCMFI indicator number for ease
of referral.
3
Health system
3. Health system resilience indicators 15
3.1 Overview
This section contains the list of HSR indicators,
which build on globally and regionally established
frameworks for health system strengthening,
primary health care, universal health coverage
and health security (see section 6). The indicators
represent the critical elements health systems
require to be functional during regular times, as well
as when the health system is undergoing more acute
or large-scale shocks and stressors. In this package,
the indicators are broadly organized according to the
health system building blocks domain with reference
to the essential public health functions, as well as
the administrative level (Table 2). Many indicators
are associated with more than one building block or
function due to the cross-cutting nature of health
system resilience.
Health system resilience indicators: an integrated package for measuring and monitoring health system resilience in countries
3.2 Summary list
Table 2. Summary list of core HSR indicators with primary domain measured
No. Main domain Indicator short name Levela
National Subnational Facility
1. Service delivery % facilities offering services according to nationally defined service package ✓
2. Service delivery % facilities conducted simulation exercise ✓
3. Service delivery % facilities conducted after- or intra-action reviews ✓
4. Service delivery % facilities that closed/discontinued services ✓
5. Service delivery % facilities with specified Infection Prevention and Control Assessment Framework level/score ✓
6. Service delivery Collaboration between facility-based and community-based delivery ✓ ✓
7. Service delivery % facilities sharing practices and lessons ✓
8. Service delivery % facilities using community voice to inform service planning ✓
9. Service delivery % facilities providing outreach according to community needs ✓
10. Workforce % subnational health workers trained in community engagement ✓ ✓
11. Workforce % facilities with focal point for emergency management and service continuity ✓
12. Workforce Roster of rapid response teams available ✓ ✓
13. Workforce % facilities covered by occupational health services ✓
14. Workforce % facilities with staff having received health system resilience training ✓
15. Health information Current state of essential public health functions delivery ascertained ✓ ✓
16. Health information Mechanism in place to assess community trust ✓ ✓
17. Health information Comprehensive surveillance and response system ✓ ✓
16
Table 2 (continued). Summary list of core HSR indicators with primary domain measured
3. Health system resilience indicators

18. Health information Completeness of reporting by facilities ✓
19. Health information Health system resilience measured and monitored in routine health information system ✓ ✓
20. Health information % facilities with risk profiles ✓
21. Health information Early warning system established ✓ ✓
22. Health information Mechanism for multisectoral information sharing ✓ ✓
23. Health information Vulnerability and risk mapping conducted ✓
24. Access to medicines National list of essential medicines ✓

and other health
products and
technologies
25. Access to medicines Regulatory mechanisms for essential health products ✓ ✓

and other health
products and
technologies
26. Access to medicines % facilities with prepositioned essential supplies ✓

and other health
products and
technologies
27. Access to medicines Availability of essential medicines ✓

and other health
products and
technologies
17
28. Access to medicines % facilities experiencing water supply interruption ✓

and other health
products and
technologies
29. Access to medicines % facilities experiencing power outages ✓

and other health
products and
technologies
30. Access to medicines % facilities with basic WASH amenities ✓

and other health
products and
technologies
31. Health financing % facilities with user fee waiver mechanisms ✓
32. Health financing Mechanism to address financial barriers ✓ ✓
33. Health financing Dedicated budget line for service continuity ✓ ✓ ✓
34. Health financing Contingency funds available ✓ ✓
35. Health financing Contingency funds accessible to facilities ✓ ✓ ✓
36. Health financing Resource mapping conducted ✓ ✓
37. Health financing Public health services funded ✓ ✓
18
3. Health system resilience indicators

38. Governance Service package meeting criteria ✓ ✓
39. Governance Availability of protocol for prioritization of services ✓ ✓ ✓
40. Governance Availability of priority disease and event case management protocols ✓ ✓ ✓
41. Governance System for conducting simulation exercises ✓ ✓
42. Governance % facilities part of collaborative networks ✓
43. Governance All-hazards emergency preparedness and response plan defines role of health services ✓ ✓
44. Governance % facilities with emergency management plans incorporating service continuity ✓
45. Governance % facilities with plans or service delivery models for hard-to-reach populations ✓
46. Governance Health facility infrastructure standards for health facility resilience ✓ ✓
47. Governance % facilities that meet standards for infrastructure ✓
48. Governance Mechanism for multistakeholder participation and community engagement ✓ ✓
49. Governance Mechanism to ensure community engagement in service planning and organization ✓ ✓
50. Governance % facilities with standard operating procedures for ensuring essential supplies ✓
51. Governance % facilities with standard operating procedures for repurposing resources ✓
52. Governance Institutionalizing learning from public health events ✓ ✓
53. Governance Health system resilience as a function in emergency management structure ✓ ✓
54. Governance Emergency policy defines role of health services ✓
55. Governance Health sector policy defines roles of health services for emergencies ✓
19
56. Governance Health sector plan includes preparedness activities ✓ ✓
57. Governance Designated entity or structure for health system resilience ✓ ✓
58. Governance Guideline on equity and ethics for service delivery ✓
59. Governance Institutional capacity for essential public health functions coordination ✓ ✓
60. Governance Focal point designated for IHR health services provision assessment ✓
61. Governance Health in All Policies approach being implemented ✓
62. Governance Recovery planning guidance ✓ ✓
63. Governance Designated authority with responsibility for recovery ✓ ✓
64. Composite IHR SPAR health services provision capacity score ✓

a. “Level” refers to the level at which data are generated and collected. Definitions for indicators can be adapted to be applicable to different levels.
20
4
Health system
with metadata
This section provides the metadata and technical

specifications for the 64 recommended health
system resilience indicators.
4. Health system resilience indicators with metadata 23
4.1 Service delivery
Indicator 1. Percentage of facilities offering services according to nationally defined essential

health service package for their level of care
Indicator short name % facilities offering services according to nationally defined service package
Indicator name Percentage of facilities offering services according to nationally defined essential
health service package for their level of care
Domain Service delivery; Governance and leadership
Definition Service package of essential health services (including primary care services) and
public health functions is developed and meets following criteria:
• Addresses comprehensive essential individual and population health services,
including:
– Health protection
– Prevention
– Promotion
– Management (diagnosis, treatment, rehabilitation, resuscitation)
– Palliation
• Includes key life course needs and disease programs:
– Foundations of care management of emergency syndromes and common pres-
entations in primary care
– Reproductive and sexual health, including pregnancy, childbirth and family plan-
ning
– Growth, development, disability and ageing
– Communicable diseases
– Noncommunicable diseases
– Mental health, neurological and substance use disorders
– Violence and injury
• The package addresses disease burden and other national priorities, including risk
factor profiles and projections
• The process for development of the service package involves a wide range of
stakeholders
• The package is based on an evaluation of existing resources
• The package is routinely revised as part of national planning processes
• The package includes and designates key services related to emergency events for
which the country is at risk
This indicator is in the Primary Health Care Measurement Framework and Indicators
(2022) [indicator 66].
Rationale Availability of health services should be aligned with a country’s defined package of
essential health services. This measures the availability of individual and public health
services in the relevant health care settings (for example, primary care, hospital,
and long-term care). It indicates the functionality and everyday resilience of the
health system for delivering services required to meet population health needs, also
considering the public health landscape, including risk profile. Where the minimum
health services are routinely unavailable, they are even more unlikely to be provided
as needed in times of crisis.
Level Facility
Indicator 1 (continued). Percentage of facilities offering services according to nationally defined

essential health service package for their level of care
Disaggregation Facility type (as relevant to context): including primary care facilities (for example,
general practitioner practices, health centres, community health posts), first-level
hospitals, second-level hospitals, specialty hospitals, long-term care facilities,
continuing care facilities
Managing authority: public, private
Subnational (as relevant to context): region, state, province, canton, municipality, or
other
National
Urban/rural
Numerator Number of facilities offering the total package of core services; number of facilities
offering each service
Denominator Total number of facilities examined
Recommended data Facility survey or facility census or routine health information system
source
Type (M&E domain) Output
Additional reading World Health Organization. 2021. 21st century health challenges: can the essential
public health functions make a difference? Discussion paper. Geneva:
WHO (https://apps.who.int/iris/handle/10665/351510)
World Health Organization. 2021. UHC compendium: health interventions for universal
health coverage. Geneva: WHO (https://www.who.int/universal-health-coverage/
compendium)
World Health Organization and United Nations Children’s Fund (UNICEF). 2022.
Primary health care measurement framework and indicators: monitoring health
systems through a primary health care lens. Web annex: technical specifications.
Geneva: WHO and UNICEF (https://apps.who.int/iris/handle/10665/352201)
Existing data From existing health facility survey tools such as WHO’s Service Availability and
collection tools Readiness Assessment (SARA) and Harmonized Health Facility Assessment (HHFA),
and the Demographic and Health Surveys (DHS) Program’s Service Provision
Assessment (SPA):
World Health Organization. Service Availability and Readiness Assessment
(https://www.who.int/data/data-collection-tools/service-availability-and-readiness-
assessment-(sara))
World Health Organization. 2023. Harmonized Health Facility Assessment. Geneva:
WHO (https://www.who.int/data/data-collection-tools/harmonized-health-facility-
assessment/introduction)
DHS Program. Service Provision Assessment, May 2022 (https://dhsprogram.com/
publications/publication-spaq8-spa-questionnaires-and-manuals.cfm)
Indicator 2. Percentage of health facilities that participated in a simulation exercise to test health
system resilience within the last year
Indicator short name % facilities conducted simulation exercise
Indicator name Percentage of health facilities that participated in a simulation exercise to test
health system resilience within the last year
Domain Service delivery
Definition The percentage of health facilities (for example, in a geographical area or within
a network of health facilities) that have participated in a simulation exercise that
specifically tests health system resilience within the last year
This indicator is included as one of the attributes of indicator 61 in the Primary Health
Care Measurement Framework and Indicators (2022 version)
Rationale In addition to simulation exercises conducted at the national or subnational/

regional level, it is important to conduct simulated interactive exercises to test
the capability of health facilities or groups of health facilities with inter- and
multidisciplinary participation as well as with a variety of stakeholders, such as the
community the health facility serves.
Much like simulation exercises conducted specifically to test emergency
preparedness and response capacities, regular and routine participation in
simulation exercises with a focus on health system resilience can facilitate learning
and improvement of services and systems, which can contribute to enhanced
maintenance of essential health services in all contexts as well as emergency
preparedness and response.
Level Facility
general practitioner practices, health centres, community health posts), first-level
continuing care facilities
Subnational (as relevant to context): region, state, province, canton, municipality,
or other
National
Urban/rural
Numerator Number of health facilities that have participated in a simulation exercise to test
health system resilience in the last year
Denominator Total number of health facilities assessed in the last year
Recommended data Facility survey

source
Type (M&E domain) Process

Indicator 2 (continued). Percentage of health facilities that participated in a simulation exercise to

test health system resilience within the last year
Additional reading World Health Organization. 2021. Health systems resilience simulation exercises.
Geneva: WHO (https://www.who.int/teams/primary-health-care/health-systems-
resilience/integrated-health-system-strengthening/health-systems-resilience-
simulation-exercises)
World Health Organization, Pan American Health Organization. 2011. Guidelines
for developing emergency simulations and drills. Area on Emergency Preparedness
and Disaster Relief. Washington, D.C.: WHO, PAHO
World Health Organization Regional Office for South-East Asia. 2006. A guide for
conducting table-top exercises for national influenza pandemic preparedness.
New Delhi: WHO Regional Office for South-East Asia (https://iris.who.int/
handle/10665/204728)
World Health Organization Regional Office for the Western Pacific. 2006. Creating
and tracking pandemic preparedness plans: a guide. Manila: WHO Regional Office
for the Western Pacific
World Health Organization Regional Office for the Western Pacific. 2006. Exercise
development guide for validating influenza pandemic preparedness plans. Manila:
WHO Regional Office for the Western Pacific
Existing data collection Not at present but existing routine health information systems or health facility
tools assessments and tools could be adapted to incorporate collection of these data
Indicator 3. Percentage of health facilities that have conducted or participated in after-action

reviews (AAR) and/or intra-action reviews (IAR) that evaluated health system performance
including maintenance of essential health services in the last year
Indicator short name % facilities conducted after- or intra-action reviews
Indicator name Percentage of health facilities that have conducted or participated in after-action
reviews (AAR) and/or intra-action reviews (IAR) that evaluated health system
performance including maintenance of essential health services in the last year
Definition The percentage of health facilities (for example, in a geographical area or within a
network of health facilities) that have either conducted, or participated in, after-
action reviews (AAR) and/or intra-action reviews (IAR) that evaluate health system
performance including maintenance of essential health services in the last year
Rationale AARs and IARs are qualitative reviews of actions usually taken in response to an
event of public health concern as a means of identifying best practices, gaps, and
challenges. AARs are usually conducted after an event whereas IARs can be conducted
during response to an event. They can enable identification of actions that need to be
implemented immediately to ensure better preparation for the next or future events as
well as more medium- and long-term actions needed to strengthen the health system.
Regular participation of facilities in AARs and IARs which specifically evaluate health
systems performance including maintenance of essential health services can enhance
emergency preparedness, response, and recovery as well as build health systems
resilience in the short, medium, and longer term. Learning and improving health
systems performance through experience is a key capacity of resilient health systems.
Level Facility
general practices, health centres, community health posts), first-level hospitals,
second-level hospitals, specialty hospitals, long-term care facilities, continuing care
facilities, etc.
Subnational
Urban/rural
Numerator Number of health facilities that have conducted or participated in AARs and/or IARs
that evaluated health system performance including maintenance of essential health
services in the last year

source
Additional reading World Health Organization. 2019. Guidance for after action review (AAR). Geneva: WHO
and references (https://www.who.int/publications/i/item/WHO-WHE-CPI-2019.4)
World Health Organization. 2020. Guidance for conducting a country COVID-19 intra-
action review (IAR). Geneva: WHO (https://www.who.int/publications/i/item/WHO-
2019-nCoV-Country_IAR-2020.1)
Existing data Not at present but existing routine health information systems or health facility
collection tools assessments and tools could be adapted to incorporate collection of this data
Indicator 4. Percentage of health facilities that were closed or discontinued routine health services
(completely or partially for one day or more) in the last year
Indicator short name % facilities closed or discontinued services
Indicator name Percentage of health facilities that were closed or discontinued routine health services
(completely or partially for one day or more) in the last year
Definition The percentage of health facilities (for example, in a geographical area or within a
network of health facilities) that were closed or discontinued delivery of routine and/
or essential health services (completely or partially for any duration) in the last year
Rationale The maintenance of routine and essential health services can suffer from health
facility closures due to unexpected public health events (such as infectious disease
outbreaks, chemical, radiological, or nuclear events, or natural disasters) or routine
health system stressors (such as staff unavailability, economic downturn, changes in
policy, planning and organization of service delivery).
Understanding the proportion of health facilities that are closed or that discontinued
routine and essential health services can enable greater understanding of the extent
of disruptions to routine functionality and resilience of the health system.
Level Facility
facilities, etc.
Subnational
Urban/rural
Numerator Number of health facilities that were closed or discontinued health services in the
last year
Recommended data Routine health information system (master facility list)

source Key informant interviews at a subnational administrative office
(for example district office)

Indicator 4 (continued). Percentage of health facilities that were closed or discontinued routine
health services (completely or partially for one day or more) in the last year
Additional reading Barnard M, Mark S, Greer SL, Trump BD, Linkov I, Jarman H. Defining and analyzing
and references health system resilience in rural jurisdictions. Environ Syst Decis. 2022;42(3):362-371.
doi: 10.1007/s10669-022-09876-w.
Fleming P, O’Donoghue C, Almirall-Sanchez A, Mockler D, Keegan C, Cylus J et al.
Metrics and indicators used to assess health system resilience in response to shocks
to health systems in high income countries-A systematic review. Health Policy. 2022
Dec;126(12):1195-1205. doi: 10.1016/j.healthpol.2022.10.001.
World Health Organization. 2021. Continuity of essential health services: facility
assessment tool: a module from the suite of health service capacity assessments in
the context of the COVID-19 pandemic: interim guidance, 12 May 2021. Geneva: WHO
(https://apps.who.int/iris/handle/10665/341306)
World Health Organization. 2021. Health service continuity planning for public health
emergencies: a handbook for health facilities. Interim version for field testing. Geneva:
WHO (https://www.who.int/publications/i/item/9789240033337)
Existing data Robust and up-to-date master facility lists should have this information available. No
collection tools specific data collection tool is necessary. Otherwise, a more manual process of going
through the facility list with the district office can show what health facilities have
closed/open in the last year.
Indicator 5. Percentage of facilities that meet specified Infection Prevention and Control
Assessment Framework (IPCAF) level/score
Indicator short name % facilities with specified Infection Prevention and Control Assessment Framework
level/score
Indicator name Percentage of facilities that meet specified Infection Prevention and Control
Domain Service delivery; Governance and leadership; Health infrastructure
Definition The Infection Prevention and Control Assessment Framework (IPCAF) at the facility
level is a tool to support implementation of WHO guidelines on core components of
Infection Prevention and Control (IPC) programs such as:
• IPC programs
• IPC guidelines
• IPC education and training
• Healthcare-associated (HAI) surveillance
• Multimodal strategies for implementation of IPC
• Monitoring/audit of IPC practices and feedback
• Workload, staffing and bed occupancy
• Built environment, materials and equipment for IPC
Through a structured, close-formatted questionnaire and associated scoring
system, the IPCAF can assess the current IPC situation in a facility. The score can be
interpreted and used to determine the assigned “IPC level” in a facility as inadequate,
basic, intermediate or advanced.
This indicator is in Primary Health Care Measurement Framework and Indicators (2022
version) [indicator 69].
Rationale Resilient health facilities and systems implement strong IPC measures including
implementation of IPC programs and guidelines, standardized protocols, staff
training, HAI surveillance, monitoring and evaluation, bed occupancy, and built
environment considerations. Strong IPC measures prevent infection, re-infection and
transmission of disease, alleviating pressure on the health system and preventing
larger scale outbreaks. The IPC score as defined by the IPCAF can also provide an
indication as to the level of progress needed from an improvement perspective which
is a key capacity of resilient health systems.
Level Facility
facilities, temporary health facilities, etc.)
Subnational (as relevant to context): region, state, province, canton, municipality, etc.
Urban/rural
Numerator Number of facilities by IPC level (inadequate, basic, intermediate, or advanced)
Denominator Total number of facilities assessed

source Self-assessment; joint assessment (for example, with facility staff, ministries of health,
WHO or other stakeholders); external assessors
Indicator 5 (continued). Percentage of facilities that meet specified Infection Prevention and Control
Type (M&E domain) Input and structure
Additional reading World Health Organization. 2016. WHO Guidelines on core components of IPC
and references programmes at the national and acute health care facility level. Geneva:
WHO (http://www.who.int/infection-prevention/publications/core-components/en/)
World Health Organization. 2018. Infection prevention and control assessment
framework at the facility level. Geneva: WHO (https://www.who.int/publications/i/
item/WHO-HIS-SDS-2018.9)
Existing data World Health Organization. 2018. Infection prevention and control assessment
collection tools framework at the facility level. Geneva: WHO (https://www.who.int/publications/i/
item/WHO-HIS-SDS-2018.9)
Indicator 6. Existence of formal linkages between facility-based and community-based

service delivery
Indicator short name Collaboration between facility-based and community-based service delivery
Indicator name Existence of formal linkages between facility-based and community-based

service delivery
Domain Service delivery; Governance and leadership; Workforce
Definition Facility level:

Percentage of primary care and first referral hospitals within a defined catchment
area that have established formal linkages with community-based service providers,
including community health workers (CHWs). These linkages may include:
• Community-based providers are integrated in the facility management structures,
facility teams, and data systems;
• Supportive supervision and training opportunities are made available by primary-
care facility to the community-based service providers;
• Other formal mechanisms of clinical decision support provided by the facility to
community service providers;
• Shared protocols for two-way referral of patients between the facility and
community-based providers and receive referrals from community-based providers.
Qualitative measurement at aggregate levels
(for example, national/subnational):
Evidence for formal linkages can be defined as either clear national or regional
guidelines that define the roles between the different service delivery platforms or
written agreements that formalize this relationship locally.
This indicator is in Primary Health Care Measurement Framework and Indicators
(2022 version) [indicator 56].
Rationale Creating sustainable, effective linkages between facilities and community settings
can improve people’s use of promotion and preventive services, their timely access
to facility-based services and their adherence to treatment. These positive outcomes
are achieved when community-based service providers are trusted by the community
they serve and by facility-based providers and when they are partnering to ensure
continuity of care and improved clinical quality (i.e., through training or formative
supervision). In addition, community-based providers have a role to alert facility-
based providers of public health issues and help carry the voice of the people they
serve to improve responsiveness of primary care services. They can act as an effective
broker between communities and district or facility managers. These linkages
connect clinical providers, community organizations, and public health agencies.
Strong linkages between different providers enhance continuity of care and enables
and promotes integrated, people-centred health services attuned to the needs of the
community. Integrated delivery of essential health services builds resilience in the
system through enhancing the patient experience and community trust in the health
system and reducing inefficiencies and errors.
Level National; subnational
Disaggregation Subnational (as relevant to context): region, state, province, canton, municipality, etc.
Urban/rural
Numerator N/A
Denominator N/A
Indicator 6 (continued). Existence of formal linkages between facility-based and community-based

service delivery

source Qualitative key informant survey and/or desk review with verification from key
country documents such as national, subnational polices, plans, and guidance
Additional reading McIntyre H, Reeves V, Loughhead M, Hayes L, Procter N. Communication pathways

and references from the emergency department to community mental health services: A systematic
review. Int J Ment Health Nurs. 2022 Dec;31(6):1282-1299. doi: 10.1111/inm.13024
World Health Organization. 2017. WHO community engagement framework for quality,
people-centred and resilient health services. Geneva: WHO (https://apps.who.int/iris/
handle/10665/259280)
Existing data World Health Organization. 2012. African partnerships for patient safety: patient
collection tools safety situational analysis (Long form). Geneva: WHO (https://apps.who.int/iris/
handle/10665/330052)
WHO is currently revising its facility survey modules to incorporate and address
primary health care specific elements.
Indicator 7. Percentage of health facilities that participate in a platform to share good practices
and lessons learned from public health challenges (including emergencies)
Indicator short name % facilities sharing practices and lessons
Indicator name Percentage of health facilities that participate in a platform to share good practices
and lessons learned from public health challenges (including emergencies)
Domain Service delivery; Governance and leadership
Definition The proportion of health facilities surveyed that participates in a platform through
which good practices and lessons learned from public health challenges (for
example, public health emergencies, public health incidents, everyday operations)
from local contexts and beyond are shared
Examples of platform to share good practices and lessons include regular regional
meetings, network of health facilities, communication or reporting channels with
the function to collect and disseminate good practices and lessons among health
facilities and other stakeholders, designated online platform to disseminate good
practices and lessons, etc.
Rationale Learning from past lessons and good practices for health facility and service
improvement is an important capacity of resilient health system which enables
them to adapt, transform and better respond to health threats while maintaining
core functions.
Level Facility
second-level hospitals, specialty hospitals, long-term care facilities, continuing
care facilities, temporary health facilities, etc.
Subnational (as relevant to context): region, state, province, canton,
municipality, etc.
Local catchment areas
Urban/rural
Numerator Number of health facilities that participate in the platform
Denominator Total number of health facilities assessed

source
Additional reading and World Health Organization. 2021. Building health systems resilience for
references universal health coverage and health security during the COVID-19 pandemic
and beyond: WHO position paper. Geneva: WHO (https://apps.who.int/iris/
handle/10665/346515)
Existing data collection Not at present

tools
Indicator 8. Percentage of facilities that use community health needs and priorities to inform
service prioritization
Indicator short name % facilities using community voice to inform service planning
Indicator name Percentage of facilities that use community health needs and priorities to inform
service prioritization
Domain Services delivery
Definition There is evidence that health facilities service planning and organization is
informed by community health needs and priorities as identified through, but not
limited to, the following activities:
• community health needs and asset assessments or equivalent
• participatory processes for priority setting
• patients and relatives’ surveys
• training of patient advocates
• membership of community representatives in advisory board at the local level or
in supervisory boards of facilities
Rationale Providing services to communities aligned with local health needs and priorities
ensure the most effective support for those greatest in need. Responding to local
needs and priorities provides an opportunity for health facilities to improve health
outcomes within a population and groups with specific health needs, or within a
specific geographical area, such as exposure to a specific environmental hazard,
or infectious disease outbreaks in a particular group of schools. It also builds trust
between the community and health providers.
Level Facility
care facilities, etc.
Subnational
Urban/rural
Numerator Number of facilities that provide services to communities according to local health
needs and priorities

source

Indicator 8 (continued). Percentage of facilities that use community health needs and priorities to
inform service prioritization
Additional reading and Centers for Disease Control and Prevention (CDC). 2022. Community Health
references Assessments & Health Improvement Plans. Atlanta: CDC (https://www.cdc.gov/
publichealthgateway/cha/plan.html)
Schmets G, Rajan D, Kadandale S, editors. 2016. Strategizing national health
in the 21st century: a handbook. Geneva: WHO (https://apps.who.int/iris/
handle/10665/250221)
World Health Organization Regional Office for Europe. 2001. Community Health
Needs Assessment: An introductory guide for the family health nurse in Europe.
Copenhagen: WHO Regional Office for Europe (https://www.euro.who.int/__data/
assets/pdf_file/0018/102249/E73494.pdf)
Existing data collection From existing health facility survey tools such as WHO’s Service Availability and
tools Readiness Assessment (SARA) and Harmonized Health Facility Assessment (HHFA),
Assessment (SPA):
DHS Program. 2022. Service Provision Assessment, May 2022 (https://dhsprogram.
com/publications/publication-spaq8-spa-questionnaires-and-manuals.cfm)
World Health Organization. Service Availability and Readiness Assessment
(https://www.who.int/data/data-collection-tools/service-availability-and-
readiness-assessment-(sara))
Indicator 9. Percentage of facilities providing outreach according to community needs
Indicator short name % facilities providing outreach according to community needs
Indicator name Percentage of facilities providing outreach according to communities needs
Domain Services delivery
Definition Percentage of facilities that provide community outreach services based on local
needs and priorities, informed by the following (not exhaustive):
Community health needs and asset assessment or equivalent
Participatory processes for priority setting at local levels
Patient and relatives’ surveys
Rationale Community outreach services increase the range and effectiveness of health services,
including protective and promotive services. Outreach services are often targeted at
the most vulnerable and can overcome access issues, increasing engagement among
this population group. Ensuring the involvement of communities in planning and
organization of health services, including outreach services, orients local providers
to the needs of all those in the community, including the most vulnerable, promotes
trust and increases accessibility of services. This advances UHC and supports uptake
of services including preventive and promotive services while also promoting
compliance with public health advice during emergencies.
Level Facility
Disaggregation Facility type (as relevant to context); including primary care facilities (for example,
general practices, health centres, community health posts), first level hospitals,
second-level hospitals, specialty hospitals, long term care facilities, continuing care
facilities, etc.)
Urban/rural
Numerator Number of facilities where outreach services are informed by local need
Recommended data Qualitative assessment based on interview with key informant and/or desk review of
source country documents

Indicator 9 (continued). Percentage of facilities providing outreach according to community needs
Additional reading Primary Health Care Performance Initiative. 2019. Primary Health Care Progression
and references Model Assessment Tool (measure 26 – community engagement) (https://
improvingphc.org/sites/default/files/PHC-Progression%20Model%202019-04-04_
FINAL.pdf)
handle/10665/259280)
World Health Organization. 2021. Voice, agency, empowerment: handbook on social
participation for universal health coverage. Geneva: WHO (https://www.who.int/
publications/i/item/9789240027794)
World Health Organization Regional Office for Europe. 2019. Indicator passport - WHO
European Primary Health Care, Impact, Performance and Capacity Tool. Copenhagen:
WHO Regional Office for Europe (https://iris.who.int/handle/10665/346478)
Existing data World Health Organization. 2020. Community Engagement: A health promotion guide
collection tools for universal health coverage in the hands of the people. Geneva: WHO (https://www.
who.int/publications/i/item/9789240010529)
4.2 Health workforce
Indicator 10. Percentage of health workers at subnational (for example, district) and primary care
levels trained in community engagement and risk communication
Indicator short name % subnational health workers trained in community engagement
Indicator name Percentage of health workers at subnational (for example, district) and primary
care levels trained in community engagement and risk communication
Domain Health workforce; Community engagement
Definition At the facility level:

Percentage of facilities with at least one health worker that has completed training
in community engagement and risk communication within the last 5 years that
includes but is not limited to:
• Communication skills
• Management of information (for example related to an emergencies)
• Authentic engagement
• Cultural responsiveness and adaptation
• Collaboration
• Advancing equity
• Using the principles of crisis and risk communication
At the health worker level:
Percentage of health workers that have undergone training in community
engagement and risk communication meeting criteria defined above.
Rationale Health workers at the primary care level are often the first point-of-contact
between communities and the health system. Engaging communities and being
able to effectively communicate risk is an important role of health workers as part
of emergency preparedness and response, and maintenance of essential
health services.
Level Subnational; facility
Disaggregation No disaggregation for key informant qualitative assessments

Facility surveys:
Facility type (as relevant to context): including primary care facilities (for example,
second level hospitals, etc.)
Sub-national
Urban/rural
Health worker surveys:
by health worker type (as relevant to context)
Numerator No numerator for key informant qualitative assessments

Facility level assessments: Number of facilities that have at least one health worker
that has been trained in community engagement and risk communication
Health worker survey: Number of health workers trained in community
engagement and risk communication
Indicator 10 (continued). Percentage of health workers at subnational (for example, district) and
primary care levels trained in community engagement and risk communication
Denominator No denominator for key informant qualitative assessments

Facility level assessments: Total number of facilities
Health worker survey: Total number of health workers assessed
Recommended Qualitative key informant survey and/or desk review with verification from key
data source country documents such as national, subnational polices, plans, and guidance
Facility-level reviews or surveys
Health worker survey
Additional reading and World Health Organization. 2017. Communicating risk in public health
references emergencies: a WHO guideline for emergency risk communication (ERC) policy and
practice. Geneva: WHO (https://www.who.int/publications/i/item/9789241550208)
World Health Organization. 2017. WHO community engagement framework for
quality, people-centred and resilient health services. Geneva: WHO (https://apps.
who.int/iris/handle/10665/259280)
World Health Organization. 2021. Voice, agency, empowerment: handbook on
social participation for universal health coverage. Geneva: WHO (https://www.who.
int/publications/i/item/9789240027794)
Existing data collection World Health Organization. 2022. Joint external evaluation tool: International
tools Health Regulations (2005) - third edition. Geneva: WHO (https://www.who.int/
Indicator 11. Percentage of facilities with a designated team or focal person(s) for emergency
management and service continuity
Indicator short name % facilities with focal point for emergency management & service continuity
Indicator name Percentage of facilities with a designated team or focal person(s) for emergency
management and service continuity
Domain Health workforce
Definition A designated team or focal person with terms of reference which include responsibility
for leading and coordinating emergency management and essential health services
continuity in a coordinated manner at the facility.
Rationale Experiences from public health emergencies and events highlight that coordination
structures and capabilities for emergency management and maintenance of essential
health services are less established at the subnational and facility level versus the
national level. The designation of a focal team or person with responsibility for
such functions can enhance their effectiveness, ensure their sustainability, enhance
accountability, and improve health outcomes.
Level Facility
general practitioner practice, health centres, community health posts), first-level
continuing care facilities, etc.)
Subnational
Urban/rural
Numerator Number of facilities with a designated team or focal person(s) for emergency
management

source
Additional reading Mustafa S, Zhang Y, Zibwowa Z, Seifeldin R, Ako-Egbe L, McDarby G, et al. COVID-19
and references Preparedness and Response Plans from 106 countries: a review from a health systems
resilience perspective. Health Policy Plan. 2022 Feb 8;37(2):255-268. doi: 10.1093/
heapol/czab089
World Health Organization. 2020. Maintaining essential health services: operational
guidance for the COVID-19 context: interim guidance, 1 June 2020. Geneva: WHO
(https://www.who.int/publications/i/item/WHO-2019-nCoV-essential_health_
services-2020.2)
Existing data World Health Organization. 2021. Continuity of essential health services: facility
collection tools assessment tool: a module from the suite of health service capacity assessments in
the context of the COVID-19 pandemic: interim guidance, 12 May 2021. Geneva:
WHO (https://apps.who.int/iris/handle/10665/341306)
Indicator 12. Functional, up to date (within the last 12 months) roster of a readily available
multidisciplinary rapid response team for emergency response and surge capacity in place
Indicator short name Roster of rapid response team available
Indicator name Functional, up to date (within the last 12 months) roster of a readily available
multidisciplinary rapid response team for emergency response and surge capacity
in place
Domain Health workforce; Governance and leadership
Definition Roster of rapid response team is readily available with the following criteria:
• Multidisciplinary (for example, surveillance officers, epidemiologists, public health
officers, clinicians, laboratory technicians, risk communication officers, point of
entry officers, social scientists, and other relevant disciplines to the context)
• Have technical knowledge and skills to investigate and rapidly respond to public
health emergencies such as infectious disease outbreaks
• Terms of references for emergency response and surge capacity
• Surge personnel includes other sectors (for example, chemical, radiation,
animal health)
• Terms of references for emergency response and surge capacity
Rationale Rapid response teams for emergency response and surge capacity enable effective
management of unexpected threats to health. Rapid response teams respond
to emergencies when and where they arise and can stop small scale events from
becoming larger scale emergencies or disasters.
Numerator N/A
Denominator N/A
Recommended data Qualitative key informant survey and/or desk review with verification from key country
source documents such as terms of reference/job descriptions of provincial/district rapid
response teams
Type (M&E domain) Input
Additional reading S Tweed, DE Stewart, E Hornsey, W Graham, Increasing role of Public Health Rapid
and references Response Teams in infectious disease outbreaks, European Journal of Public Health,
Volume 32, Issue Supplement_3, October 2022, ckac130.022, https://doi.org/10.1093/
eurpub/ckac130.022
World Health Organization. 2022. Joint external evaluation tool: International Health
Regulations (2005) - third edition. Geneva: WHO (https://www.who.int/publications/i/
item/9789240051980)
Existing data World Health Organization. 2022. Joint external evaluation tool: International Health
collection tools Regulations (2005) - third edition. Geneva: WHO (https://www.who.int/publications/i/
item/9789240051980)
Indicator 13. Percentage of facilities with access to or being covered by dedicated services for
occupational safety and health
Indicator short name % facilities covered by occupational health services
Indicator name Percentage of facilities with access to or being covered by dedicated services for
occupational safety and health
Domain Health workforce; Governance and leadership
Definition Percentage of faculties being covered by services for occupational safety and health
hazards, identified within their context (for example, occupational health, health and
safety services, including services for those health and social care workers affected by
public health emergencies or events, etc.). Arrangements for occupational safety and
health services established (for example, services in facility; services provided by local
health authorities) can be considered as facilities being covered.
Examples of risks includes (non-exhaustive):
• Harmful chemical and biological agents/substances
• Psychosocial risks and stress at work
• Electrical hazards
• Fire
• Accidents
• Noise
• Working in overcrowded spaces
• Failure of personal protective equipment
• Work overload
• Attacks on health workers
Rationale Ensuring the fundamental right to a safe and healthy working environment is essential
to prevent work-related accidents and diseases and protect and promote the health
and well-being of workers. Protecting health workers is key to ensuring the effective
delivery of quality and safe essential health services in all contexts and the resilience
of the health system.
Level Facility
general practice, health centres, community health posts), hospitals, temporary
health facilities, etc.
Subnational
Urban/rural
Numerator Number of facilities with access to or being covered by occupational safety and health
management systems and services

source
Additional reading International Labour Organization (ILO). Occupational Safety and Health Management
and references Systems. Geneva: ILO (https://www.ilo.org/safework/areasofwork/occupational-
safety-and-health-management-systems/lang--en/index.htm)
Existing data Currently not measured. It is to be included in forthcoming facility survey tools.
collection tools
Indicator 14. Percentage of facilities with personnel that have received training with a focus on
building health system resilience
Indicator short name % facilities with staff having received health system resilience training
Indicator name Percentage of facilities with personnel that have received training with a focus on
building health system resilience
Domain Health workforce
Definition At the facility level:

Percentage of facilities with at least one health worker that has completed training
in health systems or service resilience within the last 5 years (for example, WHO’s
integrated approach to building resilience, or other global actor’s resilience-
specific training).
The training should include (but is not limited to) the following contents:
Conceptual understanding of health systems resilience and linkages to other key
global health concepts (for example, universal health coverage, health security,
essential public health functions); identifying key stakeholders and their roles in
building health systems resilience; key actions required to build health systems
resilience (for example, service continuity planning, simulation exercises, post-
event reviews); monitoring and measuring of health systems resilience.
At the health worker level:
Percentage of health workers that have undergone training in health systems or
service resilience meeting criteria defined above.
Rationale To build and sustain health systems resilience, health workers require specific
training and orientation on the concept and its operationalization. To conduct key
health systems resilience building activities such as service continuity planning,
simulation exercise and post-event reviews, facilities require at least one member
of staff (preferably more) who has received dedicated training on building health
systems resilience and can apply it in decision making, and ensuing transfer of the
knowledge to others.
Level Facility
general practices, health centres, community health posts), hospitals, temporary
Subnational
Urban/rural
Numerator Number of facilities with personnel that have received training with a focus on
building health systems resilience

source
Additional reading and OpenWHO.org. An integrated approach to building health systems resilience.
references Geneva: WHO (https://openwho.org/courses/health-service-resilience)
tools assessments and tools could be adapted to incorporate collection of this data
4.3 Health information
Indicator 15. Current state of delivery of the essential public health functions (EPHFs) has been
ascertained
Indicator short name Current state of essential public health functions delivery ascertained
Indicator name Current state of delivery of the essential public health functions (EPHFs) has been
ascertained
Domain Health Information; Governance and leadership
Definition There is evidence that the current state of EPHFs delivery has been comprehensively
reviewed/assessed and documented, for example, within the last 5 years.
The review of EPHFs should consider the areas:
If the list of EPHFs has been prioritized based on national context including population
health needs and health system risks
• If EPHFs are considered and integrated into broader national health and allied
sectors’ planning, policies, strategies or plans (for example, health workforce,
water, sanitation and hygiene (WASH), health protection, health promotion, disease
prevention, antimicrobial resistance (AMR))
• If the coordination mechanism(s) for the delivery of the essential public health
functions has been reviewed
• If there are mechanism(s) for monitoring and evaluation of essential public health
functions at the national level. Mechanisms can be in the form of periodic qualitative
review of EPHFs, a part of wider routine health system monitoring and evaluation
framework, government audit of delivery of EPHFs, intersectoral etc.
• If monitoring and evaluation for EPHFs is linked to follow-up planning and actions on
findings from monitoring and evaluation
WHO lists 12 EPHFs (please see below), as a minimum requirement for Member States
to assure public health in a holistic, integrated, and sustainable manner. Countries
may utilize this list, or the lists suggested by other global and regional entities, or
develop their own list based on global consensus on EPHFs and reflective of their
population health needs.
• Public health surveillance and monitoring: Monitoring and surveillance of
population health status, risk, protective and promotive factors, threats to health,
and health system performance and service utilization
• Public health emergency management: Managing public health emergencies for
international and national health security
• Public health stewardship: Establishing effective public health institutional
structures, leadership, coordination, accountability, regulations and laws
• Multisectoral planning, financing and management for public health:
Supporting effective and efficient health systems and multisectoral planning,
financing and management for public health
• Health protection: Protecting populations against health threats, for example,
environmental and occupational hazards and communicable and noncommunicable
diseases, including mental health conditions, food insecurity, and chemical and
radiation hazards
• Disease prevention and early detection: Prevention and early detection
of communicable and noncommunicable diseases, including mental health
conditions and injuries
• Health promotion: Promoting health and well-being as well as actions to address
the wider determinants of health and inequity
Indicator 15 (continued). Current state of delivery of the essential public health functions (EPHFs)
has been ascertained
Definition • Community engagement and social participation: Strengthening community

engagement, participation and social mobilization for health and well-being
• Public health workforce development: Developing and maintaining an adequate
and competent public health workforce
• Health service quality and equity: Improving appropriateness, quality and equity
in provision of and access to health services
• Public health research, evaluation and knowledge: Advancing public health
research and knowledge development
• Access to and utilization of health products, supplies, equipment and
technologies: Promoting equitable access to and rational use of safe, effective and
quality-assured health products, supplies, equipment and technologies
Rationale Providing and maintaining EPHFs is a cornerstone for public health and resilient
systems. EPHFs are acknowledged as a cost-effective and efficient means for
advancing universal health coverage (UHC), other health-related targets of the United
Nations Sustainable Development Goals (SDGs), and health security.
The COVID-19 pandemic, climate-related threats, conflicts and other public health
challenges have exposed weaknesses in the public health capacities necessary
for resilient health systems. Routine, proactive public health activities have been
chronically under-prioritized, in terms of investment and stakeholder action,
compared with hospital-based health care and disease-specific interventions. In
addition, there has been a fragmented approach to public health capacities building
and a disproportionate focus on responding to crises – to the detriment of long-term
measures including health promotion and disease prevention. These have left health
systems and populations vulnerable to public health threats.
Applying the EPHFs can enable a comprehensive and integrated operational approach
to public health. Current state of EPHFs delivery and consideration of EPHFs in health
and allied sectors being ascertained at national and subnational level indicates
the government’s commitments and efforts to applying and strengthening EPHFs.
Moreover, understanding the current state of EPHFs delivery can help identify
strengths, critical gaps and key areas for improvement. Ascertaining the consideration
of EPHFs in health and allied sectors at national and subnational level provides
evidence that national and subnational governments applies an integrated approach
to public health capacities strengthening for resilient health systems.
Disaggregation Subnational
Numerator N/A
Denominator N/A
source documents such as national, subnational polices, plans, and guidance

Indicator 15 (continued). Current state of delivery of the essential public health functions (EPHFs)
has been ascertained
Additional reading Pan American Health Organization, Centers for Disease Control and Prevention, and
and references Centro Latino Americano de Investigación en Sistemas de Salud. 2001. Public health
in the Americas: Instrument for Performance Measurement of Essential Public Health
Functions. Washington, D.C.: WHO, PAHO (https://iris.paho.org/handle/10665.2/42814)
World Health Organization. 2018. Essential public health functions, health systems
and health security: developing conceptual clarity and a WHO roadmap for action.
Geneva: WHO (https://apps.who.int/iris/handle/10665/272597)
World Health Organization. 2021. 21st century health challenges: can the essential
public health functions make a difference?: discussion paper. Geneva: WHO
World Health Organization. 2023. Application of the essential public health functions:
an integrated and comprehensive approach to public health. Geneva: WHO.
World Health Organization Regional Office for Europe. 2015. Self-assessment tool
for the evaluation of essential public health operations in the WHO European
Region. Copenhagen: WHO Regional Office for Europe (https://apps.who.int/iris/
handle/10665/344398)
World Health Organization Regional Office for the Easter Mediterranean. 2017.
Assessment of essential public health functions in countries of the Eastern
Mediterranean Region. Assessment tool. Cairo: WHO Regional Office for the Eastern
Mediterranean (https://apps.who.int/iris/handle/10665/254383)
Existing data Not at present

collection tools
Indicator 16. Mechanism in place to assess community trust
Indicator short name Mechanism in place to assess community trust
Indicator name Mechanism in place to assess community trust
Domain Health information; Governance and leadership
Definition There is a mechanism in place in the area to assess, track and monitor community
trust through patient reported experiences and/or outcomes. Patient reported
experiences or outcomes can be used as a proxy to assess community trust in
the health system, essential health services and public health interventions.
Additionally, public trust and perceptions of health services can be captured
using community or population-based surveys or through community-based
interventions.
Rationale Positive patient experiences and health outcomes can foster trust between the
health system and service providers, and the community. Trust is key to the
success of public health interventions such as vaccination campaigns, adoption
of healthy behaviours, risk communication, etc. Community trust contributes to
the resilience of a health system by ensuring continued utilization of essential
health services, reducing pressure on acute health services as needed, preventing
more serious disease through uptake of health promotion and disease prevention
interventions, and ensuring reliable evidence-based health information is
effectively delivered to communities. Mechanisms that track and monitor
community trust in the health system can be used to inform policy, planning and
implementation further ensuring community engagement and participation in the
design and delivery of public health functions and health services.
Disaggregation Subnational (as relevant to context): region, state, province, canton,

municipality, etc.
Numerator N/A
Denominator N/A
Additional reading Larson E, Sharma J, Bohren MA, Tunçalp Ö. When the patient is the expert:
and references measuring patient experience and satisfaction with care. Bull World Health Organ.
2019 Aug 1;97(8):563-569. doi: 10.2471/BLT.18.225201
World Health Organization. 2021. Voice, agency, empowerment: handbook on
social participation for universal health coverage. Geneva: WHO (https://www.who.
World Health Organization. 2022. Joint external evaluation tool: International
Health Regulations (2005) - third edition. Geneva: WHO (https://www.who.int/
Existing data collection World Health Organization. 2022. Joint external evaluation tool: International
tools Health Regulations (2005) - third edition. Geneva: WHO (https://www.who.int/
Indicator 17. Comprehensive public health surveillance and response system in place at all service
delivery levels
Indicator short name Comprehensive surveillance and response system
Indicator name Comprehensive public health surveillance and response system in place at all
service delivery levels
Domain Health information; Service delivery
Definition There is a comprehensive public health surveillance and response system with at
least the following characteristics:
• The system conducts systematic identification, collection, collation, analysis
and interpretation of disease occurrence and public health events data, for the
purpose of taking timely and robust action
• Data are collected, analysed, interpreted, and reported in a consistent manner,
for example, by the same focal point who normally submit routine report forms
on health-related data
A comprehensive public health surveillance and response system is based on an
integrated approach to disease surveillance that aims to collect health data for
multiple conditions using standardized tools. To ensure robust early warning and
support prompt response, the system incorporates indicator-based and event-
based surveillance as integral parts of an Early Warning Alert and
Response (EWAR) system.
Rationale Comprehensive public health surveillance and response makes surveillance,

response, and laboratory data more usable and aids public health decision makers
improve detection and response to the leading causes of illness, disability and
death contributing to the resilience of the health system.
Disaggregation Service delivery levels: primary; secondary; tertiary; quaternary
Numerator N/A
Denominator N/A
Recommended Qualitative assessment based on interview with key informant and/or desk review
data source of country documents
Electronic IHR States Parties Self-Assessment Annual Reporting Tool (eSPAR)
Additional reading OpenWHO.org. Integrated Disease Surveillance and Response Course Series.
and references Geneva: WHO (https://openwho.org/channels/idsr)
World Health Organization Regional Office for Africa. 2010. Technical Guidelines for
Integrated Disease Surveillance and Response in the African Region October 2010.
Brazzaville: WHO Regional Office for Africa.
(https://www.afro.who.int/publications/technical-guidelines-integrated-disease-
surveillance-and-response-african-region-third)

tools
Indicator 18. Percentage of health facilities providing complete reports according to district and/or
national requirements
Indicator short name Completeness of reporting by facilities
Indicator name Percentage of health facilities providing compete reports according to district and/
or national requirements
Domain Health information; Health infrastructure
Definition Percentage of health facilities that use information systems for capturing and
reporting comprehensive patient and facility data and report this according to
district and/or national requirements within the required timeframe
(2022 version) [indicator 34].
Rationale Routine health information systems are one of the key building blocks of efficient,
nationally led, integrated and resilient health systems.
Routine health information systems are systems that provide health data at regular
intervals of less than a year to meet predictable health information requirements.
They include paper records or electronic/digital health records as well as facility-
and district-level health information management systems (for example, DHIS2)
and regular surveillance and epidemiological data. A well-functioning health
information system (HIS) has the following attributes:
• Generation of individual-level, facility-based and population-based data from
multiple sources: public health surveillance platforms, medical records, civil
registration data, household surveys, censuses, health service coverage and
health system input data (for example, human resources, health infrastructure
and financing).
• Capacity to detect, investigate, communicate, and contain events that threaten
public health security at the place they occur, and as soon as they occur.
• Ability to synthesize information and apply this knowledge. A good HIS
improves both demand for and supply and use of data – in health systems and
services, clinical and public health management, financing, planning, and
implementation.
Level Facility
Urban/rural
Subnational
Service/Program: for example, immunization, maternal child health,
noncommunicable diseases, etc.
Numerator Number of health facilities that are a part of the routine health information system

Indicator 18 (continued). Percentage of health facilities providing complete reports according to

district and/or national requirements
Recommended data Routine health information system

source Facility survey
The denominator can be assessed through, for example, the list of registered
facilities in authority’s database in a defined area; or through the total number of
health facility surveyed in a catchment area.
Additional reading and Hotchkiss DR, Diana ML, Foreit KG. How can routine health information systems
references improve health systems functioning in low- and middle-income countries?
Assessing the evidence base. Adv Health Care Manag. 2012;12:25-58. doi: 10.1108/
s1474-8231(2012)0000012006
World Health Organization. WHO Toolkit for Routine Health Information Systems
Data (https://www.who.int/data/data-collection-tools/health-service-data/toolkit-
for-routine-health-information-system-data/modules)
World Health Organization Regional Office for South-East Asia. 2017. UHC Technical
Brief: Strengthening health information systems. New Delhi: WHO Regional Office
for South-East Asia (https://apps.who.int/iris/handle/10665/259716)
Existing data Routine health information system

collection tools
Indicator 19. Health system resilience is measured and monitored as part of routine health
information system
Indicator short name Health system resilience measured and monitored in routine health information
system
Indicator name Health system resilience is measured and monitored as part of routine health
information system
Domain Health information
Definition Health system resilience is being measured and monitored as part of routine
health information system and can be assessed against the following criteria:
• A well-balanced set of indicators of health systems resilience should be
identified, harmonized, monitored, and utilized for system-wide improvement
within and outside emergency contexts in countries, at national, subnational,
and service-delivery levels. All indicators should have well-defined baseline
and targets; specify disaggregation including by age, sex, gender, and by other
equity dimensions; include specifications on data collection methods, digital
architecture required for reporting of key indicators
• Data for identified health system resilience indicators are collected in routine
health information systems, as appropriate
• Measuring and monitoring health systems resilience includes data quality
assurance mechanisms
Rationale Systematic, timely and regular monitoring and evaluation using contextualized
and integrated measurement approaches are essential for identifying areas for
improvement, targeting interventions, and ensuring accountability to stakeholders
when investing and building health systems resilience.
Disaggregation Subnational (as relevant to context): region, state, province, canton, municipality,
etc.
Urban/rural
Numerator N/A
Denominator N/A
Recommended data Qualitative assessment based on interview with key informant and/or desk review
source of country documents
Additional reading and World Health Organization. 2022. Health systems resilience toolkit: a WHO global
references public health good to support building and strengthening of sustainable health
systems resilience in countries with various contexts. Geneva:
Indicator 20. Percentage of facilities that have documented up to date risk profiles for potential
shocks and stressors
Indicator short name % facilities with risk profiles
Indicator name Percentage of facilities that have documented up to date risk profiles for potential
shocks and stressors
Domain Health information
Definition Percentage of facilitates that have an up to date (for example, once in the past five
years) risk profile for potential shocks and stressors informed by assessment of
risks and structural, non-structural, functionality and preparedness of health care
facilities
The risk profile of a facility informs all considerations in leading and managing its
health and safety risks, and can be assessed against the following criteria.
The risk profile includes:
• the nature and extent of the threats to health services delivery, quality,
utilization
• the likelihood of an adverse event or effect occurring
• the degree of disruption and costs associated with the different types of risk
• the effectiveness of mitigation measures in place to manage risks
Rationale Risk profiling for potential shocks and stressors leads to priority risks being
identified and prioritized for action. It informs mitigation measures and enables
health facilities to prepare for, adapt to and respond to risks and threats while
maintaining core functionality thereby building the resilience of the overall health
system.
Level Facility
Urban/rural
Numerator Number of facilities with up-to-date risk profiles

source Qualitative assessment based on interview with key informant and/or desk review
of country documents
Additional reading and United Kingdom Health and Safety Executive (HSE). Managing risks and risk
references assessment at work. Merseyside: HSE (https://www.hse.gov.uk/simple-health-
safety/risk/index.htm)
Indicator 21. Early-warning, alert and response system (EWARS) is established
Indicator short name Early-warning system established
Indicator name Early-warning, alert and response system (EWARS) is established.
Domain Health information; Service delivery
Definition Early warning systems or early warning, alert, and response systems (EWARS) are
designed to improve disease outbreak detection in emergency settings such as in
countries in conflict or following natural disaster.
Whether a country has an effective early-warning, alert and response system can
be assessed using the IHR State Party Self-Assessment Annual Report (SPAR) (2nd
edition) indicator C5.1 Early warning surveillance function:
• Level 1 - National guidelines and/or SOPs for surveillance are not available or
under development
• Level 2 - National guidelines and/or SOPs for surveillance have been developed
but not implemented. The surveillance system is functioning but lacks
systematic immediate reporting or weekly reporting of events and/or data
and are being implemented at the national level and provide immediate and
weekly reporting of events and/or data
and are being implemented at the national and intermediate levels and provide
immediate and weekly reporting of events and/or data
and implemented at national, intermediate and local levels; and the system is
exercised (as applicable), reviewed, evaluated and updated on a regular basis,
with improvement at all levels in the country
This indicator is included as one of the attributes of indicator 41 in Primary Health
Care Measurement Framework and Indicators (2022 version).
Rationale Early warning systems are often a part of surveillance systems. Early warning
systems are simple and cost-effective ways to enable the health system to prepare
for and respond to health threats.
Indicator-based surveillance is the systematic (regular) collection, monitoring,
analysis and interpretation of structured data, i.e., of indicators produced by
several well-identified, mostly health-based, formal sources, such as when health
care facilities (including primary care settings) regularly report the numbers
of cases and deaths caused certain priority diseases that are predefined and
mandated.
Event-based surveillance is the organized collection, monitoring, assessment and
interpretation of mainly unstructured ad hoc information regarding health events
or risks which may represent an acute risk to human health. It is a functional
component of the early warning and response system (such as media screening
that is conducted in a systematized manner to identify events of public health
interest).
All surveillance data are systematically analysed for informed decision-making and
dissemination.
etc.
Numerator N/A
Indicator 21 (continued). Early-warning, alert and response system (EWARS) is established
Denominator N/A
Recommended data Electronic IHR States Parties Self-Assessment Annual Reporting Tool (eSPAR)
source
Additional reading and World Health Organization. 2018. Guidance document for the State Party self-
references assessment annual reporting tool -International Health Regulations (2005).
World Health Organization. Early Warning, Alert and Response System (EWARS)
(https://www.who.int/emergencies/surveillance/early-warning-alert-and-
response-system-ewars)
Existing data collection eSPAR (https://extranet.who.int/e-spar)

tools
Indicator 22. Existence of a mechanism for sharing of relevant public health information with
other sectors
Indicator short name Mechanism for multisectoral information sharing
Indicator name Existence of a mechanism for sharing of relevant public health information with
other sectors
Definition There is evidence of a mechanism for sharing of relevant public health information
with between sectors (for example, veterinary, environment, agriculture, port
health authorities, transportation, education, finance, commence, internal affairs,
private sector, etc.). Mechanism for sharing relevant public health information
should have the following attributes:
• There are information system structures for data sharing
• Regulations and standards are in place for data sharing
• Data sharing should involve all relevant key sectors
This indicator is included as one of the attributes of indicator 1 in Primary Health Care
Measurement Framework and Indicators (2022).
Rationale Sharing of health information and data with actors within and outside the health
sector is critical for mitigation, preparedness, response and recovery from public
health events, shocks and stressors.
Numerator N/A
Denominator N/A
Recommended data Qualitative key informant survey and/or desk review with verification from key
source country documents such as national, subnational polices, plans, and guidance
Additional reading and Schmets G, Rajan D, Kadandale S, editors. 2016. Strategizing national health
references in the 21st century: a handbook. Geneva: WHO (https://apps.who.int/iris/
handle/10665/250221)
World Health Organization. 2021. Building health systems resilience for
universal health coverage and health security during the COVID-19 pandemic
handle/10665/346515)

tools
Indicator 23. Vulnerability and risk analysis and mapping has been conducted at the
subnational level
Indicator short name Vulnerability and risk mapping conducted
Indicator name Vulnerability and risk analysis and mapping has been conducted at the subnational
level
Definition There is evidence that a vulnerability and risk analysis and mapping, using the
strategic tool for assessing risk (STAR), or equivalent has been conducted at the
subnational level with reports disseminated to health facilities.
Rationale Such mapping enables national and subnational government to rapidly conduct a
strategic and evidence-based assessment of public health risks for planning and
prioritization of health emergency preparedness and disaster risk management
activities.
Level Subnational
etc.
Numerator N/A
Denominator N/A
Additional reading and World Health Organization. 2021. Strategic toolkit for assessing risks: a
references comprehensive toolkit for all-hazards health emergency risk assessment. Geneva:

tools
4.4 Access to medicines and other health

products and technologies
Indicator 24. National list of essential medicines is developed
Indicator short name National list of essential medicines
Indicator name National list of essential medicines is developed
Domain Access to medicines and other health products and technologies
Definition There is a national defined list of essential medicines. The list of essential
medicines should consider the national demographic and disease profiles.
Rationale Essential medicines are those that satisfy the priority health care needs of a
population. They are selected with due regard to national contexts (for example,
disease prevalence and public health relevance), evidence of efficacy and
safety and comparative cost-effectiveness. They are intended to be available in
functioning health systems at all times, in appropriate dosage forms, of assured
quality and at prices individuals and health systems can afford
Level National
Disaggregation N/A
Numerator N/A
Denominator N/A
Additional reading and World Health Organization. 2023. WHO Model List of Essential Medicines - 23rd list,
references 2023. Geneva: WHO (https://www.who.int/publications/i/item/WHO-MHP-HPS-
EML-2023.02)

tools
Indicator 25. Regulatory mechanisms for medicines and other essential health products
are established
Indicator short name Regulatory mechanisms for essential health products
Indicator name Regulatory mechanisms for medicines and other essential health products
are established
Definition There are regulatory mechanisms for medicines and other essential health
products (for example, vaccines, medical devices, in vitro diagnostics, protective
equipment and vector-control tools, and assistive devices), measured against the
following criteria, as applicable:
• National regulatory authority
• Marketing authorization
• Licensing of manufacturers
• Licensing of importers, exporters, wholesalers and distributors
• Licensing pharmacies and retail outlets
• Registration of pharmacy personnel
• Post-marketing surveillance and controls
• Control of drug promotion and advertising
• Pharmacovigilance
• Regulation of clinical trials
• Regulatory inspections
• Laboratory quality control
• Control of narcotics, psychotropic substances and precursors
This indicator is linked to indicator 30 in the Primary Health Care Measurement
Framework and Indicators (2022).
Rationale Health system resilience relies on access to health products including medicines,
vaccines, medical devices, in vitro diagnostics, protective equipment and vector-
control tools, and assistive devices. These must be of assured safety, efficacy/
performance and quality. In addition, they must be appropriate, available and
affordable. Poor or inadequate regulation can lead to the prevalence of poor
standard, counterfeit, harmful and ineffective drugs on national markets and in the
international commerce. This can result in serious harm to the health of individual
consumers and even to the health of a wider population. Therefore, countries must
continuously strengthen key drug regulatory responsibilities to ensure the safety,
quality and efficacy of drugs and the accuracy of product information.
Disaggregation N/A
Numerator N/A
Denominator N/A

Indicator 25 (continued). Regulatory mechanisms for medicines and other essential health products
are established
Additional reading and World Health Organization. 2014. Good governance for medicines: model
references framework, updated version 2014. Geneva: WHO (https://apps.who.int/iris/
handle/10665/129495)
World Health Organization. 2020. WHO Expert Committee on Specifications for
Pharmaceutical Preparations: fifty-fourth report (WHO technical report series; no.
1025). Geneva: WHO (https://www.who.int/publications/i/item/978-92-4-000182-4)
Existing data collection World Health Organization. 2007. WHO Data Collection Tool for the Review of Drug
tools Regulatory Systems. Geneva: WHO.
Indicator 26. Percentage of facilities with prepositioned public health emergency-relevant

health products
Indicator short name % facilities with prepositioned essential supplies
Indicator name Percentage of facilities with prepositioned public health emergency-relevant

health products
Definition Percentage of facilities that have prepositioned public health emergency-relevant

health products (for example, examination equipment, oxygen, consumable
supplied, diagnostic imaging technology, medical equipment for treatment,
medicines) that meet national or international requirements in accordance with
facility types and national and local risk profiles.
Please note: The list of essential supplies to be prepositioned should align with
local needs and services being provided in the facility. Some reference list of
essential emergency supplies that can be adapted to local contexts are: WHO
Standards Health Emergency kits; WHO General essential emergency equipment
list; and UNICEF Emergency supplies lists.
Rationale During public health emergencies, there can be a surge in demand for emergency-
relevant health products such as disease-specific medicines, prophylactic agents,
oxygen supply, or personal and protective equipment. Prepositioning stock
ensures that delivery of emergency case management and routine essential health
services are not disrupted.
Level Facility
municipality, etc.
Urban/rural
Numerator Number of facilities that have prepositioned public health emergency-relevant

health products that meet national or international requirements in accordance
with facility types.
Denominator Total number of facilities surveyed or in the catchment area.
Recommended data Facility-level reviews or surveys (for example, Site visit; storage logs)
source

Indicator 26 (continued). Percentage of facilities with prepositioned public health emergency-

relevant health products
Additional reading and World Health Organization. 2012. WHO generic essential emergency equipment
references list. Geneva: WHO (https://www.who.int/docs/default-source/integrated-health-
services-(ihs)/csy/surgical-care/imeesc-toolkit/equipment-lists-and-needs-
assessment/essential-emergency-equipment-list.pdf?sfvrsn=cb54324f_5)
World Health Organization. Access to medicines and health products
(https://www.who.int/our-work/access-to-medicines-and-health-products)
WHO Regional Office for South-East Asia. Essential Medicines (https://www.who.
int/southeastasia/health-topics/essential-medicines)
Existing data collection Facility survey

tools
Indicator 27. Percentage of health facilities that have a core set of relevant essential medicines
available and affordable on a sustainable basis
Indicator short name Availability of essential medicines
Indicator name Percentage of health facilities that have a core set of relevant essential medicines
Definition Percentage of health facilities that have a core set of relevant essential medicines
The indicator is a multidimensional index reported as a proportion (%) of health
facilities that have a defined core set of quality-assured medicines that are available and
affordable relative to the total number of surveyed health facilities at national level.
A medicine is available in a facility when it is found in this facility by the interviewer on
the day of data collection, based on the national reference list or other reference list
that is fit-for-purpose to the facility.
Below is a reference list from the Primary Health Care Measurement Framework and
Indicators (2022):
Category Medicines
Noncommunicable Salbutamol; Beclomethasone
diseases
(NCD) respiratory Gliclazide, Metformin, insulin regular [soluble]
NCD Diabetes Any two of the following hypertensives: Amlodipine,
Enalapril, Hydrochlorothiazide or Chlorthalidone,
Bisoprolol
NCD Cardiovascular Simvastatin, Acetylsalicylic acid (aspirin), Furosemide
Pain and palliative care Morphine, paracetamol, ibuprofen for adults
Central nervous system Fluoxetine; Phenytoin or Carbamazepine
Anti-infective Gentamicin, Amoxicillin for adults, Ceftriaxone, Procaine
benzylpenicillin or Benzathine benzylpenicillin
Contraception - maternal One of the following contraceptives: Ethinylestradiol +
child health (MCH) Levonorgestrel, Levonorgestrel (30 mcg cap/tab),
Medroxyprogesterone acetate injection, progesterone-
releasing implant (Etonogestrel or Levonorgestrel),
Levonorgestrel (750 mcg or 1.5 mg tablet)
MCH Oral rehydration salts, zinc sulphate, Oxytocin,
magnesium sulphate, folic acid
Anti-malarial One of the artemisinin-based combination therapies
(ACT):
Artemether + Lumefantrine, Artesunate + Amodiaquine,
Artesunate + Mefloquine, Dihydroartemisinin +
Piperaquine, Artesunate + Sulfadoxine + Pyrimethamine;
Anti-malarial Artesunate
Antiretroviral (ARV) One of combination ARV first-line treatment for HIV:
Efavirenz + Emtricitabine + Tenofovir disoproxil fumarate,
Efavirenz + Lamivudine + Tenofovir disoproxil fumarate
Neonatal care Chlorohexidine
Nutrition Ready-to-use therapeutic food (RUTF)
Antituberculosis Isoniazid + pyrazinamide + rifampicin
Indicator 27 (continued). Percentage of health facilities that have a core set of relevant essential
medicines available and affordable on a sustainable basis
Chronic kidney disease Erythropoietin
Antiallergics and One of the following: Epinephrine injection,

medicine used in Dexamethasone injection
anaphylaxis (optional)
Anti-fungal medicines Fluconazole, Nystatin
(optional)
Thyroid hormones Levothyroxine
(optional)
A medicine is affordable when no extra daily wages are needed for the lowest-paid
unskilled government sector worker to purchase a monthly dose treatment of
this medicine after fulfilling basic needs represented by the national poverty line.
Affordability is measured as a ratio of 1) the sum of the national poverty line and the
price per daily dose of treatment of the medicine, over 2) the lowest-paid government
worker salary. This measures the number of extra daily wages needed to cover the cost
of the medicines in the core set and that can vary between 0 and infinity.
Rationale Access to medicines is a composite multidimensional concept that is composed of the

availability of medicines and the affordability of their prices. Information on these
two dimensions has been collected and analysed since the 54th World Health
Assembly in 2001, when Member States adopted the WHO Medicines Strategy
(resolution WHA54.11). This resolution led to the launch of the joint project on
Medicine Prices and Availability by WHO and the international non-governmental
organization Health Action International (HAI/WHO), as well as a proposed HAI/WHO
methodology for collecting data and measuring components of access to medicines.
To this day, this methodology has been widely implemented to produce useful
analyses of availability and affordability of medicines, however the two dimensions
have been evaluated separately.
Level Facility
facilities, etc.
Subnational
Urban/rural
Numerator Number of facilities that have a core set of relevant essential medicines available and
affordable
Denominator Total number of surveyed facilities per country

source

Indicator 27 (continued). Percentage of health facilities that have a core set of relevant essential
medicines available and affordable on a sustainable basis
Additional reading World Health Organization. 2018. 2018 Global reference list of 100 core health
and references indicators (plus health-related SDGs). Geneva: WHO (https://www.who.int/
publications/i/item/2018-global-reference-list-of-100-core-health-indicators-(-plus-
health-related-sdgs))
World Health Organization. 2019. Model List of Essential Medicines, 21st List, 2019.
Geneva: WHO (https://www.who.int/publications/i/item/WHOMVPEMPIAU2019.06)
Operational framework for primary health care: transforming vision into action.
Geneva: WHO and UNICEF (https://www.who.int/publications/i/item/9789240017832)
United Nations Department of Economic and Social Affairs Statistics Division. United
Nations Sustainable Development Goals Indicators Metadata repository
(https://unstats.un.org/sdgs/metadata/)
Existing data While existing health facility survey tools such as the World Health Organization’s
collection tools facility survey assessments, World Bank’s Service Delivery Indicators), and
Demographic and Health Surveys (DHS) program’s Service Provision Assessment (SPA)
measure availability of essential medicines, they are not all fully aligned to the SDG
definition, and they also do not collect information on affordability.
DHS Program. 2022. Service Provision Assessment, May 2022 (https://dhsprogram.
com/publications/publication-spaq8-spa-questionnaires-and-manuals.cfm)
World Bank. Service Delivery Indicators (https://www.sdindicators.org/)
World Health Organization. 2015. Service Availability and Readiness Assessment.
Geneva: WHO (https://www.who.int/data/data-collection-tools/service-availability-
and-readiness-assessment-(sara))
To note: WHO is currently revising its facility survey modules to incorporate/address
specific elements on primary health care and health system resilience.
Indicator 28. Percentage of facilities that have experienced interruption in water supply in the
previous week
Indicator short name % facilities experiencing water supply interruption
Indicator name Percentage of facilities that have experienced interruption in water supply in the
previous week
Domain Access to medicines and other health products and technologies; Service Delivery
Definition The percentage of health facilities that have experienced an interruption in running
water supply or another source of safe water in the previous week
Rationale There is a need to ascertain how frequently there are disruptions to water supply over
a relatively short duration of time, i.e., in the last week (depending on how) as well
as the proportion of facilities affected. Countries can decide how frequently the data
is collected and adapt this indicator, for example, interruption in water supply in the
previous month.
This can enable identification and targeted interventions for service improvement.
The availability of water to a facility is considered adequate when the facility has
running water or another source of safe water 24 hours a day, 365 days a year. Water
supply is a foundation for public health and the maintenance of safe, quality essential
health services.
Level Facility
Urban/rural
Numerator Number of health facilities that have experienced interruption in water supply in the
previous week

source Routine health information system
Additional reading World Bank. Service Delivery Indicators (https://www.sdindicators.org/)

and references World Health Organization. 2009. Vision 2030: the resilience of water supply and
sanitation in the face of climate change: technical report. Geneva:
WHO (https://www.who.int/publications/i/item/WHO-HSE-WSH-10.01)
World Health Organization Regional Office for the Western Pacific. 2010. Safe hospitals
in emergencies and disasters: structural, non-structural and functional indicators.
Manila: WHO Regional Office for the Western Pacific (https://apps.who.int/iris/
handle/10665/207689)
Existing data World Health Organization. 2012. African partnerships for patient safety: patient
collection tools safety situational analysis (Long form). Geneva: WHO (https://apps.who.int/iris/
handle/10665/330052)
World Health Organization Regional Office for Africa. 2003. Tools for Assessing the
Operationality of District Health Systems. Brazzaville: WHO Regional Office for Africa.
Indicator 29. Percentage of facilities that have experienced power outages in the previous week
Indicator short name % facilities experiencing power outages
Indicator name Percentage of facilities that have experienced power outages in the previous week
Domain Access to medicines and other health products and technologies;

Service delivery
Definition The percentage of health facilities (for example, in a given geographical area or
group of facilities) that have experienced electrical power outages in the
previous week
Rationale There is a need to ascertain how frequently there are disruptions to electrical
power over a relatively short duration of time i.e., in the last week, as well as
the proportion of facilities experiencing power outages by disaggregation. This
can enable identification and targeted interventions for service improvement.
The availability of electrical power to a facility is essential for lighting, use of
information technology, power supply to medical equipment and devices,
refrigeration of medicines and health products, temperature regulation, and
maintenance of safe, quality essential health services.
Level Facility
municipality, etc.
Urban/rural
Numerator Number of health facilities that have experienced power outages in the previous
week

source Routine health information system
Type (M&E domain) Inputs and structure
Additional reading World Bank. Service Delivery Indicators (https://www.sdindicators.org/)

and references World Health Organization Regional Office for the Western Pacific. 2010. Safe
hospitals in emergencies and disasters: structural, non-structural and functional
indicators. Manila: WHO Regional Office for the Western Pacific (https://apps.who.
int/iris/handle/10665/207689
Existing data collection World Health Organization. 2012. African partnerships for patient safety: patient
tools safety situational analysis (Long form). Geneva: WHO (https://apps.who.int/iris/
handle/10665/330052)
World Health Organization Regional Office for Africa. 2003. Tools for Assessing the
Operationality of District Health Systems. Brazzaville: WHO Regional Office for
Africa.
Indicator 30. Percentage of facilities with availability of water, sanitation, and hygiene
(WASH) amenities
Indicator short name % facilities with basic WASH amenities
Indicator name Percentage of facilities with availability of water, sanitation,

and hygiene (WASH) amenities
Domain Access to medicines and other health products and technologies;

Service delivery; Governance and leadership
Definition Percentage of facilities that have basic WASH amenities as defined by:
• Water: available from an improved source, on premises
• Sanitation: Improved facilities are usable, with at least one toilet for staff, one
sex-separated with menstrual hygiene facilities and at least one accessible for
those with limited mobility
• Hand hygiene: functional hand hygiene facility (water with soap and/or ABHR) at
points of care and within 5 meters of toilets
• Health care waste: waste is safely segregated into three bins and sharps and
infectious waste and treated and disposed of safely
• Cleaning: basic protocols for cleaning are available and staff with cleaning
responsibilities have received training
Rationale The availability of basic WASH amenities in health facilities is fundamental

to delivering quality and resilient health services and adhering to infection
prevention and control standards. Without basic WASH amenities, health services
and systems are more prone to healthcare-acquired infections, staff infections,
poorer health outcomes, larger scale outbreaks and disruptions to health services
and systems.
Level Facility
Managing authority: government, non-government; public, private
Urban/rural
Numerator Number of health facilities that meet basic WASH standards
Denominator Total number of facilities examined

source

Indicator 30 (continued). Percentage of facilities with availability of water, sanitation, and hygiene
(WASH) amenities
Additional reading and World Health Organization. 2020. Global progress report on WASH in health care
references facilities: Fundamentals first. Geneva: WHO (https://www.who.int/publications/i/
item/9789240017542)
Core questions and indicators for monitoring WASH in health care facilities in the
Sustainable Development Goals. Geneva: WHO and UNICEF (https://www.who.int/
water_sanitation_ health/publications/monitoring-wash-in-health-care-facilities-
aug-2018.pdf)
World Health Organization and United Nations Children’s Fund (UNICEF).
WHO/UNICEF Joint Monitoring Programme. Latest database:
(http://washdata.org/data/healthcare).
Existing data From existing health facility survey tools such as WHO’s Service Availability and
collection tools Readiness Assessment (SARA) and Harmonized Health Facility Assessment (HHFA),
Assessment (SPA):
DHS Program. Service Provision Assessment, May 2022 (https://dhsprogram.com/
publications/publication-spaq8-spa-questionnaires-and-manuals.cfm)
World Bank. Service Delivery Indicators (https://www.sdindicators.org/)
World Health Organization. 2015. Service Availability and Readiness Assessment
(https://www.who.int/data/data-collection-tools/service-availability-and-
readiness-assessment-(sara))
4.5 Health financing

Indicator 31. Percentage of health facilities with user fees waiver mechanisms for public health
emergency-related health services
Indicator short name % facilities with user fees waiver mechanisms
Indicator name Percentage of health facilities with user fees waiver mechanisms for public health
emergency-related health services
Domain Health financing; Governance and leadership
Definition There is evidence of user fee waiver mechanisms for public health emergency-
related health services such as consultations, treatment, investigations, and
provision of medicines.
Evidence can be policies or guidelines on user fee waiver in public health
emergencies; patient experiences, financial reports, etc.
Rationale User fees can be a barrier to the uptake of essential health services (both
emergency case management and routine essential health services).
Level Facility
municipality, etc.
Urban/rural
Numerator Number of facilities with user fee waiver mechanisms

source
Additional reading and Inter-Agency Standing Committee Global Health Cluster. 2010. Removing user fees
references for PHC services during humanitarian crises. Geneva: WHO (https://www.who.int/
docs/default-source/documents/publications/removing-user-fees-for-primary-
health-care-services-during-humanitarian-crises.pdf?sfvrsn=19631353_1)

tools
Indicator 32. Mechanism in place to ensure financial barriers do not impede diagnosis and
treatment to a range of health threats
Indicator short name Mechanism to address financial barriers
Indicator name Mechanism in place to ensure financial barriers do not impede diagnosis and
treatment to a range of health threats
Domain Health financing; Governance and leadership
Definition Availability of functioning system to ensure financial barriers do not impede the
process of diagnosing and treating cases in different contexts (including infectious
disease outbreaks, natural disasters, etc.).
A functioning system should have the following attributes:
consideration of the health needs of vulnerable populations
public financing for provision of health services in need
financial support to populations in accessing health services
Examples of such mechanisms can include: essential services included in health
benefits package; contingency funds available for emergencies should have
dedicated budget for providing essential diagnosis and treatment services; etc.
Rationale Financial barriers can impede patients from seeking essential health services
thereby impeding timely diagnosis and treatment, and associated public health
actions like notification of relevant authorities and others, risk communication,
contact tracing, etc. This can lead to worsened health outcomes and greater
pressure on secondary and tertiary levels of the health system.
Level National, subnational

municipality, etc.
Urban/rural
Numerator N/A
Denominator N/A
Additional reading and World Health Organization Regional Office for Europe. Financing (https://www.
references who.int/europe/emergencies/our-work-in-emergencies/health-systems-for-
emergencies/financing)
World Health Organization Regional Office for the Western Pacific. 2017. Removing
financial barriers to accessing quality health services. Manila: WHO Regional Office
for the Western Pacific (https://www.who.int/china/activities/removing-financial-
barriers-to-accessing-quality-health-services)

tools
Indicator 33. Availability of dedicated budget line to support health services continuity in
all contexts
Indicator short name Dedicated budget line for service continuity
Indicator name Availability of dedicated budget line to support health services continuity in all
contexts
Domain Health financing
Definition As a key informant qualitative assessment at national and subnational

administrative levels:
There is evidence in the financial system of a dedicated budget line or space for
maintenance and continuity of essential health services in all contexts (including in
routine settings and during public health emergencies).
The budget line for health services continuity can be within health service
continuity plan, multi-hazards management plans, health sector development
plan, health disaster and emergency management plans, etc.
At the facility level:
Percentage of facilities that have a dedicated budget line on provision and
continuity of essential health services in all contexts (including in routine settings
and during public health emergencies). The budget line can be a part of local
health departments’ budgets.
The facility level measurement of this indicator is an attribute in indicator 61 in the
Primary Health Care Measurement Framework and Indicators (2022 version).
Rationale During health systems shocks, stressors, and public health emergencies, the
focus can be on the acute need such as emergency preparedness and response
activities, however, there is a need to augment budgets for essential health
services continuity and ensure resilience of the health system. Provision of
essential health services in routine time is also an attribute of the everyday
resilience of health systems.
The budget line creates a space to pool financial resources to the maintenance and
continuity of essential health services.
Level National; subnational; facility

Facility surveys:
second level hospitals, temporary health facilities, etc.)
Sub-national
Urban/rural

Facility level assessments: Number of facilities that have a dedicated budget line
for supporting health services continuity.

Facility level assessments: Total number of facilities.
Indicator 33 (continued). Availability of dedicated budget line to support health services continuity
in all contexts
Additional reading and Mustafa S, Zhang Y, Zibwowa Z, Seifeldin R, Ako-Egbe L, McDarby G, etc. COVID-19
references Preparedness and Response Plans from 106 countries: a review from a health
systems resilience perspective. Health Policy Plan. 2022 Feb 8;37(2):255-268. doi:
10.1093/heapol/czab089
Schmets G, Rajan D, Kadandale S, editors. 2016. Strategizing national health
in the 21st century: a handbook. Geneva: WHO (https://apps.who.int/iris/
handle/10665/250221)

tools
Indicator 34. Contingency funds available in the country for emergencies
Indicator short name Contingency funds available
Indicator name Contingency funds available in the country for emergencies
Definition Contingency funds available for health emergencies, measured against the following
criteria:
• A contingency fund exists at the subnational, national, regional, or international
level, with which a national or subnational authority can coordinate the reception
and distribution of funds to the health facility for responding to emergencies is in
place at the national, intermediate, and local levels. (IHR SPAR C1.3).
• A contingency fund having explicit coverage on maintenance of essential health
services, including primary care services.
• Financing can be executed and monitored in a timely and coordinated manner at all
levels and for all relevant sectors, with an emergency contingency fund in place, for
response to an acute public health emergency. (IHR JEE P1.3)
This indicator is in Primary Health Care Measurement Framework and Indicators (2022)
[indicator 18].
Rationale Contingency funds for emergencies that allow access funds to respond to
emergencies, often in 24 hours or less, are a critical part of emergency response
preparedness. Ability to quickly respond to emergencies can stave off unnecessary
suffering and save lives. This emergency fund also serves to support continuity of
services during an emergency when there are gaps.
This indicator measure if the budget space for contingency and health services
continuity is filled with financial resources.
Numerator N/A
Denominator N/A
Additional reading World Health Organization. 2019. Health emergency and disaster risk management
and references framework. Geneva: WHO (https://apps.who.int/iris/handle/10665/326106) (Caveat: it
does not cover funding “maintenance of essential health services” aspects.
World Health Organization. 2022. Joint External Evaluation Tool: International Health
Regulations (2005) 3rd ed. Geneva: WHO (https://www.who.int/publications/i/
item/9789240051980)
World Health Organization. State Party Annual Report for IHR (e-SPAR)
(https://extranet.who.int/e-spar).
Existing data World Health Organization. 2018. IHR (2005) State Party Self-Assessment Annual
collection tools Reporting Tool (SPAR). Geneva: WHO (https://www.who.int/publications/i/item/WHO-
WHE-CPI-2018-16)
Indicator 35. Contingency or service continuity funds are accessible to the facility
Indicator short name Contingency funds accessible to facilities
Indicator name Contingency or service continuity funds are accessible to the facility
Definition At system level:

Contingency funds or service continuity funds are accessible to facilities for response
to an acute public health emergency, measured against the following criteria:
• Existence of mechanism to execute emergency funds (for example, allocate or
release contingency funds) to health facilities OR evidence showing that contingency
funds were allocated to facilities to ensure continuity of health services in previous
public health emergencies
• Allocation of contingency funds is monitored in a timely and coordinated manner at
all levels and for all relevant sectors, with an emergency contingency fund in place
At facility level:
Percentage of facilities that have access to contingency funding in the context of
emergencies, supported by clear mechanisms (for example, defined triggers of
contingency fund, stewardship of contingency fund) OR that were allocated with
contingency funds to ensure continuity of health services in previous public health
emergencies
Rationale Contingency funds for emergencies that allow access funds to respond to
emergencies, often in 24 hours or less, are a critical part of emergency response
preparedness. Ability to quickly respond to emergencies can stave off unnecessary
suffering and save lives. This emergency fund also serves to support continuity of
services during an emergency when there are gaps.
This indicator measures if the available contingency funding can be used, i.e. allocated
and accessed by health facilities to implement activities in relation to continuity of
essential health services.

Facility surveys:
second level hospitals, temporary health facilities, etc.)
Sub-national
Urban/rural

Facility level assessments: Number of facilities that have access to contingency
funding in context of emergencies

Recommended data At system level: qualitative assessment based on interview with key informant and/or
source desk review of facility documents
At facility level: Facility survey

Indicator 35 (continued). Contingency or service continuity funds are accessible to the facility
Additional reading World Health Organization. 2019. Health emergency and disaster risk management
and references framework. Geneva: WHO (https://apps.who.int/iris/handle/10665/326106). (Caveat: it
does not cover funding “maintenance of essential health services” aspects)
World Health Organization. 2022. Joint External Evaluation Tool: International Health
Regulations (2005) 3rd ed. Geneva: WHO (https://www.who.int/publications/i/
item/9789240051980)
World Health Organization. State Party Annual Report for IHR (e-SPAR) (https://
extranet.who.int/e-spar).

collection tools
Indicator 36. Mapping of all health sector assets (resources) has been conducted in the last
two years
Indicator short name Resources mapping conducted
Indicator name Mapping of all health sector assets (resources) has been conducted in the last
two years
Domain Health financing; Health Information
Definition Health sector assets and resources mapping has been conducted against the
following criteria:
• existing assets (for example, infrastructure, supplies) and resources (for example,
financial, human) are comprehensively identified and documented in the
mapping process
• mapping should be conducted relatively regularly (for example, at least within
the last two years)
Rationale Mapping of all health sector assets and resources creates an informational
resource that can be used to enhance planning and delivery of health services and
ensure health service continuity in all contexts.
etc.
Numerator N/A
Denominator N/A
Additional reading and Institute for Healthcare Improvement (IHI). How Can Asset Mapping Improve
references Community Health? Boston: IHI (https://www.ihi.org/education/IHIOpenSchool/
resources/Pages/Activities/Bintz-AssetMapping.aspx)

tools
Indicator 37. Health financing arrangement includes public funding of public

health services
Indicator short name Public health services funded
Indicator name Health financing arrangement includes public funding of public health services
Definition • There is evidence of health financing arrangements for a defined set of basic
public health services, against the following criteria:
• There is a set of explicitly defined package of essential health services for the
entire population
• The defined package of essential health services includes public health services
within the scope of essential public health functions, often including health
promotion, disease prevention, health protection, public health surveillance and
monitoring
• There are clear budget lines for basic public health services in health financing
arrangement
Public health services refer to services with the primary purpose of protecting
and promoting the health and well-being of a defined population as a whole. The
scope often includes health promotion, disease prevention and health protection
services, as well as the legislative, regulatory, administrative, technical and
behaviour-modifying interventions that impact on determinants of health.
Rationale On many occasions, public health services are cost-effective and efficient to
protect and improve population health. But routine, proactive public health
services have been chronically under-prioritized, in terms of investment and
stakeholder action compared with hospital-based health care and disease-specific
interventions. A clear budget line and implementation of a budget indicates
political commitment to public health services and supports delivery of public
health services.
There are different approaches to what constitutes expenditure on public
health services. According to the 2011 edition of the System of Health Accounts,
“prevention and public health services” are defined as “services designed
to enhance the health status of the population as distinct from curative
services, which repair health dysfunction. An upcoming WHO publication on
operationalizing EPHFs will describe a compendium of public health services for
reference.
Disaggregation Type of services: for example, prevention, promotion, treatment/rehabilitation,

palliation
etc.
Numerator N/A
Denominator N/A
Recommended data National health account (NHA)

source Qualitative assessment based on interview with key informant or review of
national budgets, financial report, policies, strategies, or plans
National government audit

Indicator 37 (continued). Health financing arrangement includes public funding of public

health services
Additional reading and European Observatory on Health Systems and Policies, Rechel, Bernd,
references Jakubowski, Elke, McKee, Martin. et al. 2018. Organization and financing of public
health services in Europe. Copenhagen: World Health Organization Regional Office
for Europe (https://apps.who.int/iris/handle/10665/326254)
Organisation for Economic Co-operation and Development. 2017. Expenditure
on Prevention Activities under SHA 2011: Supplementary Guidance. Paris: OECD
(https://www.oecd.org/els/health-systems/Expenditure-on-prevention-activities-
under-SHA-2011_Supplementary-guidance.pdf)
World Health Organization. 2016. Strengthening essential public health functions
in support of the achievement of universal health coverage. Geneva: WHO (https://
apps.who.int/iris/handle/10665/252781)
World Health Organization. 2021. 21st century health challenges: can the essential
public health functions make a difference?: discussion paper. Geneva: WHO
World Health Organization. 2021. Measuring primary health care expenditure
under SHA 2011: technical note, December 2021. Geneva: WHO (https://apps.who.
int/iris/handle/10665/352307)
World Health Organization. 2023. Operationalizing the essential public health
functions: an integrated and comprehensive approach to public health.
Geneva: WHO
World Health Organization, Organisation for Economic Co-operation and
Development & Statistical Office of the European Communities. 2017. A
system of health accounts 2011: revised edition. Paris: OECD (https://doi.
org/10.1787/9789264270985-en)

tools
4.6 Governance and leadership
Indicator 38. Service package for essential health services and public health functions is developed
and meets criteria
Indicator short name Service package meeting criteria
Indicator name Service package for essential health services and public health functions is
developed and meets criteria
Domain Governance and leadership
Definition Service package of essential health services (including primary care services) and
public health functions is developed and meets following criteria:
• Addresses comprehensive essential individual and population health
services including:
1. Health protection
2. Prevention
3. Promotion
4. Management (diagnosis, treatment, rehabilitation, resuscitation)
5. Palliation
6. Includes key life course needs and disease programs
7. Foundations of care management of emergency syndromes and
common presentations in primary care
8. Reproductive and sexual health, including pregnancy, childbirth, and
family planning
9. Growth, development, disability and ageing
10. Communicable diseases
11. Noncommunicable diseases
12. Mental health, neurological and substance use disorders
13. Violence and injury
• The package addresses disease burden and other national priorities
including risk factor profiles and projections
• The process for development of the service package involves a wide range
of stakeholders
• The package is based on an evaluation of existing resources
• Is routinely revised as part of national planning processes
• The package includes and designates key services related to emergency
events for which the country is at risk
Indicator 38 (continued). Service package for essential health services and public health functions is
Rationale For health systems to be resilient, they must be able to maintain essential health
services in all contexts. A prerequisite for this capacity, is to have a nationally
defined and prioritized set of essential health services, often referred to as an
‘essential package of health services’.
For health systems to comprehensively meet population health needs, in routine
contexts and during shocks, the defined package of essential health services
should prioritize public as well as individual health services encompassing
promotive, preventive, curative, rehabilitative and palliative services at all levels of
service delivery.
Applying the PHC approach supports this holistic and comprehensive approach to
service delivery with equity and whole-of-society participation to meet population
health needs throughout the life course.
The exercise of specifying a core package is a value-laden process, looking to
decision-makers and system stewards to establish a strategic policy position and
equitable framework for protected access to quality individual and population
health services when faced with competing priorities (such as short-term shocks or
chronic stressors to the system).
Numerator N/A
Denominator N/A

Indicator 38 (continued). Service package for essential health services and public health functions is
Additional reading and Mustafa S, Zhang Y, Zibwowa Z, Seifeldin R, Ako-Egbe L, McDarby G, Kelley E, Saikat
references S. COVID-19 Preparedness and Response Plans from 106 countries: a review from
a health systems resilience perspective. Health Policy Plan. 2022 Feb 8;37(2):255-
268. doi: 10.1093/heapol/czab089
World Health Organization. 2014. Making fair choices on the path to universal
health coverage. Final report of the WHO Consultative Group on Equity and
Universal Health Coverage. Geneva: WHO (https://www.who.int/publications/i/
item/9789241507158)
World Health Organization. 2018. Integrating health services: brief. Geneva: WHO
World Health Organization. 2018. Primary health care: closing the gap between
public health and primary care through integration. Geneva: WHO (https://apps.
World Health Organization. UHC Compendium (https://www.who.int/universal-
health-coverage/compendium)
World Health Organization and the United Nations Children’s Fund (UNICEF).
2020. Operational framework for primary health care: transforming vision
into action. Geneva: WHO and UNICEF (https://www.who.int/publications/i/
item/9789240017832)
World Health Organization Regional Office for the Eastern Mediterranean.
Universal health coverage (UHC) – priority benefits package.
Existing data collection National authority websites, for example, website of ministries of health, can be
tools checked for evidence of national service package.
A qualitative service delivery assessment to measure this indicator is under
development by WHO.
Indicator 39. Availability of a protocol or guidance for prioritization of health services to be

maintained following health systems shocks or stressors
Indicator short name Availability of protocol for prioritization of services
Indicator name Availability of a protocol or guidance for prioritization of health services to be

maintained during health systems shocks or stressors
Definition As a key informant qualitative assessment at national and subnational

There is a protocol or guidance in place at facility level that supports the
prioritization of those services to be maintained, including key elements, in all
contexts, when it is not possible to maintain all routine health services, such as:
During shocks or stresses to the health system including:
• infectious disease outbreaks
• natural disasters
• chemical or radiological threats
• sudden conflict
Under routine pressures or challenging conditions as a demonstration of ‘everyday
resilience’:
• changing patient and community expectations
• evolving disease profile and burden
• altered governance structures and changes in policy directives
• payment delays
• health workforce issues
• protracted conflict
Assessment at the facility level:
Percentage of facilities that have received the protocol or guidance to prioritize
services in different contexts, including shocks, stresses to the health system,
routine pressures and challenging conditions.
An attribute in indicator 61 in the Primary Health Care Measurement Framework and
Indicators (2022 version, at facility level measurement only).
Rationale Health systems often have limited resources and face additional, unexpected, and/
or routine fluctuations in demand and pressures. The availability of a protocol
or guidance which identifies those routinely provided essential health services
(such as acute and/or critical interventions) that must be maintained when it is
not possible to deliver all routine health services, can minimize the impact of
disruptions and reduce avoidable morbidity and mortality.

Facility surveys:
Sub-national
Urban/rural
Indicator 39 (continued). Availability of a protocol or guidance for prioritization of health services to

be maintained following health systems shocks or stressors

Facility level assessments: Number of facilities that have a protocol or guidance to
prioritize services.

World Health Organization. 2021. Analysing and using routine data to monitor the
effects of COVID-19 on essential health services: practical guide for national and
subnational decision-makers: interim guidance, 14 January 2021. Geneva: WHO
Indicator 40. Availability of clinical protocols for case management of common and high priority
infectious diseases and hazards
Indicator short name Availability of priority disease and event case management protocols
Indicator name Availability of clinical protocols for case management of common and high priority
diseases and events at facility level
Definition Clinical protocols for case management are structured plans that include clinical
guidance and map the routes of care through the health system for individuals
with specific clinical problems. Core conditions can be defined as common medical
conditions for which preventive, diagnostic and treatment approaches are well
established and for which a lack of treatment can cause significant harm to a
patient.
As a key informant qualitative assessment at national and subnational
There is a clinical case management protocol or equivalent for that includes the
following conditions (or include other priority diseases and events identified):
A. FOUNDATIONS OF CARE
1. Diarrhoea
2. Difficulty in breathing
3. Fever
4. Sepsis
B. GROWTH, DEVELOPMENT AND AGEING
5. Undernutrition
C. REPRODUCTIVE AND SEXUAL HEALTH
6. Complications of pregnancy (maternal)
D. COMMUNICABLE DISEASES
7. Lower respiratory infection
8. Malaria
E. NONCOMMUNICABLE DISEASES
9. Asthma
10. Breast cancer
11. Chronic heart disease
12. Chronic kidney disease
13. Chronic obstructive pulmonary disease
14. Depression
15. Diabetes [mellitus]
16. Hearing impairment
F. VIOLENCE AND INJURY
17. Serious injury
AND
specifies the following attributes:
a. Key care elements are based on evidence and best practice
b. Details on communication among the team members and with patients and
families are included
c. Roles and responsibilities, including sequencing of activities across the
multidisciplinary care team, patients and their relatives are defined
d. Guidance on monitoring and evaluation of variances and outcomes is
included
e. Health practitioner training in the use of care pathways
Indicator 40 (continued). Availability of clinical protocols for case management of common and high
priority infectious diseases and hazards
Assessment at the facility level: Percentage of facilities that have received the
case management protocol or equivalent for priority diseases and events
This system-level measurement of the indicator is similar to indicator 50 in Primary
Health Care Measurement Framework and Indicators (2022 version). The facility-level
measurement of the indicator is included as one of the attributes of indicator 61 in
Primary Health Care Measurement Framework and Indicators (2022 version).
Rationale The resilience of health systems is tested everyday by common or high priority
diseases and events, some of which can become public health emergencies.
Protocols, guidelines and/or equivalent which consider system-wide issues
(for example, workforce training and availability, essential health products and
medicines, care pathways, multisectoral considerations such as discharge into
community or social care) can enable provision of optimal care throughout the
entirety of such diseases, illnesses, conditions, or events. They can also prevent
small events including outbreaks of infectious diseases from becoming larger,
more consequential events which disrupt essential health services and capacities
and functional systems for health. The availability of protocols or equivalent can
standardize clinical practice, reduce error, enhance quality of service delivery,
reduce the risk of complications, and increase the chance of positive health
outcomes thereby reducing pressure on the health system and, ultimately, the
need for more costly services and interventions further down the line.

Facility surveys:
National/sub-National
Urban/rural

Facility level assessments: Number of facilities that have a protocol or guidance to
prioritize services

Recommended data Review of national/subnational policies, plans or guidance

source Qualitative key informant survey and/or desk review with verification from key

Indicator 40 (continued). Availability of clinical protocols for case management of common and high
priority infectious diseases and hazards
Additional reading and World Health Organization. 2022. Clinical management and infection prevention
references and control for monkeypox: interim rapid response guidance, 10 June 2022.
World Health Organization. 2022. Clinical management of COVID-19: living
guideline, 13 January 2023. Geneva: WHO (https://www.who.int/teams/health-
care-readiness/covid-19)
Existing data collection World Health Organization. 2023. Harmonized Health Facility Assessment. Geneva:
tools WHO (https://www.who.int/data/data-collection-tools/harmonized-health-facility-
Of note, WHO is currently revising its facility survey modules.
Indicator 41. National or subnational system in place for conducting simulation exercises that
meets criteria
Indicator short name System for conducting simulation exercises
Indicator name National or subnational system in place for conducting simulation exercises that
meets criteria
Definition Nationally or sub-nationally, there is a system for conducting simulation exercises

that includes the following elements:
• Monitored annual requirement to conduct
• Key stakeholders involved in/responsible for routine and emergency health
services are included
• Relevant stakeholders from outside the health sector are included
• The simulation exercise focuses on testing the resilience of the health system
including plans for essential health services continuity
Rationale Simulation exercises are fully simulated, interactive exercises that test the
capability of organizations or groups of organizations/health facilities with intra-
and inter-sectoral participation to respond to simulated emergency, disaster,
crisis, or routine situations.
Regular participation in simulation exercises enable learning and improvement of
services delivery as well as decision-making, planning, and other required system
inputs which contributes to building resilience.

municipality, etc.
Type of simulation exercises
Numerator N/A
Denominator N/A
Recommended data Review of national and subnational policies, plans or guidance

source Qualitative or key informant survey or desk review with verification from key

Indicator 41 (continued). National or subnational system in place for conducting simulation

exercises that meets criteria
Additional reading and World Health Organization. 2021. Health Systems Resilience Simulation Exercises.
references Geneva: WHO (https://www.who.int/teams/integrated-health-services/health-
service-resilience/integrated-health-system-strengthening/health-systems-
resilience-simulation-exercises)
World Health Organization Regional Office for the Western Pacific. 2006. Creating
and tracking pandemic preparedness plans: a guide. Manila: WHO Regional Office
for the Western Pacific
World Health Organization Regional Office for the Western Pacific. 2006. Exercise
development guide for validating influenza pandemic preparedness plans. Manila:
WHO Regional Office for the Western Pacific
World Health Organization Regional Office for South-East Asia. 2006. A guide for
conducting table-top exercises for national influenza pandemic preparedness.
New Delhi: WHO Regional Office for South-East Asia (https://iris.who.int/
handle/10665/204728)
World Health Organization, Pan American Health Organization. 2011. Guidelines
for developing emergency simulations and drills. Area on Emergency Preparedness
and Disaster Relief. Washington, D.C: WHO, PAHO (https://www.nab.vu/sites/
default/files/documents/SimulationsGuide.pdf)
Indicator 42. Percentage of health facilities that are a part of a collaborative network or mutual aid
arrangements for managing public health challenges and maintaining routine functions
Indicator short name % facilities part of collaborative networks
Indicator name Percentage of health facilities that are a part of a collaborative network or mutual
aid arrangements for managing public health challenges and maintaining routine
functions
Definition The percentage of health facilities and other platforms/units of service delivery
(for example mobile/outreach clinics, community health organizations, school
health services, public health departments), in a given geographical area or
within a network/group, that are a part of a collaborative network or mutual aid
arrangement for managing public health challenges including emergencies, and
maintaining routine functions.
A collaborative network or mutual aid (voluntary exchange of services and
resources for mutual benefit) arrangement can include an agreement, sometimes a
legal document, that provides a formal framework for assistance between parties.
Rationale Being a part of a collaborative network of health facilities and/or mutual aid
arrangement can facilitate efficient transfer of resources (for example financial,
human) and technical support, and even lending of support such as emergency
responders across jurisdictional, geographical or sectoral boundaries. This is of
mutual benefit to parties as such an agreement can facilitate the rendering of aid
for another during disruptive public health events or even routine/everyday shocks
and stressors to the health system.
Level Facility
etc.
Urban/rural
Numerator Number of health facilities that are a part of a collaborative network or mutual aid
arrangement

source
Additional reading and Stier DD, Goodman RA. Mutual aid agreements: essential legal tools for public
references health preparedness and response. American Journal of Public Health, 2007, 97
(Supplement 1): 62–68
World Health Organization. 2014. Hospital preparedness for epidemics. Geneva:
WHO (https://www.who.int/publications/i/item/hospital-preparedness-for-
epidemics)
Indicator 43. Existence of an all-hazard emergency preparedness and response plan (or equivalent)
which defines the role of health services (including primary care) in emergency management and
the maintenance of essential health services
Indicator short name All-hazard emergency preparedness and response plan defines role of health
services
Indicator name Existence of an all-hazard emergency preparedness and response plan (or
equivalent) which defines the role of health services (including primary care) in
emergency management and the maintenance of essential health services
Definition There is an all-hazard emergency preparedness and response plan (or equivalent)
that specifies the routine role of health services (including primary care services)
in emergency management (i.e., from prevention to preparedness, response and
recovery) and the maintenance of essential health services
Rationale Planning for and reducing the health risks and consequences of public health
emergencies, including the maintenance of essential health services, requires the
specification of roles and responsibilities of health service actors at all service
delivery levels.
etc.
Numerator N/A
Denominator N/A
source country documents such as subnational polices, plans, and guidance
Additional reading and World Health Organization. 2018. Primary health care and health emergencies.
references Geneva: WHO (https://apps.who.int/iris/ handle/10665/328105)
World Health Organization. 2019. Health emergency and disaster risk management
framework. Geneva: WHO (https:// apps.who.int/iris/handle/10665/326106)
World Health Organization. State Party Annual Report for IHR (e-SPAR) (https://
extranet.who.int/e-spar)
Existing data collection Not at present. Qualitative assessment tool with recommended scoring
tools methodology under development by WHO.
Indicator 44. Percentage of health facilities that have emergency management plans incorporating
consideration of health services continuity
Indicator short name % facilities with emergency management plans incorporating service continuity
Indicator name Percentage of health facilities that have emergency management plans that
incorporate considerations of health services continuity
Definition Percentage of health facilities (for example, in a geographical area or within a network
of health facilities) that have an emergency management and routine/essential health
services continuity plan
Rationale Service continuity planning is a process that identifies and prioritizes the critical
functions of a health facility, evaluates the potential impact of various hazards, and
identifies actions to ensure the continuity of critical functions (that is, essential health
services) in all contexts (for example, in response to public health events/emergencies,
shocks, or routine/everyday stressors. The inclusion of service continuity
considerations within emergency management plans in health facilities contributes
to minimizing disruptions and therefore, health system resilience. Such plans (or
equivalent) should also consider context specific considerations, if applicable, such as
special considerations for health in fragile, conflict and violence (FCV) settings.
Level Facility
facilities, etc.
Subnational
Urban/rural
Numerator Number of health facilities that have emergency management and routine health
services continuity plans

source

Indicator 44 (continued). Percentage of health facilities that have emergency management plans
incorporating consideration of health services continuity
Additional reading Mustafa S, Zhang Y, Zibwowa Z, Seifeldin R, Ako-Egbe L, McDarby G, Kelley E, Saikat
and references S. COVID-19 Preparedness and Response Plans from 106 countries: a review from a
health systems resilience perspective. Health Policy Plan. 2022 Feb 8;37(2):255-268.
doi: 10.1093/heapol/czab089
World Health Organization. 2021. Health service continuity planning for public health
emergencies: a handbook for health facilities. Interim version for field testing. Geneva:
collection tools assessments and tools could be adapted to incorporate collection of this data.
Indicator 45. Percentage of facilities that have plans or service delivery models that take essential
services to hard-to-reach populations
Indicator short name % facilities with plans or service delivery models for hard-to-reach populations
Indicator name Percentage of facilities that have plans for service delivery models to take essential
Definition The percentage of health facilities (for example, in a geographical area or within
a network of health facilities) that have plans or service delivery models to take
essential health services to hard-to-reach populations in their areas of responsibility
Service delivery models are approaches to delivering health services (for example,
centralized national health services, managed care, concierge services, self-directed
services, telemedicine, community of care model). Populations that are hard-to-
reach such as the disadvantaged and marginalized, migrants, refugees, displaced,
geographically distant, homeless, criminal offenders and chronically mental ill have
distinct health needs that may not be readily accessible at health facilities. Therefore,
tailored plans and service delivery models may be needed to reach them and provide
the necessary health services to meet their needs.
Rationale Without specific plans to take essential health services to those that are hard-to-
reach, significant proportions of the population are left without contact with the
health system which can delay notification of infectious diseases and other health
hazards. This can mean that preventable health issues are not picked up early and
can cause greater strain on the health system in future, as well as reducing general
population resilience through ill-health. Moreover, smaller outbreaks of infectious
diseases can circulate un-reported or undetected in hard-to-reach populations
increasing the chance of becoming larger scale emergencies.
Level Facility
facilities, etc.
Subnational
Urban/rural
Numerator Number of facilities that have plans for service delivery models to take essential

source
Additional reading Bonevski B, Randell M, Paul C, Chapman K, Twyman L, Bryant J, et al. Reaching the
and references hard-to-reach: a systematic review of strategies for improving health and medical
research with socially disadvantaged groups. BMC Med Res Methodol. 2014 Mar
25;14:42. doi: 10.1186/1471-2288-14-42
Expanding universal health coverage among refugees and migrants: challenges
and opportunities. East Mediterr Health J. 2021;27(4):427–428 https://doi.
org/10.26719/2021.27.4.427
collection tools assessments and tools could be adapted to incorporate collection of this data.
Indicator 46. Existence of a standard, guideline, specification or equivalent that defines

infrastructural standards for health facilities
Indicator short name Health facility infrastructure standards for health facility resilience
Indicator name Existence of national or subnational standard, guideline, specification or equivalent

that defines infrastructural standards for health facilities
Domain Governance and leadership; Health infrastructure
Definition Existence of standards or equivalent that mandate the development of health facility
infrastructure such that the physical structures are appropriate to provide essential
medical services as well as withstand threats such as natural disasters, security or
other threats, in line with local or national risk assessments.
The standard, guideline or specification is recommended to cover the following areas:
• structural safety in the context of priority risks
• adequate, safe and accessible infrastructure (beds, stations, rooms, etc.) including
in the context of a surge
• sustainable and safe management of water, sanitation, hygiene (WASH), and health
care waste services
• sustainable energy services
Rationale The standard, guideline, specification or equivalent of health facilities can provide a
useful and standardized mechanism for ensuring compliance with requirements for
infrastructures for their resilience to routine/every day and unexpected shocks and
stressors.
Understanding of the safety and functionality of facilities in each geographical area
or other disaggregation can be useful for policy, planning and designing service and
system improvements to build resilience.
Numerator N/A
Denominator N/A
Additional reading World Health Organization. 2020. WHO guidance for climate-resilient and
and references environmentally sustainable health care facilities. Geneva: WHO (https://www.who.
int/publications/i/item/climate-resilient-and-environmentally-sustainable-health-
care-facilities)
World Health Organization. 2022. Health systems resilience toolkit: a WHO global
public health good to support building and strengthening of sustainable health
systems resilience in countries with various contexts. Geneva: WHO (https://www.
World Health Organization, Pan American Health Organization. 2019. Hospital Safety
Index. Guide for Evaluators. Second Edition. Washington, D.C.: WHO, PAHO (https://
iris.paho.org/handle/10665.2/51448)
Existing data World Health Organization. 2023. Harmonized Health Facility Assessment. Geneva:
collection tools WHO (https://www.who.int/data/data-collection-tools/harmonized-health-facility-
Indicator 47. Percentage of health facilities that meet standards for infrastructure
Indicator short name % facilities that meet standards for infrastructure
Indicator name Percentage of health facilities that meet standards for infrastructure
Domain Governance and leadership; Access to medicines and other health products
and technologies
Definition The percentage of health facilities that meet national or subnational standard,
guideline, specification or equivalent to guide the development of infrastructure such
that the physical structures are appropriate to provide essential medical services
as well as withstand threats such as natural disasters, security or other threats, in
line with local or national risk assessments. The facilities should meet standards for
infrastructure in the following areas:
• structural safety in the context of priority risks
• adequate, safe and accessible infrastructure (beds, stations, rooms, etc.) including in
the context of a surge
• sustainable and safe management of water, sanitation, hygiene (WASH), and health
care waste services
• sustainable energy services
• appropriate information technologies in place
Rationale The standard, guideline, specification or equivalent of health facilities can provide a
useful and standardized mechanism for ensuring compliance with requirements for
their resilience to routine/every day and unexpected shocks and stressors.
These include their suitability for essential health service continuity, safety, WASH,
utilities, conducting simulation exercises and learning activities, and space for adequate
workforce, considering their risk profile. Understanding of the safety and functionality
of facilities in each geographical area or other disaggregation can be useful for policy,
planning and designing service and system improvements to build resilience.
Level Facility
facilities, temporary health facilities, etc.
Managing authority: public, private; government, non-government
Urban/rural
Numerator Number of facilities that meet standards for health facility infrastructure
Denominator Total number of facilities examined / sampled

source

Indicator 47 (continued). Percentage of health facilities that meet standards for infrastructure
Additional reading World Health Organization. 2020. WHO guidance for climate-resilient and
and references environmentally sustainable health care facilities. Geneva: WHO (https://www.who.
int/publications/i/item/climate-resilient-and-environmentally-sustainable-health-
care-facilities)
World Health Organization. 2022. Health systems resilience toolkit: a WHO global
public health good to support building and strengthening of sustainable health
systems resilience in countries with various contexts. Geneva: WHO (https://www.who.
Existing data World Health Organization. 2023. Harmonized Health Facility Assessment. Geneva:
collection tools WHO (https://www.who.int/data/data-collection-tools/harmonized-health-facility-
It can be used to capture some of the data.
Indicator 48. A national coordination mechanism for multistakeholder participation and

community engagement with a focus on public health exists
Indicator short name Mechanism for multistakeholder participation and community engagement
Indicator name A national coordination mechanism for multistakeholder participation and

Domain Governance and leadership; Community engagement
Definition A national coordination mechanism exists meeting the following criteria:

• Responsible for coordinating, monitoring and implementing health (for example,
EPHF, PHC and/or UHC-related strategies and policies within the national health
sector policy, strategies and plans)
• Engagement and participation include a broad range of stakeholders, including:
a. Community groups, including vulnerable, marginalized and excluded popula-
tions (for example, ethnic minorities, women, the elderly, etc.)
b. Members of parliamentary health committee
c. Health worker associations, patient groups
d. Civil society organizations and advocacy groups
e. Health insurance bodies
f. Provider organizations/associations
g. Private sector
h. Academia and research institutes
i. UN agencies and other international organizations operating within the national
context
• The coordination mechanism has accountability for the range of health activities
defined by national health policies and plans
• The coordination mechanism/authority has adequate budget and sufficient staff
• The mandate includes the public sector as well as oversight and regulation of the
private sector where feasible
This indicator is in Primary Health Care Measurement Framework and Indicators (2022)
[indicator 7].
Rationale A key role of the ministry of health is to plan, initiate, coordinate, and oversee
strategies, policies and plans, where relevant, through health sector coordination
mechanisms. Policymakers must thus lead the process, ensure broad and meaningful
stakeholder participation and engagement including with the communities they
serve, ensure that the priorities that are set reflect stakeholder input in a balanced
way, and be held accountable for the results. The process must be transparent, with
clear roles and responsibilities, especially when it comes to evaluating and discussing
evidence from different viewpoints.
Numerator N/A
Denominator N/A

Indicator 48 (continued). A national coordination mechanism for multistakeholder participation and

Additional reading Schmets G, Rajan D, Kadandale S, editors. 2016. Strategizing national health
and references in the 21st century: a handbook. Geneva: WHO (https://apps.who.int/iris/
handle/10665/250221)
Primary Health Care Performance Initiative (PHCPI). Primary health care progression
model (https://improvingphc.org/primary-health-care-progression-model)
World Health Organization. 2021.Voice, agency, empowerment: handbook on social
Existing data World Health Organization. 2018. IHR (2005): State Party self-assessment annual
collection tools reporting tool, 1st ed. Geneva: WHO (https://www.who.int/publications/i/item/WHO-
WHE-CPI-2018-16)
Indicator 49. Mechanism to ensure community voices informing planning and organization of
services at the local level
Indicator short name Mechanism to ensure community engagement in service planning and organization
Indicator name Mechanism to ensure community voices informing planning and organization of
services at the local level
Domain Governance and leadership; Community engagement
Definition There is a mechanism to ensure the planning and organization of services is informed
by the voices of the population, communities, and civil society, at the local level
(district or local health systems and facilities). Such mechanism(s) should involve:
• recognizing that communities can take on roles and responsibilities in planning and
organization
• utilizing the role of the community effectively by communicating needs upwards
to policymakers as well as downwards by gathering and coordinating community
voices
• enhancing technical knowledge and skills of decision-makers, managers, and health
workers to fully engage in discussions and engagement with the community
• engaging communities in processes such as needs assessment, community
development, planning, design, development, delivery, and evaluation.
Such mechanism(s) include but not limited to the following activities and
demonstrates involvement of communities including vulnerable groups in the
planning process:
• Community health needs and asset assessment
• Participatory processes for priority setting
• Patient and relatives’ surveys
• Training of patient advocates
• Membership of community representatives in advisory boards at the local level (for
example, council boards) or in supervisory boards of facilities
This indicator in linked to indicator 57 in Primary Health Care Measurement Framework
and Indicators (2022).
Rationale Community engagement is the inclusion of local health system users and community
members in all aspects of health planning, provision, and governance. It is a central
component of ensuring that the services delivered are tailored to population needs,
priorities and values, which can be achieved through the involvement of communities
in the design, financing, governance, and implementation of PHC. To ensure that the
needs of all community members are met, it is important that community engagement
efforts include representation from diverse members of the community. This may
require multiple mediums for engagement, to best capture the needs and opinions of
traditionally underrepresented community members.
Ensuring that community voices are systematically used to inform the planning and
organization of health services leads to increased trust in services and providers, more
aligned decision making and addressing of the real needs of the community, enhanced
community satisfaction, trust, and patient reported outcomes in relation to health
services, greater chance of community acceptance and compliance to public health
advice and interventions, and more politically robust planning, policymaking and
implementation.
Numerator N/A
Indicator 49 (continued). Mechanism to ensure community voices informing planning and

organization of services at the local level
Denominator N/A
Additional reading Schmets G, Rajan D, Kadandale S, editors. 2016. Strategizing national health in the 21st
and references century: a handbook. Geneva: WHO (https://apps.who.int/iris/handle/10665/250221)
Primary Health Care Performance Initiative (PHCPI). 2019. Primary Health Care
Progression Model Assessment Tool (https://improvingphc.org/sites/default/files/
PHC-Progression%20Model%202019-04-04_FINAL.pdf )
handle/10665/259280)
World Health Organization. 2020. Community Engagement: A health promotion guide
for universal health coverage in the hands of the people. Geneva: WHO (https://www.
World Health Organization. 2021. Voice, agency, empowerment: handbook on social
World Health Organization Regional Office for Europe. 2019. Indicator passports:
WHO European Primary Health Care, Impact, Performance and Capacity Tool (PHC-
IMPACT): version 1. Copenhagen: WHO Regional Office for Europe (https://iris.who.int/
handle/10665/346478)
Existing data World Health Organization. 2022. Joint external evaluation tool: International Health
collection tools Regulations (2005) - third edition. Geneva: WHO (https://www.who.int/publications/i/
item/9789240051980)
A qualitative assessment tool with recommended scoring methodology is under
development by WHO and will be forthcoming.
Indicator 50. Percentage of facilities that have standard operating procedures (SOPs) for ensuring
essential supplies
Indicator short name % facilities with SOPs for ensuring essential supplies
Indicator name Percentage of facilities that have standard operating procedures (SOPs) for
ensuring essential supplies
Domain Governance and leadership; Access to essential health products
Definition Facility has standard operating procedures for ensuring essential supplies such as
medicines, personal protective equipment (PPE), oxygen, bed nets are available
during a shock event or surge.
Rationale The availability of essential supplies is critical for ensuring maintenance of

essential health services including emergency case management. Standard
operating procedures (SOPs) reduce errors and increase efficiency for intended
outcomes such as ensuring essential supplies (for example, medicines, personal
protective equipment, oxygen, bed nets) are available during a shock event or
surge in need.
Level Facility
municipality, etc.
Urban/rural
Numerator Number of health facilities that have SOPs for ensuring essential supplies

source
Additional reading and World Health Organization. Access to medicines and health products
references (https://www.who.int/our-work/access-to-medicines-and-health-products)
Indicator 51. Percentage of facilities that have standard operating procedures (SOPs) to enable
health facility staff to repurpose resources
Indicator short name % facilities with SOPs for repurposing resources
Indicator name Percentage of facilities that have standard operating procedures (SOPs) to enable
health facility staff to repurpose resources
Domain Governance and leadership; Access to medicines and supplies
Definition Percentage of facilities that have SOPs to enable health facility staff to repurpose
resources without disrupting essential health services, in response to evolving
population health needs (for example, infectious disease outbreaks, natural disasters,
or everyday stressors such as staff absences, temporary budgetary issues, etc), and
include SOPs for:
• repurposing of infrastructure (for example, hospital beds)
• staff (for example, redeployment to areas of greater need)
• medical supplies (for example, redirecting oxygen supplies for acute, high-
dependency and intensive care)
SOPs represent the translation of policies, guidelines, standards, etc into practice
at the service delivery level. SOPs reduce errors and increase efficiency for intended
outcomes.
Rationale Ensuring SOPs to enable health facility staff to repurpose resources can enhance the
ability of the system to better prepare for, adapt to, respond to, and recover from
evolving health needs, shocks, and stressors, while maintaining core functionality.
Level Facility
Urban/rural
Numerator Number of facilities that have standard operating procedures to enable staff to
repurpose resources

source
Type (M&E domain) Input and structures
Additional reading World Health Organization. 2021. Building health systems resilience for universal
and references health coverage and health security during the COVID-19 pandemic and beyond: WHO
position paper. Geneva: WHO (https://www.who.int/publications/i/item/WHO-UHL-
PHC-SP-2021.01)
collection tools assessments and tools could be adapted to incorporate collection of this data
Indicator 52. Mechanisms in place to support the systematic capture and translation of lessons
identified from public health shocks, incidents and events
Indicator short name Institutionalizing learning from public health events
Indicator name Mechanisms in place to support the systematic capture and translation of lessons
identified from public health shocks, incidents and events
Domain Governance and leadership; Health information
Definition There is evidence of mechanisms or processes to support the systematic capture

and translation of lessons identified from public health shocks, incidents and
events, to inform decision making, planning and policymaking, resource allocation
and health systems performance improvement. Examples include:
• Systematic inclusion of intra- and after-action review (IAR/AAR) findings and
recommendations within health sector and system planning process
• Integration and alignment between National Action Plans for Health Security
and health sector development planning process
Rationale A key capacity of resilient health systems is the ability to apply lessons learnt from
past and ongoing experiences to adapt, transform, and improve. Lessons are not
automatically translated into improvements even when systematic mechanisms
to capture those lessons (for example, intra- and after-action reviews) are in place.
In order to institutionalize learning, lessons must be systematically integrated into
existing processes.

municipality, etc.
National
Numerator N/A
Denominator N/A
Additional reading and McDarby G, Seifeldin R, Zhang Y, Mustafa S, Petrova M, Schmets G, Porignon
references D, Dalil S and Saikat S (2023) A synthesis of concepts of resilience to inform
operationalization of health systems resilience in recovery from disruptive public
health events including COVID-19. Front. Public Health. 11:1105537. doi: 10.3389/
fpubh.2023.1105537

tools
Indicator 53. Existence of health system resilience function within emergency management
structures at all levels
Indicator short name Health system resilience as a function in emergency management structures
Indicator name Existence of health system resilience function within emergency management
structures at all levels
Definition There is evidence that a health system resilience function, for example, continuity
of essential health services during emergencies, and support to health system
recovery and strengthening based on lessons learnt form emergencies, exists
within emergency management structures at all administrative levels. This
includes:
• Health system resilience is identified within the terms of reference of emergency
structures at all levels (i.e., national, subnational, local)
• Focal point for health system resilience is identified in the organograms of
emergency management structure
• Activities include a focus on health system resilience involving relevant
stakeholders at system and service delivery levels
Rationale Effective emergency management with maintenance of essential health services

requires intra- and inter-sectoral coordination and participation with a focus on
resilience of the health system.
etc.
National
Numerator N/A
Denominator N/A
source country documents such as national, subnational polices, plans, guidance or
terms of reference of emergency structures, etc.
Type (M&E domain) Inputs and structure
World Health Organization. 2017. Emergency response framework (ERF), 2nd
edition. Geneva: WHO (https://www.who.int/publications/i/item/9789241512299)
World Health Organization. 2020. Maintaining essential health services:
operational guidance for the COVID-19 context: interim guidance, 1 June 2020.
World Health Organization. 2020. Multisectoral preparedness coordination
framework: Best practices, case studies and key elements of advancing
multisectoral coordination for health emergency preparedness and health
security. Geneva: WHO (https://www.who.int/publications/i/item/9789240006232)

tools
Indicator 54. National emergency policies and strategies define the role of health services in
emergency preparedness and response, and recovery
Indicator short name Emergency policy defines role of health services
Indicator name National emergency policy and strategy (or equivalent) defines the role of health
services in emergency preparedness and response, and recovery
Definition There is evidence that national emergency policies and strategies define the roles
of health services in emergency preparedness and response and recovery, against
the following criteria:
• Describing the roles and responsibilities of health services at all levels
• Describing the roles and responsibilities of health services comprehensively
in terms of health emergency management cycle, i.e., addresses prevention,
preparedness, response and recovery measures
• Describing roles in relation to (but not limited to):
a. designating focal points in health services providers health emergency and
disaster risk management, or incorporating health services in emergency
management structures
b. simulation exercises
c. continuity and the maintenance of quality essential health services during
response
d. safe restoration of services and addressing the backlog of health care needs in
the recovery phase
e. after action review or intra-action review
f. ensuring equity and addressing the needs of vulnerable populations and
communities
National emergency policies and strategies can include health emergency and
disaster risk management strategies, national pandemic preparedness plans, etc.
This indicator is included as one of the attributes of indicator 5 in the Primary Health
Care Measurement Framework and Indicators (2022).
Rationale Health services functions play a key role in emergency preparedness and response
and require formally defining roles and responsibilities to ensure effective
emergency management in tandem with maintaining core functions of the broader
health system.
National emergency policy defining the roles of health services in emergency
management supports the integration between efforts for health security and
health systems strengthening for resilience.
Level National
Disaggregation N/A
Numerator N/A
Denominator N/A

Indicator 54 (continued). National emergency policies and strategies define the role of health
services in emergency preparedness and response, and recovery
handle/10665/346515)

tools
Indicator 55. National health sector policies and strategies define the roles of health services at all
levels for public health emergencies
Indicator short name Health sector policies define roles of health services for emergencies
Indicator name National health sector/health system policies and strategies (or equivalent) define
the roles of health services at all levels for public health emergencies
Definition There is evidence of national health sector policies and strategies (or equivalent)
which define the role of health services (primary, secondary, tertiary care) during
public health emergencies, for example, roles in relation to providing essential
health services including public health services on disease prevention, health
promotion, health protection, public health surveillance and monitoring, etc.
Rationale Specifying the roles of health services for public health emergency management
in national health sector plans can support the integration of health security and
health systems strengthening for resilience.
Primary care is often the first point of contact between communities and the
health system and as such play a key role in emergency management activities
such as surveillance and disease notification, testing, contact tracing, vaccine
delivery, etc.
Level National
Disaggregation N/A
Numerator N/A
Denominator N/A
handle/10665/250221)
World Health Organization. 2018. Primary health care and health emergencies.
Geneva: WHO (https://iris.who.int/handle/10665/328105)
handle/10665/346515)

tools
Indicator 56. Annual operational health sector plan includes emergency preparedness activities
Indicator short name Health sector plan includes preparedness activities
Indicator name Annual operational health sector plan includes emergency preparedness activities
Definition There is evidence of emergency preparedness activities in the annual operational

health sector plan. Emergency preparedness activities should include activities in
relation to:
• Simulation exercises
• After-action reviews or intra-action reviews
• Training on health systems resilience or equivalent training covering key
conceptual and operational aspects on health systems resilience
The evidence should be in the form of activities specified in written plans.
Rationale National annual operational health sector plans set the operational scope
of health sector activities and to ensure health systems are resilient there is
a need to incorporate emergency preparedness and other health systems
activities in tandem. This would allow mainstreaming of health system resilience
considerations in routine health system functions including at service
delivery levels.

municipality, etc.
National
Numerator N/A
Denominator N/A
handle/10665/250221)
handle/10665/346515)

tools
Indicator 57. Availability of a designated entity or structure for health system resilience function
Indicator short name Designated entity or structure for health system resilience
Indicator name Availability of a designated entity or structure for health system resilience function
Definition There is evidence of the availability of a designated authority or entity mandated

with responsibility for coordination and implementation of health system resilience
functions in the government.
Evidence is usually demonstrated through clear terms of reference or mandates that
describe roles of coordination and oversight of health system resilience in the country.
The designated authority can be in the form of a unit in ministry, a technical group,
etc. as long as coordination and oversight of health system resilience function is
presented in the terms of reference or list of mandates.
Rationale A designated responsible authority or entity for health systems functions ensures
intended activities and outcomes are pursued as well as accountability for
implementation.
National
Numerator N/A
Denominator N/A
Additional reading World Health Organization. 2021. Building health systems resilience for universal
and references health coverage and health security during the COVID-19 pandemic and beyond: WHO
position paper. Geneva: WHO (https://apps.who.int/iris/handle/10665/346515)

collection tools
Indicator 58. Availability of national guideline on equity and ethics for delivery of routine and
emergency-related health services in the context of public health emergencies
Indicator short name Guideline on equity and ethics for service delivery
Indicator name Availability of national guideline on equity and ethics for delivery of routine and
emergency related health services in the context of public health emergencies
Definition There is national guideline(s) on equity and ethics for delivery of routine and
emergency-related health services in the context of public health emergencies.
The national guideline should have the following characteristics:
• It should provide guidance on equity and ethics for providing both routine
essential health services and emergency-related health services
• It should have specific consideration for meeting the needs of vulnerable
populations
• It should be available and disseminated to health facilities
It could be in the format of a part of other documents. It does not have to be
standalone guideline.
Rationale During emergencies, vulnerable populations such as women, children, elderly,

migrants, etc. may be disproportionately affected by the impacts and as such there
is a need for guidelines on the equitable and ethical delivery of essential health
services (both emergency case management and routine).
Level National
Disaggregation N/A
Numerator N/A
Denominator N/A
Additional reading and ICRC, IFRC, IOM, NRC, UNICEF, UN-HABITAT, UNHCR, and WHO in consultation with
references IASC members. 2020. Inter-Agency Standing Committee (IASC). Public health and
social measures for COVID-19 preparedness and response in low capacity and
humanitarian settings (https://www.who.int/publications/m/item/public-health-
and-social-measures-for-covid-19-preparedness-and-response-in-low-capacity-
and-humanitarian-settings)
handle/10665/346515)

tools
Indicator 59. Existence of a national entity or structure that is responsible for the
coordination of the essential public health functions (EPHFs) in an integrated manner
Indicator short name Institutional capacity for EPHF coordination
Indicator name Existence of a national entity or structure that is responsible for the coordination
of the essential public health functions (EPHFs) in an integrated manner
Domain Governance and leadership; service delivery
Definition There is a dedicated national entity or structure (for example, standalone national
public health institute, semi-autonomous institution under a national health
authority, department within the MoH, network of agencies with the responsibility
to carry out public health functions collectively, etc.) with a clear mandate for
coordinating the planning and delivery of essential public health functions in
the country.
This entity or structure has the characteristics:
• It is a public institution operating as part of the government or with the
concurrence of the government.
• Coordination of all or most of the essential public health functions at the national
level is clearly defined in its mandate or terms of reference
• It is empowered by the minister or the parliament to coordinate among different
agencies in the planning and delivery of the essential public health functions.
Rationale The COVID-19 pandemic, climate-related threats, conflicts and other public health
challenges have exposed weaknesses in the public health capacities necessary for
resilient health systems. Applying the EPHFs is a holistic, integrated operational
approach to public health. It is important to have institutions such as NPHIs that
are responsible for leading, and able to coordinate the planning, delivery and
monitoring and evaluation of EPHFs reflective of the national context. Without
dedicated responsible entity(ies) these public health functions may not be carried
out adequately or in an integrated, coordinated and holistic manner. Furthermore,
NPHIs provide independent scientific evidence to inform policymaking in a
national context as well as provide visibility and prominence to public health.
National
Numerator N/A
Denominator N/A

Indicator 59 (continued). Existence of a national entity or structure that is responsible for the
coordination of the essential public health functions (EPHFs) in an integrated manner
Additional reading and International Association of National Public Health Institutes (IANPHI). 2007.
references Framework for the Creation and Development of National Public Health Institutes.
Paris: IANPHI (https://ianphi.org/_includes/documents/sections/tools-resources/
all-frameworks/frameworkfornphi.pdf)
World Health Organization. 2016. Strengthening essential public health functions
in support of the achievement of universal health coverage. Geneva: WHO (https://
apps.who.int/iris/handle/10665/252781)
World Health Organization. 2018. Primary health care: closing the gap between
public health and primary care through integration. Geneva: WHO (https://apps.
handle/10665/346515)
World Health Organization. 2023. Operationalizing essential public health
functions – an integrated and comprehensive approach to public health.
Geneva: WHO.
World Health Organization Regional Office for Europe. 2021. A guide to establishing
national public health institutes through mergers. Copenhagen: WHO Regional
Office for Europe (https://apps.who.int/iris/handle/10665/340282)

tools
Indicator 60. Availability of a designated health system focal point responsible for health services
provision assessment process in IHR monitoring and evaluation
Indicator short name Focal point designated for IHR health services provision assessment
Indicator name Availability of a designated health system focal point responsible for health
services provision assessment process in IHR monitoring and evaluation
Definition There is evidence of availability of a designated health system focal point (for
example, a focal person or team) responsible for providing, drawing and coordinating
inputs from health system and multisectoral stakeholders to the health services
provision assessment process in IHR monitoring and evaluation (for example, State
Party Self-Assessment Annual Report second edition, C8 health services provision;
Joint External Evaluation third edition, R3 health services provision).
Evidence for availability of a designated focal point can be in the form of clear
terms of reference describing the roles and responsibilities.
Rationale State Party Self-Assessment Annual Report (SPAR) second edition C8 health
services provision requires specific health systems technical expertise for accurate
and effective evaluation.
Level National
Disaggregation N/A
Numerator N/A
Denominator N/A
Additional reading and World Health Organization. 2021. International Health Regulations (2005): State
references Party Self-assessment annual reporting tool, second edition. Geneva: WHO
(https://www.who.int/publications/i/item/9789240040120)
World Health Organization. 2022. Joint external evaluation tool: International
Health Regulations (2005), third edition. Geneva: WHO (https://www.who.int/

tools The IHR State Party Self-assessment annual reporting tool and Joint external
evaluation tool collects data on the existence and functions of IHR focal point.
Indicator 61. Implementation of a Health in All Policies (HiAP) approach
Indicator short name Health in All Policies approach being implemented
Indicator name Implementation of a Health-in-all-Policies (HiAP) approach
Definition The country has implemented an HiAP approach that includes the following elements:
• Existence of a national HiAP strategy and plan of action involving multiple sectors
• Existence of recognized functional mechanisms to manage and monitor HiAP
development and implementation
• Mechanism for monitoring and oversight to examine the impact on health and equity
of outcomes of HiAP
• Evidence of collaborations across sectors to address health issues or determinants
of health including:
– Existence of operational policy/strategy/action plan to reduce physical inactivity
– Age limits alcohol service/sales
– Alcohol taxation
– Drunk driving laws
– Alcohol advertising restrictions
– Alcohol licensing requirements
– Existence of a national seat-belt law
– Existence of national speed limit
– MPOWER measures fully implemented (tobacco)
– Existence of any policies to reduce population salt consumption
– Existence of policies on marketing of foods to children
– Existence of tax on sugar-sweetened beverages
• Training opportunities and knowledge change for health workforce and institutions
• Opportunities for community engagement through consultations and level of
community participation.
This indicator is in the Primary Health Care Measurement Framework and Indicators
(2022) [Indicator 1].
Rationale Multisectoral policies and action are a core component of primary health care.
To bring about policy changes in other sectors, the health community needs to
advocate for change and to generate evidence on the health impacts of multisectoral
determinants. This is particularly important because several the policy changes that
are most important for improving health and well-being involve vested commercial
interests, which often have significant influence over policymakers. HiAP is a whole-of-
government approach to multisectoral policy and action at the national, subnational,
and regional levels: “an approach to public policies across sectors that systematically
takes into account the health implications of decisions, seeks synergies, and avoids
harmful health impacts in order to improve population health and health equity”
(WHA67.12). HiAP underscores the alignment of interests across policies to serve
all people’s basic right to a healthy, productive life. It provides a framework for
addressing determinants by developing the needed leadership and governance and
providing an umbrella for multiple sets of actions across sectors. In an HiAP approach,
the health sector is seen as the champion for health, keeping health on the agenda but
aware of the need for policy action with mutual benefit with other sectors, seeking
overall societal gains. National health assemblies can bring together key stakeholders,
including those from other sectors, to shape policymaking.
Level National
Disaggregation N/A
Indicator 61 (continued). Implementation of a Health in All Policies (HiAP) approach
Numerator N/A
Denominator N/A
Additional reading Schmets G, Rajan D, Kadandale S, editors. 2016. Strategizing national health in the 21st
and references century: a handbook. Geneva: WHO (https://apps.who.int/iris/handle/10665/250221)
World Health Organization. 2014. Health in all Policies (HiAP). Framework for Country
Action. Geneva: WHO (https:// www.who.int/healthpromotion/hiapframework.pdf)
World Health Organization. 2018. Health in All Policies as part of the primary health
care agenda on multisectoral action. Geneva: WHO (https://apps.who.int/iris/
handle/10665/326463)
Existing data A qualitative assessment tool with recommended scoring methodology is currently
collection tools under development by WHO and forthcoming.
Indicator 62. Availability of national and subnational guidance (or equivalent) on health system
recovery planning and actions
Indicator short name Recovery planning guidance
Indicator name Availability of national and subnational guidance (or equivalent) on health system
recovery planning and actions
Definition There is evidence that guidance document exists for health systems recovery
planning and actions, with the following attributes:
describing comprehensive and specific approach to recovery, for example, guiding
principles and steps informed by situational reviews, evidence, and analyses
The guidance could be a distinct document or a part of other national or
subnational guidance, for example, for emergency management or health sector
planning including a focus on recovery aspects.
Rationale Health systems recovery planning and actions can be overlooked during and
beyond health emergencies/events but offer significant opportunities to adapt,
transform and improve the health system. Facilities can benefit from evidence-
based guidance based on global, national and subnational lessons learned and
best practices.
Level National; Subnational

municipality, etc.
National
Numerator N/A
Denominator N/A
handle/10665/250221)
handle/10665/346515)
WHO has an upcoming publication on Health System Recovery Planning Guide.

tools
Indicator 63. Existence of a designated entity or structure with the responsibility for recovery
process following a public health event
Indicator short name Designated entity with responsibility for recovery
Indicator name Existence of a designated entity or structure with the responsibility for recovery
process following a public health event
Definition There is evidence of the availability of a designated entity or structure (for

example, a multiagency working group; an existing governmental agency or
department; etc.) mandated with responsibility for multisectoral coordination
and implementation of recovery processes following public health emergencies/
events, humanitarian crises, natural disasters; etc.
Examples of responsivities for recovery process include transitioning government
arrangements from response to recovery, planning for health system recovery, etc.
Evidence for availability of a designated entity or structure can be in the form of
clear terms of reference covering responsibility for recovery process.
Rationale A designated responsible authority or dedicated structure for health systems

recovery functions ensures intended activities and outcomes are pursued as well
as accountability.

municipality, etc.
National
Numerator N/A
Denominator N/A
Additional reading and World Health Organization. 2021. Building health systems resilience for
references universal health coverage and health security during the COVID-19 pandemic
handle/10665/346515)

tools
4.7 General/composite indicators
Indicator 64. IHR State Party Self-Assessment Annual Report (SPAR) health service provision
capacity score
Indicator short name IHR SPAR health services provision capacity score
Indicator name IHR State Party Self-Assessment Annual Report (SPAR) health services provision
capacity score
Domain Composite; service delivery
Definition The SPAR (second edition, 2021) C8 health services provision capacity score
is calculated through self-evaluation using different levels of indicators in the
following areas:
C8.1. Case management

Level 1 National clinical case management guidelines for priority health events are
not available or under development
developed but not being implemented
developed and being implemented at national level
developed and being implemented at national and subnational levels
implemented at all levels and are exercised (as applicable), reviewed, evaluated
and updated on regular basis
C8.2. Utilization of health services

Level 1 Very low levels of service utilization (number of outpatient department
visits per person per year < 1.00 visit/person/ year in both urban and rural areas)
Level 2 Low levels of service utilization (number of outpatient department visits
per person per year 1.0 ≤ X < 2.0 visit/ person/year, in both urban and rural areas)
Level 3 Satisfactory levels of service utilization in tertiary health care facilities
at national level (number of outpatient department visits per person per year
≥ 2.0 visit/person/year, in both urban and rural areas)
Level 4 Strong levels of service utilization at all tertiary and secondary health care
facilities at intermediate and national levels and geographical contexts (number of
outpatient department visits per person per year ≥ 3.0 visit/person/ year, in both
urban and rural areas)
Level 5 Strong levels of service utilization at all tertiary, secondary and primary
health care facilities at national, intermediate and local levels and geographical
contexts (number of outpatient department visits per person per year ≥ 3.0 visit/
person/year, in both urban and rural areas) and information on service utilization is
reviewed, evaluated and updated on a regular basis to inform policy and planning
Indicator 64 (continued). IHR State Party Self-Assessment Annual Report (SPAR) health service
provision capacity score
Definition C8.3. Continuity of essential health services (EHS)

Level 1 A package of EHS is not defined and there are no plans or guidelines for
continuity EHS during emergency
Level 2 A package of EHS is defined but plans/guidelines on continuity of EHS in
emergencies is not developed
Level 3 A package of EHS and plans/guidelines on continuity of EHS in emergencies
are developed and mechanism for monitoring service continuity during emergency
is in place at national level
Level 4 A package of EHS and plans/guidelines on continuity of EHS in emergencies
are developed and mechanism for monitoring service continuity during emergency
is in place at national and intermediate levels
Level 5 A package of EHS, plans/guidelines on continuity of EHS in emergencies,
and mechanisms for monitoring service continuity based on existing guidelines
are defined and functional at national, intermediate and local levels and exercised,
reviewed, evaluated and updated, with improvements based on simulation exercise
(SimEx) and lessons learned from real- world events, for example, IARs or AARs
Rationale Resilient health systems are essential if countries are to prevent, detect, respond
to and recover from public health events while also ensuring the continuity of
health services at all levels. Health services provision for both event-related case
management and routine health services are as equally important. Ensuring
minimal disruption in health services utilization before, during, and beyond an
emergency and across the varied contexts within a country is a critical aspect of
health systems resilience.
This existing indicator in IHR monitoring and evaluation framework can be used in
conjunction with other health system resilience indicators to understand health
services provision capacities in both routine and emergency settings.
Level National
Disaggregation N/A
Numerator N/A
Denominator N/A
Recommended data IHR State Party Self-Assessment Annual Report questionnaire

source Electronic IHR States Parties Self-Assessment Annual Reporting Tool
Type (M&E domain) Composite / Output
Additional reading and World Health Organization. 2021. International Health Regulations (2005): State
references Party Self-assessment annual reporting tool, second edition. Geneva: WHO
Existing data collection World Health Organization. 2021. International Health Regulations (2005): State
tools Party Self-assessment annual reporting tool, second edition. Geneva: WHO
World Health Organization. Electronic IHR States Parties Self-Assessment Annual
Reporting Tool (https://extranet.who.int/e-spar)
5
Supplementary indicators
of relevance to health
system resilience
This section provides a set of supplementary

indicators that have been identified as of relevance
to health system resilience and can contribute to
the comprehensive measurement, monitoring and
analysis of the resilience of health systems
and services.
Table 5. Supplementary indicators and sources
5. Supplementary indicators of relevance to health system resilience

Indicators Main sources and references
Service delivery
Number of inpatient beds per World Health Organization. Global Health Observatory (https://www.who.int/data/gho)
10 000 population World Health Organization and United Nations Children’s Fund (UNICEF). 2022. Primary health care measurement framework
and indicators: monitoring health systems through a primary health care lens. Web annex: technical specifications. Geneva:
WHO and UNICEF (https://apps.who.int/iris/handle/10665/352201)
Average bed occupancy rate World Health Organization and United Nations Children’s Fund (UNICEF). 2022. Primary health care measurement framework
Average number of health workers per Related indicators in:

inpatient bed World Health Organization. Global Health Observatory (https://www.who.int/data/gho)
Outpatient department, primary health Organisation for Economic Co-operation and Development. Health at a glance 2021: OECD indicators. Paris: OECD
care and emergency department service (https://doi.org/10.1787/19991312)
utilization rate (before, during and after Sphere Association. 2018. The sphere handbook: humanitarian charter and minimum standards in humanitarian response,
emergencies) fourth edition. Geneva: Sphere Association (https://spherestandards.org/handbook-2018/)
Number of patients who are admitted to Related indicators in:

or leave a hospital after staying at least Organisation for Economic Co-operation and Development. Health at a glance 2021: OECD indicators. Paris: OECD (https://doi.
one night per 1000 population (includes org/10.1787/19991312)
death following inpatient care but
World Health Organization. Global Health Observatory (https://www.who.int/data/gho)
excludes same-day discharges)
Average length of stay (ALOS) at hospital Organisation for Economic Co-operation and Development. Health at a glance 2021: OECD indicators. Paris: OECD (https://doi.
or health facility (average number of org/10.1787/19991312)
days a patient has stayed at the facility World Health Organization. Global Health Observatory (https://www.who.int/data/gho)
from admission to discharge)
World Health Organization Regional Office for Europe. European health information gateway. Indicators explorer.
Copenhagen: WHO Regional Office for Europe (https://gateway.euro.who.int/en/hfa-explorer/)
Average number of consultations per Organisation for Economic Co-operation and Development. Health at a glance 2021: OECD indicators. Paris: OECD (https://doi.
capita per year org/10.1787/19991312)
Sphere Association. 2018. The sphere handbook: humanitarian charter and minimum standards in humanitarian response,
fourth edition. Geneva: Sphere Association (https://spherestandards.org/handbook-2018/)
123
Table 5 (continued). Supplementary indicators and sources
Implementation of a triage process in the Similar indicators in:

outpatient department (OPD) World Health Organization. Harmonized Health Facility Assessment (HHFA).
Geneva: WHO (https://indicator-inventory.hhfa.online/)
General readmission rate at the facility Related indicators in:

(hospital readmission within specified World Health Organization. 2015. Global reference list of 100 core health indicators. Geneva: WHO (https://apps.who.int/iris/
days of discharge) handle/10665/173589)
World Health Organization and United Nations Children’s Fund (UNICEF). 2022. Primary health care measurement framework
Readmission rates for a tracer condition World Health Organization and United Nations Children’s Fund (UNICEF). 2022. Primary health care measurement framework
(relevant to the country context, and indicators: monitoring health systems through a primary health care lens. Web annex: technical specifications. Geneva:
for example, cases of malnutrition, WHO and UNICEF (https://apps.who.int/iris/handle/10665/352201)
caesarean section or surgical procedure)
Rate of a specific healthcare associated Similar indicator in:

infection (HAI) (which is relevant to the World Health Organization and United Nations Children’s Fund (UNICEF). 2022. Primary health care measurement framework
country context) in patients and indicators: monitoring health systems through a primary health care lens. Web annex: technical specifications. Geneva:
Rates of return to intensive care unit Related indicators in:

(ICU) (return to ICU within specified World Health Organization and United Nations Children’s Fund (UNICEF). 2022. Primary health care measurement framework
hours of hospital discharge) and indicators: monitoring health systems through a primary health care lens. Web annex: technical specifications. Geneva:
Availability of an antimicrobial Food and Agriculture Organization of the United Nations, United Nations Environment Programme, World Health
resistance (AMR) stewardship Organization, and World Organization for Animal Health. Global Database for Tracking Antimicrobial Resistance (AMR).
programme? (yes or no) Country Self- Assessment Survey (TrACSS). (http://www.amrcountryprogress.org/)
World Health Organization. 2016. Global action plan on antimicrobial resistance. Geneva: WHO (https://www.who.int/
World Health Organization. 2021. WHO policy guidance on integrated antimicrobial stewardship activities.
124

Percentage of bloodstream infections United Nations Statistics Division. Sustainable development goals (SDGs) Indicators (https://unstats.un.org/sdgs/metadata/)
due to selected antimicrobial-resistant
organisms
Percentage of health facilities that have World Health Organization and United Nations Children’s Fund (UNICEF). 2022. Primary health care measurement framework
a core set of relevant essential medicines and indicators: monitoring health systems through a primary health care lens. Web annex: technical specifications. Geneva:
available and affordable on a sustainable WHO and UNICEF (https://apps.who.int/iris/handle/10665/352201)
basis (disaggregated by medicine types,
for example, antibiotics).
Immunization coverage rate for measles/ World Health Organization. Global Health Observatory. Immunization coverage. (https://www.who.int/data/gho/data/
yellow fever/polio or other country themes/topics/immunization-coverage)
specific tracer vaccine World Health Organization. WHO immunization data portal. (https://immunizationdata.who.int/listing.html?topic=coverage)
United Nations Statistics Division. Sustainable development goals (SDGs) Indicators (https://unstats.un.org/sdgs/metadata/)
Percentage of children aged six months World Health Organization: Global Health Observatory. Immunization coverage. (https://www.who.int/data/gho/data/
to 15 years who have received measles themes/topics/immunization-coverage)
vaccination, on completion of a measles
vaccination campaign
Percentage of children aged six months World Health Organization. 2011. Guideline: Vitamin A supplementation in infants and children 6–59 months of age. Geneva:
to 59 months who have received an WHO ( https://www.who.int/publications/i/item/9789241501767)
appropriate dose of vitamin A, on World Health Organization. Global Health Observatory (https://www.who.int/data/gho)
completion of a measles vaccination
campaign
Percentage of children aged 12 months World Health Organization. Global Health Observatory (https://www.who.int/data/gho)
who have had three doses of the World Health Organization Regional Office for the Eastern Mediterranean. Eastern Mediterranean Health Observatory
combined diphtheria, tetanus toxoid and (https://rho.emro.who.int/metadata-Registry)
pertussis vaccine (DPT)
125
Percentage of primary care facilities Related indicators and concepts in:

that offer basic Expanded Program on World Health Organization. Harmonized Health Facility Assessment (HHFA). (https://indicator-inventory.hhfa.online/)
Immunization (EPI) services at least 20
World Health Organization. Essential Programme on Immunization. (https://www.who.int/teams/immunization-vaccines-
days/month
and-biologicals/essential-programme-on-immunization)
Percentage of noncompliance Related concepts in:

to tuberculosis (TB) treatment World Health Organization. 2022. WHO consolidated guidelines on tuberculosis: module 4: treatment: drug-susceptible
disaggregated by type of TB case tuberculosis treatment. Geneva: WHO (https://apps.who.int/iris/handle/10665/353829)
World Health Organization. 2022. WHO consolidated guidelines on tuberculosis: module 4: treatment: tuberculosis care and
support. Geneva: WHO (https://apps.who.int/iris/handle/10665/353399)
Annual in-patient cause-specific Related indicators in:

mortality rates for a tracer NCD World Health Organization and United Nations Children’s Fund (UNICEF). 2022. Primary health care measurement framework
condition (for example, cardiovascular and indicators: monitoring health systems through a primary health care lens. Web annex: technical specifications. Geneva:
diseases, diabetes or other specific WHO and UNICEF (https://apps.who.int/iris/handle/10665/352201)
condition, to be defined with reference
to disease burden) at the last
measurement point
Under-five crude mortality rate - United Nations Children’s Fund (UNICEF). Under-five mortality (https://data.unicef.org/topic/child-survival/under-five-
deaths/10,000 children under 5 years/day mortality/#data)
Is effective anti-malarial treatment Related indicators in:

provided in a timely manner to all World Health Organization. The Global Health Observatory (https://www.who.int/data/gho/indicator-metadata-registry/imr-
children under age five years presenting details/14)
with malaria? (yes or no)
Is oral rehydration salts (ORS) and zinc Related indicators in:

supplementation provided in a timely World Health Organization. The Global Health Observatory. Health inequality monitor: Newborn and child health
manner to all children under age five interventions: Care-seeking for sick children. https://www.who.int/data/gho/data/themes/topics/indicator-groups/indicator-
years presenting with diarrhoea? group-details/GHO/health-equity-monitor-care-seeking-for-sick-children
(yes or no)
126

Is appropriate care provided in a timely Related indicators in:

manner to all children under age five World Health Organization. The Global Health Observatory. Health inequality monitor: Newborn and child health
years presenting with pneumonia? interventions: Care-seeking for sick children. https://www.who.int/data/gho/data/themes/topics/indicator-groups/indicator-
(yes or no) group-details/GHO/health-equity-monitor-care-seeking-for-sick-children
Presence of a specimen referral system Related indicators and technical questions in:
(or protocol) between facilities and labs World Health Organization. 2021. International health regulations (2005): state party self-assessment annual reporting tool,
2nd ed. Geneva: WHO (https://www.who.int/publications/i/item/9789240040120)
World Health Organization. 2022. Joint external evaluation tool: International Health Regulations (2005) - third edition.
Geneva: WHO (https://www.who.int/publications/i/item/9789240051980)
Proportion of samples within Related guidance:

recommended turnaround time (for World Health Organization. Monitor adherence to the turnaround times as determined for each examination (https://extranet.
priority diseases) to/at the reference who.int/lqsi/content/monitor-adherence-turnaround-times-determined-each-examination)
laboratory
Percentage of facilities located in a Related concepts in:

hazardous/at risk zone (hazardous Sphere Association. 2018. The sphere handbook: humanitarian charter and minimum standards in humanitarian response,
zone: for example, a zone prone to fourth edition. Geneva: Sphere Association (https://spherestandards.org/handbook-2018/)
earthquakes, natural disasters, periodic/
World Health Organization, Pan American Health Organization. Smart Hospitals initiative. (https://www.paho.org/en/health-
seasonal health risks and hazards/
emergencies/smart-hospitals-initiative)
outbreaks)
Incidence of major communicable Sphere Association. 2018. The sphere handbook: humanitarian charter and minimum standards in humanitarian response,
diseases is stable or not increasing fourth edition. Geneva: Sphere Association (https://spherestandards.org/handbook-2018/)
against pre-crisis level? (yes or no)
Percentage of suspected cases confirmed Sphere Association. 2018. The sphere handbook: humanitarian charter and minimum standards in humanitarian response,
by a diagnostic method as determined by fourth edition. Geneva: Sphere Association (https://spherestandards.org/handbook-2018/)
an agreed protocol
Percentage of health facilities with Sphere Association. 2018. The sphere handbook: humanitarian charter and minimum standards in humanitarian response,
protocols for the acutely injured fourth edition. Geneva: Sphere Association (https://spherestandards.org/handbook-2018/)
including formal triage instruments
127
Percentage of health facilities with staff Sphere Association. 2018. The sphere handbook: humanitarian charter and minimum standards in humanitarian response,
that have received basic training in the fourth edition. Geneva: Sphere Association (https://spherestandards.org/handbook-2018/)
approach to the acutely injured
Percentage of health facilities Sphere Association. 2018. The sphere handbook: humanitarian charter and minimum standards in humanitarian response,
implementing quality improvement fourth edition. Geneva: Sphere Association (https://spherestandards.org/handbook-2018/)
measures to reduce baseline morbidity
and mortality according to available data
Percentage of secondary healthcare Sphere Association. 2018. The sphere handbook: humanitarian charter and minimum standards in humanitarian response,
facilities with trained and supervised fourth edition. Geneva: Sphere Association (https://spherestandards.org/handbook-2018/)
staff and systems for managing mental
health conditions
Percentage of primary healthcare Sphere Association. 2018. The sphere handbook: humanitarian charter and minimum standards in humanitarian response,
facilities providing care for priority NCDs fourth edition. Geneva: Sphere Association (https://spherestandards.org/handbook-2018/)
Percentage of population that can Sphere Association. 2018. The sphere handbook: humanitarian charter and minimum standards in humanitarian response,
access primary healthcare (PHC) within fourth edition. Geneva: Sphere Association (https://spherestandards.org/handbook-2018/)
one hour’s walk from dwellings (or live
within 5km of a PHC facility)
Number of beds designated for isolation Related indicators in:

of infectious diseases at the healthcare Sphere Association. 2018. The sphere handbook: humanitarian charter and minimum standards in humanitarian response,
facility fourth edition. Geneva: Sphere Association (https://spherestandards.org/handbook-2018/)
World Health Organization. Global Health Observatory (https://www.who.int/data/gho/data/themes/topics/topic-details/
GHO/health-service-delivery)
128

Number of ICU beds per Similar indicators in:

10,000 population World Health Organization. Harmonized Health Facility Assessment (HHFA). Geneva:
WHO (https://indicator-inventory.hhfa.online/)
Percentage of healthcare facilities Similar indicators in:

delivering the full essential package of Health systems standard 1.1: Health service delivery in, Sphere Association. 2018. The sphere handbook: humanitarian
health services (EPHS) routinely charter and minimum standards in humanitarian response, fourth edition. Geneva: Sphere Association (https://
spherestandards.org/handbook-2018/)
Percentage of the population that is Sphere Association. 2018. The sphere handbook: humanitarian charter and minimum standards in humanitarian response,
requiring a referral, to the next level or fourth edition. Geneva: Sphere Association (https://spherestandards.org/handbook-2018/)
specialty of healthcare, is seen at the
next level or specialty of healthcare
Percentage of patients referred in Sphere Association. 2018. The sphere handbook: humanitarian charter and minimum standards in humanitarian response,
adequate time using standardized fourth edition. Geneva: Sphere Association (https://spherestandards.org/handbook-2018/)
treatment protocols
Percentage of healthcare facilities Communicable diseases standard 2.1.3: Diagnosis and case management in, Sphere Association. 2018. The sphere handbook:
supporting a crisis-affected population humanitarian charter and minimum standards in humanitarian response, fourth edition. Geneva: Sphere Association
using standardized treatment protocols (https://spherestandards.org/handbook-2018/)
for a specified illness due to PHE
129
Case fatality rate is reduced to an Sphere Association. 2018. The sphere handbook: humanitarian charter and minimum standards in humanitarian response,
acceptable level: for example, fourth edition. Geneva: Sphere Association (https://spherestandards.org/handbook-2018/)
Cholera <1 per cent
Meningitis <15 per cent
Hepatitis E <4 per cent in general
population, 10–50 per cent in pregnant
women in third trimester
Diphtheria (respiratory) <5–10 per cent
Pertussis <4 per cent in children aged
one year, <1 per cent in those aged one to
four years
Dengue <1 per cent
Percentage of health facilities that have Related indicators in:

an emergency/disaster plan including World Health Organization. Harmonized Health Facility Assessment (HHFA). (https://indicator-inventory.hhfa.online/)
management of mass casualties,
reviewed and rehearsed on a
regular basis
Percentage of the community population Related concepts in:

with access to essential health services Maintaining essential health services: operational guidance for the COVID-19 context: interim guidance, 1 June 2020.
during a public health emergency (PHE) https://www.who.int/publications/i/item/WHO-2019-nCoV-essential_health_services-2020.2
Percentage of facilities meeting World Health Organization and United Nations Children’s Fund (UNICEF). 2022. Primary health care measurement framework
minimum standards to deliver tracer and indicators: monitoring health systems through a primary health care lens. Web annex: technical specifications. Geneva:
services WHO and UNICEF (https://apps.who.int/iris/handle/10665/352201)
Community satisfaction rates on specific Similar indicators measuring community satisfaction on certain specific services can be found in:
health services (determined by country) World Health Organization. Global Health Observatory (https://www.who.int/data/gho/indicator-metadata-registry/)
in emergency context
130

Health Workforce
Number of health workers per World Health Organization. Global Health Observatory (https://www.who.int/data/gho/indicator-metadata-registry/)
10,000 population by occupation World Health Organization and United Nations Children’s Fund (UNICEF). 2022. Primary health care measurement framework
Number of community health workers World Health Organization. Global Health Observatory (https://www.who.int/data/gho/indicator-metadata-registry/)
(CHW) per 1,000 population World Health Organization and United Nations Children’s Fund (UNICEF). 2022. Primary health care measurement framework
Average number of staff, by occupation Similar indicators in:

in primary care facilities and hospitals World Health Organization. Harmonized Health Facility Assessment (HHFA) (https://indicator-inventory.hhfa.online/)
Health worker absenteeism rate Related concept in:

World Health Organization. 2010. Monitoring the building blocks of health systems: a handbook of indicators and their
measurement strategies. Geneva: WHO (https://apps.who.int/iris/handle/10665/258734)
Health workforce attrition rate Related indicators and concepts in:

Health Finance and Governance Project. Human Resources for Health Indicators. Washington, D.C.: United States Agency for
International Development (https://www.hfgproject.org/human-resources-health-indicators/)
World Health Organization. 2017. National health workforce accounts: a handbook. Geneva: WHO (https://www.who.int/
World Health Organization. Global Health Observatory (https://www.who.int/data/gho/indicator-metadata-registry/)
131
Rural-to-urban distribution ratio of Related indicators on health worker density in:

health workers World Health Organization. Global Health Observatory (https://www.who.int/data/gho/indicator-metadata-registry/)
Related concepts in:
World Health Organization. 2010. Increasing access to health workers in remote and rural areas through improved retention:
global policy recommendations. Geneva: WHO (https://www.who.int/publications/i/item/increasing-access-to-health-
workers-in-remote-and-rural-areas-through-improved-retention)
Percentage of births attended by skilled United Nations Statistics Division. Sustainable development goals (SDGs) Indicators (https://unstats.un.org/sdgs/metadata/)
personnel (doctors, nurses, midwives) World Health Organization. Global Health Observatory (https://www.who.int/data/gho/indicator-metadata-registry/)
Skilled care is available for emergency Similar indicators in:

obstetrics and new-born care at all times World Health Organization. Harmonized Health Facility Assessment (HHFA) (https://indicator-inventory.hhfa.online/)
(yes or no)
Percentage of health workers that are World Health Organization. 2016. Monitoring and evaluation for viral hepatitis B and C: recommended indicators and
vaccinated against Hepatitis B (and other framework. Geneva: WHO (https://apps.who.int/iris/handle/10665/204790)
vaccinations specific to the country
context)
Rate of hospital acquired infections World Health Organization and United Nations Children’s Fund (UNICEF). 2022. Primary health care measurement framework
(HAIs) (specific to country context) and indicators: monitoring health systems through a primary health care lens. Web annex: technical specifications. Geneva:
among health workers WHO and UNICEF (https://apps.who.int/iris/handle/10665/352201)
132

Percentage of health workers that Related indicators in:

received training and qualifications from World Health Organization. 2017. National health workforce accounts: a handbook. Geneva: WHO (https://www.who.int/
an accredited educational or training publications/i/item/9789241513111)
institution or body
World Health Organization. 2021. International health regulations (2005): state party self-assessment annual reporting tool,
All health staff performing clinical work Related indicators in:

in emergencies have received training in World Health Organization. Harmonized Health Facility Assessment (HHFA). Geneva:
clinical protocols and case management WHO (https://indicator-inventory.hhfa.online/)
(yes or no)
Percentage of health staff in high-risk Related indicators in:

areas trained on outbreak response plan Sphere Association. 2018. The sphere handbook: humanitarian charter and minimum standards in humanitarian response,
and protocols fourth edition. Geneva: Sphere Association (https://spherestandards.org/handbook-2018/)
World Health Organization. Harmonized Health Facility Assessment (HHFA) (https://indicator-inventory.hhfa.online/)
All health facilities have trained staff, Related indicators in:

sufficient supplies and equipment World Health Organization. Harmonized Health Facility Assessment (HHFA) (https://indicator-inventory.hhfa.online/)
for clinical management of rape
survivor services based on national or
international protocols (yes or no)
National total expenditure on World Health Organization. 2017. National health workforce accounts: a handbook. Geneva: WHO (https://www.who.int/
health workforce publications/i/item/9789241513111)
Percentage of facilities with a reporting Related concepts and rationale in:

mechanism for occupational hazard International Labour Organization. 1996. Recording and notification of occupational accidents and diseases. Geneva: ILO
incidents (https://www.ilo.org/safework/info/standards-and-instruments/codes/WCMS_107800/lang--en/index.htm)
133
Health Information
Percentage of notifiable public health Related indicators or technical questions in:

events reported to the appropriate Sphere Association. 2018. The sphere handbook: humanitarian charter and minimum standards in humanitarian response,
authorities within 24 hours fourth edition. Geneva: Sphere Association (https://spherestandards.org/handbook-2018/)
Percentage of complete Early Warning, Sphere Association. 2018. The sphere handbook: humanitarian charter and minimum standards in humanitarian response,
Alert and Response (EWAR)/surveillance fourth edition. Geneva: Sphere Association (https://spherestandards.org/handbook-2018/)
reports submitted on time
Percentage of reported alerts being Related indicators or technical questions in:

verified within 24 hours Sphere Association. 2018. The sphere handbook: humanitarian charter and minimum standards in humanitarian response,
Frequency of health information reports Sphere Association. 2018. The sphere handbook: humanitarian charter and minimum standards in humanitarian response,
(for example, epidemiological bulletin) fourth edition. Geneva: Sphere Association (https://spherestandards.org/handbook-2018/)
produced by the lead health actor
Use of electronic information and World Health Organization. 2022. Joint external evaluation tool: International Health Regulations (2005) - third edition.
surveillance systems? (yes or no) Geneva: WHO (https://www.who.int/publications/i/item/9789240051980)
World Health Organization. Benchmarks for IHR Capacities. (https://ihrbenchmark.who.int/document/9-surveillance)
Health workers training on surveillance Related technical questions and standards in:
and information systems? (yes or no) Sphere Association. 2018. The sphere handbook: humanitarian charter and minimum standards in humanitarian response,
134
World Health Organization. Benchmarks for IHR Capacities. (https://ihrbenchmark.who.int/document/9-surveillance)

Defined procedures and deadlines for Related technical questions and standards in:
the transmission of health information Health systems standard 1.5: Health information in, Sphere Association. 2018. The sphere handbook: humanitarian charter
between facilities and across different and minimum standards in humanitarian response, fourth edition. Geneva: Sphere Association (https://spherestandards.org/
levels? (yes or no) handbook-2018/)
Percentage of facilities with access to World Health Organization and United Nations Children’s Fund (UNICEF). 2022. Primary health care measurement framework
communications system and indicators: monitoring health systems through a primary health care lens. Web annex: technical specifications. Geneva:
Percentage of facilities that experienced Related technical questions in:

any interruption to access to telephone World Health Organization. 2021. Continuity of essential health services: facility assessment tool: a module from the suite of
service (landline or mobile) in previous health service capacity assessments in the context of the COVID-19 pandemic: interim guidance, 12 May 2021. Geneva: WHO
week (https://apps.who.int/iris/handle/10665/341306)
Proportion of households in at-risk Similar indicators in:

areas that report receiving appropriate World Health Organization. 2021. International health regulations (2005): state party self-assessment annual reporting tool,
information/education from assigned 2nd ed. Geneva: WHO (https://www.who.int/publications/i/item/9789240040120)
community health workers, on specified
priority public health threats
Access to Essential Health Products
Is the availability of essential medicines Related indicators in:

and supplies being monitored? World Health Organization. Harmonized Health Facility Assessment (HHFA). (https://indicator-inventory.hhfa.online/)
(yes or no)
Number of days essential medicines are Sphere Association. 2018. The sphere handbook: humanitarian charter and minimum standards in humanitarian response,
not available during a month fourth edition. Geneva: Sphere Association (https://spherestandards.org/handbook-2018/)
System in place for the emergency Related definitions and standards in:
procurement (ordering) of medicines and Sphere Association. 2018. The sphere handbook: humanitarian charter and minimum standards in humanitarian response,
medical supplies in the event of a public fourth edition. Geneva: Sphere Association (https://spherestandards.org/handbook-2018/)
health emergency (yes or no)
135
Presence of a national and/or regional Related definitions and indicator in:

list of emergency medicines and supplies Sphere Association. 2018. The sphere handbook: humanitarian charter and minimum standards in humanitarian response,
identified based on priority diseases fourth edition. Geneva: Sphere Association (https://spherestandards.org/handbook-2018/)
Percentage of health facilities with World Health Organization. Harmonized Health Facility Assessment (HHFA). (https://indicator-inventory.hhfa.online/)
essential medicines
Are all medicines dispensed to patients Related indicator in:

within the expiry date? (yes or no) Sphere Association. 2018. The sphere handbook: humanitarian charter and minimum standards in humanitarian response,
World Health Organization. Harmonized Health Facility Assessment (HHFA). (https://indicator-inventory.hhfa.online/)
Availability of Infection Prevention and Related indicators in:

Control supplies for example, exam World Health Organization. Harmonized Health Facility Assessment (HHFA). (https://indicator-inventory.hhfa.online/)
gloves; long plastic gloves; protective
masks; plastic apron; PPE; triple
packaging kit; stock of soap; stock of
disinfectants
Availability of standard medical Similar indicator in:

equipment (essential medical equipment World Health Organization and United Nations Children’s Fund (UNICEF). 2022. Primary health care measurement framework
can be defined by WHO list of priority and indicators: monitoring health systems through a primary health care lens. Web annex: technical specifications. Geneva:
medical equipment and devices, or local/ WHO and UNICEF (https://apps.who.int/iris/handle/10665/352201)
priority need)
Facility has access to a blood bank with Related indicators in:

blood and blood products, and standard World Health Organization. Harmonized Health Facility Assessment (HHFA). (https://indicator-inventory.hhfa.online/)
operating procedures (SOPs) and
guidelines for their correct storage
and handling
All transfused blood is screened and Related indicators in:

is free of transfusion-transmissible World Health Organization. Harmonized Health Facility Assessment (HHFA). (https://indicator-inventory.hhfa.online/)
infections, including HIV
136

Facilities with access to functional Related definitions and standards in:

transport services for logistics needs for Sphere Association. 2018. The sphere handbook: humanitarian charter and minimum standards in humanitarian response,
essential supplies and services fourth edition. Geneva: Sphere Association (https://spherestandards.org/handbook-2018/)
Percentage of facilities that have access Related indicators in:

to a functional ambulance service (as World Health Organization. Harmonized Health Facility Assessment (HHFA). Geneva:
recommended in national guidelines) WHO (https://indicator-inventory.hhfa.online/)
Are supply chain management protocols Related indicators in:

in place for activating and coordinating World Health Organization. 2022. Joint external evaluation tool: International Health Regulations (2005) - third edition.
stockpiles during a public health Geneva: WHO (https://www.who.int/publications/i/item/9789240051980)
emergency (PHE)? (yes or no)
Percentage of health facilities that Similar indicator in:

have an appropriate set of essential in World Health Organization and United Nations Children’s Fund (UNICEF). 2022. Primary health care measurement framework
vitro diagnostics (IVDs) and associated and indicators: monitoring health systems through a primary health care lens. Web annex: technical specifications. Geneva:
laboratory equipment and consumables WHO and UNICEF (https://apps.who.int/iris/handle/10665/352201)
for their health care facility level
available on a sustainable basis
Percentage of facilities that have a Related indicators in:

functional waste management system? World Health Organization. Harmonized Health Facility Assessment (HHFA). (https://indicator-inventory.hhfa.online/)
Are all inpatients in healthcare settings Related indicators in:

use long-lasting insecticide nets (LLINs) Sphere Association. 2018. The sphere handbook: humanitarian charter and minimum standards in humanitarian response,
in malarial zones? (yes or no) fourth edition. Geneva: Sphere Association (https://spherestandards.org/handbook-2018/)
World Health Organization. Harmonized Health Facility Assessment (HHFA). (https://indicator-inventory.hhfa.online/)
137
Resilience of health facility Related concepts in:

infrastructure to disasters is assessed as World Health Organization. 2022. Health care accreditation and quality of care: exploring the role of accreditation and
part of accreditation process external evaluation of health care facilities and organizations. Geneva: WHO (https://www.who.int/publications/i/
item/9789240055230)
Facility safety has been assessed within Related indicators and concepts in:
the past 12 months Sphere Association. 2018. The sphere handbook: humanitarian charter and minimum standards in humanitarian response,
World Health Organization, Pan American Health Organization. 2019. Hospital Safety Index. Guide for Evaluators. Second
Edition. Washington, D.C.: WHO, PAHO (https://iris.paho.org/handle/10665.2/51448)
Percentage of facilities with access to World Health Organization and United Nations Children’s Fund (UNICEF). 2022. Primary health care measurement framework
emergency transport for interfacility and indicators: monitoring health systems through a primary health care lens. Web annex: technical specifications. Geneva:
transport WHO and UNICEF (https://apps.who.int/iris/handle/10665/352201)
Percentage of facilities that use an World Health Organization and United Nations Children’s Fund (UNICEF). 2022. Primary health care measurement framework
electrical power source (excluding and indicators: monitoring health systems through a primary health care lens. Web annex: technical specifications. Geneva:
standalone medical devices) at least WHO and UNICEF (https://apps.who.int/iris/handle/10665/352201)
some of the time
Governance
There is a national policy, strategy or World Health Organization and United Nations Children’s Fund (UNICEF). 2022. Primary health care measurement framework
plan guiding the engagement of the and indicators: monitoring health systems through a primary health care lens. Web annex: technical specifications. Geneva:
private sector in health service delivery WHO and UNICEF (https://apps.who.int/iris/handle/10665/352201)
that includes WHO-recommended
behaviours
Private sector representatives are World Health Organization and United Nations Children’s Fund (UNICEF). 2022. Primary health care measurement framework
involved in development of national and indicators: monitoring health systems through a primary health care lens. Web annex: technical specifications. Geneva:
crisis management plans WHO and UNICEF (https://apps.who.int/iris/handle/10665/352201)
138

Availability of multisectoral emergency Similar indicators in:

management forum with community World Health Organization. 2021. International health regulations (2005): state party self-assessment annual reporting tool,
representation 2nd ed. Geneva: WHO (https://www.who.int/publications/i/item/9789240040120)
Financing
Current percentage of health World Health Organization. Global Health Expenditure Database (GHED). (https://apps.who.int/nha/database)
expenditure that is externally sourced World Health Organization. Global Health Observatory. (https://www.who.int/data/gho/indicator-metadata-registry/)
Domestic general government World Health Organization and United Nations Children’s Fund (UNICEF). 2022. Primary health care measurement framework
expenditure on PHC as a share of and indicators: monitoring health systems through a primary health care lens. Web annex: technical specifications. Geneva:
domestic general government health WHO and UNICEF (https://apps.who.int/iris/handle/10665/352201)
expenditure nationally
Appropriate provider payment methods World Health Organization and United Nations Children’s Fund (UNICEF). 2022. Primary health care measurement framework
are in place in national as measured and indicators: monitoring health systems through a primary health care lens. Web annex: technical specifications.
against criteria Geneva: WHO and UNICEF (https://apps.who.int/iris/handle/10665/352201)
Out-of-pocket (OOP) payment for health World Health Organization. Global Health Observatory. (https://www.who.int/data/gho/indicator-metadata-registry/)
(% of current expenditure on health) World Health Organization. Global Health Expenditure Database (GHED). (https://apps.who.int/nha/database)
139
6
Resources of indicator sets
and monitoring and evaluation
frameworks as sources
Main resources of indicator sets and monitoring and evaluation frameworks which informed the development of this health system resilience package and metadata
are listed below. Links to these resources are provided for convenient reference.
6. Resources of indicator sets and monitoring and evaluation frameworks as sources

No. Resource Year Source/ Author(s) Link to the resource
1 Assessment of essential public health 2017 WHO Regional Office for the Eastern https://www.emro.who.int/about-who/public-health-functions/
functions in countries of the Eastern Mediterranean assessment-public-health-functions.html
Mediterranean Region
2 Building resilient health systems: a 2017 Kruk ME, Ling E J, Bitton A, Cammett M, https://doi.org/10.1136/bmj.j2323
proposal for a resilience index Cavanaugh K, Chopra M et al.
3 Checklist and Indicators for Monitoring 2013 WHO https://iris.who.int/handle/10665/84933

Progress in the Development of IHR Core
Capacities in States Parties
4 Continuity of essential health services: 2021 WHO https://iris.who.int/handle/10665/341306

facility assessment tool
5 Harmonized Health Facility Assessment 2022 WHO https://www.who.int/data/data-collection-tools/harmonized-health-

(HHFA) facility-assessment/introduction
6 Health at a Glance 2021: OECD Indicators 2021 OECD https://www.oecd-ilibrary.org/social-issues-migration-health/health-

at-a-glance-2021_ae3016b9-en
7 Health Emergency and Disaster Risk 2019 WHO https://www.who.int/publications/i/item/9789241516181

Management Framework
8 Health emergency preparedness self- 2018 European Centre for Disease Prevention https://www.ecdc.europa.eu/en/publications-data/hepsa-health-
assessment tool and Control emergency-preparedness-self-assessment-tool-user-guide
9 Health financing country diagnostic: 2016 WHO, McIntyre D, Kutzin J https://iris.who.int/handle/10665/204283

a foundation for national strategy
development
10 Health Resources and Services - WHO https://www.who.int/initiatives/herams

Availability Monitoring System (HeRAMS)
141
11 Health Sector Self-Assessment Tool for 2010 WHO, Pan American Health Organization https://iris.paho.org/handle/10665.2/34974
Disaster Risk Reduction
12 Health system performance assessment 2022 WHO https://iris.who.int/handle/10665/352686
13 Health system preparedness for 2019 Palagyi A, Marais BJ, Abimbola S, Topp https://doi.org/10.1080/17441692.2019.1614645
emerging infectious disease: A synthesis SM, McBryde ES, Negin J
of the literature
14 Health System Strengthening - A 2017 Diana M, Yeager V, Hotchkiss D https://www.measureevaluation.org/resources/publications/tr-17-

Compendium of Indicators 167b.html
15 Hospital emergency response 2011 WHO https://iris.who.int/handle/10665/349374

checklist: an all-hazards tool for
hospital administrators and emergency
managers
16 Hospital safety index: guide for 2015 WHO https://iris.who.int/handle/10665/258966

evaluators, 2nd ed.
17 IHR (2005): guidance document for the 2018 WHO https://www.who.int/publications/i/item/WHO-WHE-CPI-2018.17

State Party self-assessment annual
reporting tool
18 IHR Core Capacity Monitoring 2017 WHO https://iris.who.int/handle/10665/255756

Framework: Questionnaire
for Monitoring Progress in the
Implementation of IHR Core Capacities
in States Parties
19 IHR-PVS National Bridging Workshops - FAO, OIE, WHO https://extranet.who.int/sph/ihr-pvs-bridging-workshop#parallax-

our-work
20 Infection Prevention and Control 2018 WHO https://www.who.int/publications/i/item/WHO-HIS-SDS-2018.9

Assessment Framework at the
Facility Level
142
21 Joint Assessment of a National Health 2014 International Health Partnership https://www.uhc2030.org/what-we-do/improving-collaboration/

Strategy (JANS) health-systems-strengthening/jans-tool-and-guidelines/
22 Joint External Evaluation (JEE) - WHO https://extranet.who.int/sph/jee
23 Joint External Evaluation (JEE) Tool, 2022 WHO https://www.who.int/publications/i/item/9789240051980

3rd Edition
24 Monitoring the building blocks of health 2010 WHO https://iris.who.int/handle/10665/258734

systems: a handbook of indicators and
their measurement strategies
25 National health workforce accounts: 2017 WHO https://iris.who.int/handle/10665/259360

a handbook
26 PATH – Performance Assessment Tool 2007 WHO https://iris.who.int/handle/10665/107808

for Quality Improvement in Hospitals
27 Patient Safety Assessment 2012 WHO Regional Office for the Eastern https://www.who.int/publications/i/item/9789290221203
Mediterranean
28 Primary health care measurement 2022 WHO and UNICEF https://www.who.int/publications/i/item/9789240044210

framework and indicators: monitoring
health systems through a primary health
care lens
29 Primary Health Care Vital Signs 2018 Primary Health Care Performance https://www.improvingphc.org/sites/default/files/2018PHCPI_
Initiative VitalSignsReport_3.pdf
30 Public health emergency preparedness: 2018 Khan Y, O’Sullivan T, Brown A, Tracey S, https://bmcpublichealth.biomedcentral.com/articles/10.1186/
a framework to promote resilience Gibson J, Généreux M, Henry B, Schwartz s12889-018-6250-7
B
31 Recovery toolkit: supporting countries 2016 WHO https://iris.who.int/handle/10665/205944

to achieve health service resilience: a
library of tools and resources available
during the recovery period of a public
health emergency
143
32 Resilience Quality Indicators Report - WHO Available on request
33 Resilient Health System as Conceptual 2017 Olu O https://www.frontiersin.org/articles/10.3389/fpubh.2017.00263/full

Framework for Strengthening Public
Health Disaster Risk Management:
An African Viewpoint
34 Safe hospitals in emergencies and 2010 WHO https://iris.who.int/handle/10665/207689

disasters: structural, non-structural and
functional indicators
35 Sendai Framework for Disaster Risk 2015 United Nations https://www.undrr.org/publication/sendai-framework-disaster-risk-

Reduction 2015–2030 reduction-2015-2030
36 Service availability and readiness 2015 WHO https://www.who.int/data/data-collection-tools/service-availability-

assessment (SARA) and-readiness-assessment-(sara)
37 Service Delivery Indicators 2010 World Bank https://www.worldbank.org/en/programs/service-delivery-indicators
38 Service Provision Assessment (SPA) 2012 DHS Program, USAID https://dhsprogram.com/methodology/Survey-Types/SPA.cfm
39 State Party Self-Assessment Annual 2021 WHO https://www.who.int/publications/i/item/9789240040120

Reporting Tool (SPAR), 2nd edition
40 Strategic Partnership for Health Security - WHO https://extranet.who.int/sph/

and Emergency Preparedness (SPH)
Portal
41 Strengthening health-system emergency 2012 WHO https://iris.who.int/handle/10665/352566

preparedness: toolkit for assessing https://iris.who.int/handle/10665/352568
health-system capacity for crisis
management
42 Support tool to assess health 2015 WHO Regional Office for Europe https://iris.who.int/handle/10665/172761
information systems and develop and
strengthen health information strategies
144
43 The sphere handbook: humanitarian 2018 Sphere Association https://www.spherestandards.org/handbook/

charter and minimum standards in
humanitarian response, fourth edition
44 Tools for Assessing the Operationality of 2003 WHO Regional Office for Africa, Sambo Available on request
District Health Systems LG, Chatora RR and Goosen ESM
45 Tools for District Health Systems - WHO Available on request

functionality assessment for IHR
46 UN Common Guidance on Helping Build 2021 United Nations https://unsdg.un.org/resources/un-common-guidance-helping-build-

Resilient Societies resilient-societies
47 Universal Health and Preparedness - WHO https://www.who.int/emergencies/operations/universal-health---

Review (UHPR) preparedness-review
48 WHO country assessment tool on the 2012 WHO https://iris.who.int/handle/10665/77947

uses and sources for human resources
for health (HRH) data
49 WHO Simulation Exercise (SimEx) 2017 WHO https://www.who.int/publications/i/item/WHO-WHE-CPI-2017.10

Manual
50 Worldwide Governance Indicators - World Bank https://datacatalog.worldbank.org/search/dataset/0038026

DHS: Demographic and Health Surveys; FAO: Food and Agriculture Organization; OECD: Organisation for Economic Co-operation and Development; OIE: World Organization for Animal Health; UNICEF: United Nations Children’s Fund;
USAID: United States Agency for International Development
145
146
References
1. McDarby G, Seifelden R, Zhang Y, Mustafa 6. Kruk ME, Ling EJ, Bitton A, Cammett M,
S, Petrova M, Schmets G et al. A synthesis Cavanaugh K, Chopra M et al. Building resilient
of concepts of resilience to inform health systems: a proposal for a resilience index.
operationalization of health systems resilience BMJ. 2017;357:j2323.
in recovery from disruptive public health events
7. Fleming P, O’Donoghue C, Almirall-Sanchez
including COVID-19. Front Public Health. 2023:11.
A, Mockler D, Keegan C, Cylus J et al. Metrics
2. Health Systems Resilience Toolkit: a WHO and indicators used to assess health system
global public health good to support building resilience in response to shocks to health
and strengthening of sustainable health systems in high income countries: a systematic
systems resilience in countries with various review. Health Policy. 2022;126(12):1195–205.
contexts. Geneva: World Health Organization; doi:10.1016/j.healthpol.2022.10.001.
2022 (https://www.who.int/publications/i/
8. Building health systems resilience for universal
item/9789240048751, accessed 28 October 2023).
health coverage and health security during the
3. Mustafa S, Zhang Y, Zibwowa Z, Seifeldin R, Ako- COVID-19 pandemic and beyond: WHO position
Egbe L, McDarby G et al. COVID-19 preparedness paper. Geneva: World Health Organization; 2021
and response plans from 106 countries: a review (https://iris.who.int/handle/10665/346515,
from a health systems resilience perspective. 3 November 2023).
Health Policy Plan. 2022;37(2):255–68.
9. Monitoring the building blocks of health systems:
doi:10.1093/heapol/czab089.
a handbook of indicators and their measurement
4. WHA64.10: Strengthening national health strategies. Geneva: World Health Organization;
emergency and disaster management capacities 2010 (https://iris.who.int/handle/10665/258734,
and resilience of health systems. In: Sixty-fourth accessed 3 November 2023).
World Health Assembly, May 2011. Geneva: World
10. World Health Organization & United Nations
Health Organization; 2011 (https://apps.who.int/
Children’s Fund (UNICEF). Primary health care
iris/handle/10665/3566, accessed 28 October 2023).
measurement framework and indicators:
5. Zero draft of the WHO CA+ for the consideration monitoring health systems through a primary
of the Intergovernmental Negotiating Body health care lens. Geneva: World Health
at its fourth meeting: WHO convention, Organization; 2022 (https://iris.who.int/
agreement or other international instrument handle/10665/352205, accessed
on pandemic prevention, preparedness and 3 November 2023).
response (“WHO CA+”). A/INB/4/3. In: Fourth
11. Continuity of essential health services:
meeting of the Intergovernmental Negotiating
facility assessment tool: a module from the
Body to draft and negotiate a WHO convention,
suite of health service capacity assessments
agreement or other international instrument
in the context of the COVID-19 pandemic:
on pandemic prevention, preparedness and
interim guidance, 12 May 2021. Geneva:
response, February 2023. Geneva: World Health
World Health Organization; 2021 (https://
Organization; 2023 (https://apps.who.int/gb/
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inb/e/e_inb-4.html, accessed 28 October 2023).
3 November 2023).
References 147
12. International Health Regulations (2005): IHR 14. Papanicolas I, Rajan D, Karanikolos M, Soucat A,
monitoring and evaluation framework. Geneva: Figueras J, editors. Health system performance
World Health Organization; 2018 (https:// assessment: a framework for policy analysis.
iris.who.int/handle/10665/276651, accessed Geneva: World Health Organization; 2022
3 November 2023). (https://iris.who.int/handle/10665/352686,
accessed 3 November 2023).
13. Universal Health and Preparedness Review.
Geneva: World Health Organization; 2023 15. Primary health care measurement framework
(https://www.who.int/emergencies/operations/ and indicators: monitoring health systems
universal-health---preparedness-review, through a primary health care lens. Web
accessed 3 November 2023). annex: Technical specifications. Geneva:
World Health Organization: 2022 (https://
iris.who.int/handle/10665/352201, accessed
3 November 2023).
148
Annex. Methodological approach

to HSR indicator development
Defining health system resilience capacities Through an emergency and disaster risk
management lens, resilience can be further
Definitions of resilience vary among different actors delineated as “the ability of a system, community
and communities of practice (for example, peace and or society exposed to hazards to resist, absorb,
security, development, human rights, disaster risk accommodate, adapt to, transform and recover
reduction and climate change). However, within the from the effects of a hazard in a timely and efficient
United Nations system, there is a unified definition, manner, including through the preservation and
as follows (1): restoration of its essential basic structures and
[Resilience is] the ability of individuals, households, functions through risk management” (5).
communities, cities, institutions, systems and For the purpose of developing this package of
societies to prevent, resist, absorb, adapt, respond indicators, it was necessary to consider how
and recover positively, efficiently and effectively definitions of health system resilience can be
when faced with a wide range of risks, while expressed in functional terms of relevance to health
maintaining an acceptable level of functioning service delivery at health facilities. To do so, a
and without compromising long-term prospects desk review of the literature and existing relevant
for sustainable development, peace and security, indicator sets was conducted, as well as technical
human rights and well-being for all. consultations with WHO experts. From these
In the context of health systems, health system exercises, four categories of health system resilience
resilience can be defined as the capacity of health capacities were identified:
actors, institutions, and populations to prepare • the capacity to forecast, prevent, and prepare for
for and effectively respond to public health events public health needs (such as emergencies, shocks
and regular stressors; maintain essential, routine and routine stressors);
and core functions in all contexts; and, informed
• the capacity to maintain the delivery of routine and
by lessons learned, adapt and improve (2). Health
essential health services in all contexts (such as
systems are resilient if they protect human life and
emergencies, shocks and routine stressors);
produce good health outcomes for all during a crisis
and in its aftermath (2). Health system resilience • the capacity to absorb, adapt and respond to
means that the system is able to adapt its functioning changes in demand and the need for health
to absorb shocks and daily stressors and transform, services;
if necessary, to recover and maintain functionality • the capacity to learn and improve, as required,
(3). The ability of a health system to respond and based on experience, maintaining the course
adapt to external shocks and stressors – including towards long-term objectives.
infectious disease outbreaks and natural disasters –
is seen as one of the key elements of health system
resilience (3, 4).
Annex. Methodological approach to HSR indicator development 149
Data collection The data generated from these consultations were

used to:
Literature review
• ensure that the conceptual framework for
Iterative literature reviews underpinned by a resilience was comprehensive;
systematic search protocol were conducted • generate information on relevant indicators and
throughout October 2019 to December 2022. The sets of indicators on topics related to the four
research questions addressed through the review capacities;
were as follows:
• assist in determining an inclusion criterion for the
• How is health system resilience defined? selection of indicators for the package.
• What core capacities must be in place to achieve Consultations with key experts in Monrovia, Liberia,
resilience? were conducted within the scope of the KOICA-
• How is resilience measured, and how might it be funded health system resilience project. Participants
measured more comprehensively and effectively? included representatives of the ministries of health,
national public health institutes, health facilities,
The findings from the review were used to:
universities, research institutes, and WHO country
• develop a conceptual framework for the offices in Liberia and Ethiopia. Consultations were
monitoring and evaluation of health system conducted by way of key informant interviews,
resilience; discussion groups and plenary sessions. The data
• identify key resilience capacities and attributes; generated were consolidated and used to refine the
indicators, with the added consideration of feasibility
• identify and define key phases in the emergency
and applicability to the local context. Further
cycle and consider what structures, resources,
rounds of technical consultations were conducted
policies, mechanisms and outputs are required for
throughout 2021 and 2022 at WHO headquarters and
resilience outcomes and impacts;
with regional offices to further review the indicators
• identify relevant indicators and indicator sets; and inform the next steps.
• consider current constraints at the operational
level (feasibility and affordability) and future goals Indicator set review
for health systems and health security;
A review of indicator sets related to health system
• enable the specification of key questions for strengthening, primary health care, emergency
the next stage of data collection – the technical management and health system resilience was
consultation, as described below. conducted. An initial list of indicator sets was
identified from the literature review and expert
Technical consultation
consultations. Academic databases and online
Consultations with key experts were conducted at searches were used to identify additional indicator
WHO headquarters in Geneva from 2019 to 2022. sets. Drawing on the conceptual framework, and
Participants were recruited according to their insights from the literature review and expert
expertise in key technical areas, including: consultations, the indicator sets were assessed for
• emergency preparedness and response relevance to the four capacity categories defined
(including in fragile, conflict-affected and above. The indicators assessed as most relevant
vulnerable settings); were used to develop an initial compendium (or
“longlist”) of potential indicators for inclusion.
• humanitarian intervention;
• service delivery before, during and in recovery
from health emergencies;
• animal health and One Health approaches;
• health system governance, policy and
effectiveness;
• primary health care;
• risk management for health emergencies
and disasters.
relevant were selected. The remaining indicator

Data analysis and indicator selection set (n=432) was then assessed, and indicators that
were unlikely to be measurable, or were primarily
The indicators were grouped according to the WHO
relevant to high-income country settings, were
health system building blocks framework. From the
excluded. Duplicates were excluded, while others
“long list” of indicators (n=830), each indicator was
that were substantively related were combined.
assessed for relevance to the four capacities with a
Figure A.1 illustrates how the final set of indicators
focus on an integrated approach to health system
was generated.
resilience and its determinants; those deemed most
Figure A.1 Generation of final set of indicators
Relevant indicator sets identified via

Individual indicators extract
literature review, expert consultation
from search of academic databases
and online search
and grey literature
Inclusion criteria: must relate to one or
Inclusion criteria: must relate to one or
more of the four resilience capacities
more of the four resilience capacities
Identification (n=43 indicator sets;
(n=82)
n=748 individual indicators)
Compendium of
indicators relating Similar/duplicate
to one or more indicators excluded
resilience capacities (n=398)
(n=830)
Screening
Indicators after
Low feasibility
similar/duplicate
indicators excluded
indicators were removed
(n=259)
(n=432)
Indicators deems
Grouping as feasible
(n=173)
Final HSR indicator set

(relevant and feasible)
(n=64)
Included +
Supplementary indicators
of HSR relevance
(n=101)
151
References: Annex
1. United Nations Development Group/Inter-Agency 4. Health Systems Global (2016). Resilient and
Standing Committee (2015). Risk and Resilience: responsive health systems for a changing world
A Proposed Approach for better UN Cross-Pillar (http://healthsystemsresearch.org/hsr2016/
Integration. about/theme/, accessed 3 November 2023).
2. Kruk ME, Myers M, Varpilah ST, Dahn BT (2015). 5. United Nations, General Assembly (2016). Report
What is a resilient health system? Lessons from of the open-ended intergovernmental expert
Ebola. The Lancet 385(9980):1910-12. working group on indicators and terminology
relating to disaster risk reduction. Note by the
3. Blanchet K (2015). Thinking shift on health
Secretary-General.
systems: from blueprint health programmes
towards resilience of health systems. Int J Health
Policy Manag. 4(5):307-9.
World Health Organization
20 Avenue Appia
1211 Geneva 27
Switzerland
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Health system

1.2 Target audience 3

1.3 Approach and guiding principles 4

2 Using the package of HSR indicators 5

2.2 Using the technical specifications or metadata 13

3 Health system resilience indicators 14

3.2 Summary list 16

4 Health system resilience indicators with metadata 21

4.2 Health workforce 39

4.3 Health information 45

4.4 Access to medicines and other health products and technologies 58

4.5 Health financing 70

4.6 Governance and leadership 80

4.7 General/composite indicators 119

5 Supplementary indicators of relevance to

6 Resources of indicator sets and monitoring and evaluation

Annex. Methodological approach to HSR indicator development 148

Data collection 149

Data analysis and indicator selection 150

References: Annex 151

DHS Program Demographic and Health Surveys Program

be seen as a continuum, with the same capabilities

Box 1. Resilience against different types of stressors

• to provide a consolidated reference of indicators

system, health security, and disease-, program- and

Box 2. Feasibility criteria

represent similar and even overlapping aspects of

General guidance on how to use the health system Section

A set of 64 recommended health system resilience Section

A supplementary 101 indicators of relevance to Section

2.1 Step-by-step process

1. Map HSR indicators

5. Measure and monitor 3. Define targets

4. Build measurement capacity

• Specificity. The indicators chosen should be

Box 3. Examples of indicators on community engagement and participation to be

Measurable and specific

Box 5. Examples of targets of HSR indicators

include information such as the short and long

Table 1. Structure of technical specifications (metadata) for indicators, with explanations of

Metadata Explanation of information provided

Indicator short name Contains the indicator’s short name.

Indicator name Contains the indicator’s full name.

Domain Categorizes the indicator according to the WHO health system

Disaggregation Describes the possible separation or disaggregation of compiled

Numerator If the indicator requires a calculation (common in percentage or

Denominator If the indicator requires a calculation (common in percentage or

Type (M&E domain) Categorizes the indicator on the input/structures–process–output

No. Main domain Indicator short name Levela

National Subnational Facility

2. Service delivery % facilities conducted simulation exercise ✓

3. Service delivery % facilities conducted after- or intra-action reviews ✓

4. Service delivery % facilities that closed/discontinued services ✓

6. Service delivery Collaboration between facility-based and community-based delivery ✓ ✓

7. Service delivery % facilities sharing practices and lessons ✓

8. Service delivery % facilities using community voice to inform service planning ✓

9. Service delivery % facilities providing outreach according to community needs ✓

10. Workforce % subnational health workers trained in community engagement ✓ ✓

12. Workforce Roster of rapid response teams available ✓ ✓

6 Resources of indicator sets and monitoring and evaluation