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LESSON 1: Vision, Mission, Core Values, and Objectives of the Institutions Educational Institution An educational institution is a place where learners of different ages gain education. Education is based on an age grade system from preschool, primary, intermediate, and secondary level (ju...

LESSON 1: Vision, Mission, Core Values, and Objectives of the Institutions Educational Institution An educational institution is a place where learners of different ages gain education. Education is based on an age grade system from preschool, primary, intermediate, and secondary level (junior and senior high school), to tertiary level (colleges and universities). Educational institutions carry out educational activities that engage students with various learning environments and spaces. However, not all types of educational institutions are structured and formalized. While established educational institutions follow a well-defined curriculum, some learning environments are spontaneous and have no fixed timetables. There are two types of education: formal and informal. Formal education deals with the conventional classroom setup where structured methods of learning are administered in educational institutions. Government recognition in terms of the curricular offering that predetermines the books and materials to be used for instruction is necessary to establish standards in the academic community. Faculty and instructors follow the curricula set by a technical committee appointed by the government. Formal education starts at around age 4 from preschool up to higher education. It takes place in a stipulated period in which learners complete each level by acquiring the required competencies in preparation for higher learning Informal education, on the other hand, is anything learned independently outside the conventional classroom setup. It is not restricted to a certain location and is usually integrated with the surroundings such as the home, cultural setting, and even in formal education institutions. Informal education involves the students' behavior skills through interaction and exploration on a daily basis as well as the teachers traits that vary based on their expertise, skills, and experience. Vision and Mission Statement Vision Statement A vision statement conveys the desired end of an academic institution. It is usually a one-sentence statement that describes the distinct and motivating long-term desired transformation resulting from institutional programs. The vision statement should be clear, memorable, and concise with an average length of 14 words. The shortest contains only three words-such as "Equality for Everyone, a human rights campaign-while the longest may contain up to 26 words such as "A World in which every person enjoys all of the human rights enshrined in the Universal Declaration of Human Rights and other international human rights instruments" of Amnesty International. Mission Statement A mission statement is a one-sentence statement relating the intention of an institution's existence. This communicates what you do or who you do this for. The mission statement must be clear by using simple language with an average of 5 to 20 words. Examples include "Spreading Ideas" by TED, "The increase and diffusion of knowledge" by the Smithsonian, and "Seeking to put Gods love into action, Habitat for Humanity brings people together to build homes, community and hope" by Habitat for Humanity. Comparison between a vision statement and a mission statement Vision Statement Mission Statement It inspires to give the best It defines the key measure of Function shapes your understanding of the institution‟s success. why you are in the institution. When do you want to reach success? What do we do today? Developing Statement Where do we want to go For whom do we do it? forward? Why do we do what we do? How do we want to do it? Talks about the present Time Talks about the future leading to the future What makes you different? Where do you aim to be? Question How will you get where you Where do you want to be? want to be? Value Statement A value statement, or the core values, is a list of fundamental doctrines that guide and direct the educational institution. This sets the moral direction of the institution and its academic community that guides decision-making and provides a yardstick against any action. The core values shape the standard structure that is shared and acted upon by the academic community. In developing an institution's value statement, consider the following questions:  What values are distinct to our educational institution?  What values should direct our institution? For an educational institution to have a useful value statement, its values must be incorporated in all levels of the institution to give direction to its engagements, viewpoints, and decision-making processes. Objectives Educational objectives, or goals, are short statements that learners should achieve within or at the end of the course or lesson. When setting the objectives, curriculum developers must think of the SMART criteria; that is, objectives must be Specific, Measurable, Attainable, Realistic and Time bound. Below is a list of educational objectives set by the Commission on Higher Education (CHED) through CHED Memorandum Order No. 14, series of 2006 on "Policies, Standards, and Guidelines for Medical Technology Education." The Medical Technology Education aims to: 1. Develop the knowledge, attitudes, and skills in the performance of clinical laboratory procedures needed to help the physician in the proper diagnosis, treatment, prognosis, and prevention of diseases; 2. Develop skills in critical and analytical thinking to advance knowledge in Medical Technology/Clinical Laboratory Science and contribute to the challenges of the profession; 3. Develop leadership skills and to promote competence and excellence; and Uphold moral and ethical values in the service of society and in the practice of the profession. Key Points to Remember  An educational institution carries out educational activities that engage students with various learning environments and spaces.  Education is based on an age grade system from preschool, primary, intermediate, and secondary level to the tertiary level.  A vision statement is the desired end of an academic institution. It is usually a one- sentence statement that describes the distinct and motivating long-term desired transformation resulting from institutional programs.  A mission statement is a one-sentence statement relating the intention of an institution‟s existence.  A value statement, or core values, is a list of fundamental doctrines that guide and direct the educational institution.  An educational objective is a short statement that a learner should achieve within or at the end of the course or lesson. LESSON 2: Health System Health system is "the combination of resources, organization, financing, and management that culminate in the delivery of health services to the population (Roemer. 1991)." This system consists of many parts such as the community, department or ministries of health, health care providers, health service organizations, pharmaceutical companies, health financing bodies, and other organizations related to the health sector. Each plays a role in the system such as governance, health service provision, and financing and managing resources. In the World Health Report (WHO, 2000), health system is defined as all the organizations, institutions, resources, and people whose primary purpose is to improve health. Thus, a well-performing health system provides direct health-improving activities whether in personal health care, public health services, or intersectoral initiatives, to achieve high health equity. Goals and Functions of a Health System The World Health Organization (WHO) identifies three (3) main goals of a health system: 1. Improving the health of populations Improving the health of the population is the overarching goal of a health system. Health status should thus be measured over the entire population and across different socioeconomic groups Populations must be protected from existing and emerging health risks. Intensive preparations for resilience to impending but still unknown health risks must be executed to ensure the safety of populations. Health systems should strive for equity in health by minimizing inequitable disparities which may be caused by certain factors such as income, ethnicity, occupation, gender, geographic location, and sexual orientation, among others. There are significant variations in health outcomes across the world, within regions and within countries. Countries and regions with relatively simili socioeconomic status may have quite disparate health outcomes. The way health systems are organized contributes to this disparity. These disparities are most effectively reduced when they are recognized and their minimization becomes an explicit national goal. 2. Improving the responsiveness of the health system Responsiveness refers to providing satisfactory health services and engaging people as active partners. It embodies the values of respectfulness, dignity, confidentiality, autonomy, quality, and timeliness in the delivery of health services. Health systems also have an obligation to respond to the legitimate non-health needs and expectations of populations. Responsive health systems maximize people‟s autonomy and control, allowing them to make choices and placing them at the center of the health system. 3. Providing fair health financing An ideal health system provides social and financial risk protection in health. Thus, all health systems must be adequately funded to provide essential services to all citizens. WHO defines a fairly financed health system as one that does not deter individuals from receiving needed care due to payments required at the time of service, and one in which each individual pays approximately the same percentage of their income for needed services. A health financing system that dissuades people from seeking needed services for impoverished individuals and families worsens health outcomes. The four (4) vital health system functions are: 1. Health service provision The most visible product of the health system is public and private health service provision. A health service is any service, not limited to clinical services, aimed at improving the health of populations. Preventive measures as well as promotion of a healthy way of living to avoid illnesses also form part of the best systems. Thus, the system has to perform a wide range of activities to cater to these various demands. 2. Health service inputs Health service inputs, or managing resources, means generating the essential physical resources for the delivery of health services which include medications, human resources, and medical equipment. Resources such as trained doctors and medical staff and supply of medications often take time to be produced; hence, the health system policymakers have to respond and use the available resources to address short-term population needs. 3. Stewardship Stewardship, or the overall system oversight, is the main responsibility of the government. This function sets the direction, context, and policy framework for the overall health system. The core of the stewardship function includes: a. Identifying health priorities for allocation of public resources; b. Identifying an institutional framework; c. Coordinating activities with other systems related to external health care; d. Analyzing health priorities and resource generation trends and their implications; and e. Generating appropriate data for effective decision-making and policymaking on health matters. 4. Health financing Health system financing includes raising and pooling resources to pay for health services. a. Revenue collection Revenue is earned from payments for health care services. The mechanisms for revenue collection include general taxation, direct household out-of-pocket expenditures mandatory payroll contributions, mandatory or voluntary risk-rated contributions, donor financing, and other forms of personal savings. Each source of health financing is associated with a specific manner of organizing and pooling of funds and purchasing services. Public health systems rely on general taxation for its financing, while social security organizations are funded through the mandatory payroll contributions from workers and employers. b. Risk pooling Financial risk pooling is a form of risk management which aims to spread financial risks from an individual to all pool members. It is considered a core function of health insurance companies. This mechanism prevents outright  payment for health services which discourages patients belonging to the poor sector from seeking health Participation in effective risk pooling helps families from financial losses due to health shocks, thus ensuring financial protection. Each country has its own approach to managing its financial risk to finance its health care system. Multiple and fragmented forms of risk pooling arrangements exist in most developing countries. Most high-income countries follow one of the two main models: the Bismarck model and the Beveridge model.  Bismarck Model (Bismarck's Law on Health Insurance of 1883) This model is named after the Prussian Chancellor, Otto von Bismarck, known for inventing the welfare state in the 19th century as part of the unification of Germany. The Bismarck model uses an insurance system where the sickness fund finances both the employers and the employees through payroll deduction. But unlike the US insurance industry, the Bismarck-type health insurance plan covers everybody, thus collecting no profit. This is considered a multi-payer model with tight regulation giving the government the cost-control clout. This model is widely used in Germany, France, Belgium, Netherlands, Japan, Switzerland, and, to a degree, in Latin America.  Beveridge Model (Beveridge Report or the Social Insurance and Allied Services of 1942) This model is named after William Beveridge, the social reformer responsible for designing Britain's Social Security System and the National Health Service. In the Beveridge model, health care is provided and funded by the government through tax payments. The government owns many, but not all, hospitals and clinics in the country. Doctors may be government or private employees who collect their professional fees from the government. This results in low cost per capita since the government controls the health care services. Countries using the Beveridge plan include Hong Kong. Great Britain, Spain, most of Scandinavia, New Zealand, and Cuba. The Cuban government, for instance, uses total government control. c. Strategic purchasing In strategic purchasing, risk-pooling organizations use collected funds and pooled financial resources to finance health care services for the members. The purchaser defines the substantial part of the health provider's external incentives to develop the provider user interaction and the health service delivery models. WHO Health System Framework In its World Health Report 2000, WHO released a single framework (Figure 2.1) with six clearly defined building blocks and priorities which are necessary in strengthening health systems and improving the overall health outcomes. Figure 2.1 WHO Health Systems Framework (Figure by World Health Organization (2007), licensed under CC BY-SA 4.0) One building block is service delivery which refers to the timely delivery of quality and cost-effective personal and non-personal health services. Another is health workforce which includes individuals and groups working towards the achievement of the best health outcomes by being responsive, fair, and efficient. The number of staff should be sufficient and fairly distributed to ensure competency, responsiveness, and productivity. Information (health information system) which analyzes disseminates and uses reliable and relevant information on health status, determinants, and systems performance is also a valuable building block. Another important building block is that of health products, vaccines, and technologies which are made accessible through uninterrupted supply, well-managed pharmaceutical services, and education on proper use of medication. Financing (health financing system) is a building block which takes care of the funding for health care services to guarantee that people can use health services when needed without fear of having not enough resources to pay for them. Lastly, leadership and governance involves the task of ensuring effective stewardship of the entire health system. This building block also covers the monitoring of the accountability of private and public health agencies, proper system design, and appropriate regulation of health systems. The Philippine Health System Historical Background The health reform initiatives carried out over the years in the Philippines were primarily focused on these areas of concern: health service delivery, health regulation, and health financing. These health reforms aimed at addressing issues such as poor accessibility, inequity, and inefficiency of the Philippine health system. 1. 1979: Adoption of Primary Health Care Strategy (LOI 949) - promoted participatory management of the local health care system 2. 1982: Reorganization of DOH (EO 851) - integrated the components of health care delivery in. its field operations 3. 1988: The Generics Act (RA 6675) - ushered the writing of prescriptions using the generic name of the drug 4. 1991: Local Government Code (RA 7160) - transferred the responsibility of providing health service to the local government units 5. 1995: National Health Insurance Act (RA 7875) - instituted a national health insurance mechanism for financial protection with priority given to the poor 6. 1999: Health Sector Reform Agenda - ordered the major organizational restructuring of the DOH to improve the way health care is delivered, regulated, and financed 7. 2005: FOURmula One (F1) for Health - adopted an operational framework to undertake reforms with speed, precision, and effective coordination and to improve the Philippine health system 8. 2008: Universally Accessible Cheaper and Quality Medicines Act (RA 9502) - promoted and ensured access to affordable quality drugs and medicines for all 9. 2010: Kalusugan Pangkalahatan or Universal Health Care (AO 2010-0036) - provided universal health coverage and access to quality health care for all Filipinos Leadership and Governance The Department of Health (DOH) is mandated to provide the appropriate direction for the nation's health care industry. Its other tasks include (1) the development of plans, guidelines and standards for the health sector. (2) technical assistance; (3) capacity building: (4) advisory services for disease prevention: and (5) control of medical supplies and vaccines. DOH coordinates its national health programs through the local government units (LGUS), LGUs take care of their own health services and are given autonomy under the Local Government Code (1.GC) 1991 (R.A. 7160). 78 provincial governors, 138 city mayors, 1.496 municipal mayors, and 42,025 barangay chairpersons compose the local government units of the country (NSCB. 2010). In terms of administration, LGUs are grouped into 17 regions Although they operate in a decentralized system, LGUS are under the supervision of the DOH regional health offices. The provincial government is tasked to provide health services through provincial and district hospitals. The city and municipal governments rely on public health and primary health care centers for their primary care. (For a detailed organizational structure of the Philippine health sector, see The Philippines Health System Review (2011) published in Health System in Transition, vol. 1, no. 2.) DOH is duty-bound to: 1. develop policies and programs for the health sector, 2. provide technical assistance to its partners, 3. encourage performance of the partners in the priority health programs, 4. develop and enforce policies and standards, 5. design programs for large segments of the population, and 6. provide specialized and tertiary level care. Under the decentralized or devolved structure, the state is represented by national offices and LGUs, with provincial, city, municipal, and barangay or village offices. DOH, LGUs and the private sector participate, cooperate and collaborate in the care of the population. Before devolution, the national health system consisted of a three-tiered system under the direct control of the DOH: (1) the tertiary hospitals at the national and regional levels; (2) the provincial and district hospitals and city and municipal health centers; and (3) the barangay (village) health centers. With the enactment of the LGC of 1991, the government health system now consists of basic health services-including health promotion and preventive units- provided by cities and municipalities provincial and province-run district hospitals of varying capacities, and mostly tertiary medical specialty hospitals, and a number of re-nationalized provincial hospitals managed by DOH. Directions of the Philippine Health Sector 1. The Philippine Health Agenda 2016-2022 (DOH Administrative Order 2016-0038) This agenda adopts the slogan "All for Health Towards Health For All as the rallying point for vision of a Healthy Philippines by 2020. It expanded the scope of the Universal Health Care (UHC directions, particularly through a whole-of-government approach. With this agenda, the health system guarantees: a. population- and individual-level interventions for all life stages that promote health and wellness, prevent and treat the triple burden of disease, delay complications, rehabilitation, and provide palliation for both the well and the sick; b. access to health interventions through functional service delivery networks (SDNs); and c. financial freedom when accessing these interventions through Universal Health Insurance. 2. The Philippine Development Plan 2017-2022 This is the first of the four key medium-term plans to translate the vision of a "matatag maginhawa, at panatag na buhay" for the Filipinos and the country. 3. NEDA AmBisyon Natin 2040 A product of the Philippine Development Plan 2017-2022, this collective long-term plan envisions better life for the Filipinos and the country in the next 25 years by formulating policies and implementing programs and projects to attain this AmBisyon. This plan focuses on four areas: building a prosperous, predominantly middle-class society where no one is poor; promoting a long and healthy life; becoming smarter and more innovative, and building a high-trust society. 4. Sustainable Development Goals 2030 Also known as the 2030 Agenda, this compilation of 17 global development goals targets to end poverty, fight inequality and injustice, and confront issues involving climate change. Key Points to Remember  Health system combines resources, organization, financing, and management to deliver health services to the population. According to the World Health Report (WHO, 2000), health system is defined as "all the organizations, institutions, resources, and people whose primary purpose is to improve health."  The primary goals of a health system are improved health outcomes (attaining the best average level health care for the entire population by minimizing disparities), more responsive health system (meeting the people's expectations of and satisfaction from health service delivery), and more equitable health care financing (protecting each individual from financial risks).  The four functions of the health system are health services provision (for appropriate and cost-effective health delivery); health service inputs (for generating human resources, technology, and capital); health financing (by revenue collection, risk pooling, and strategic purchasing); and stewardship and initiatives (to strengthen governance, accountability, and responsiveness).   A health system can be analyzed in its totality by using a framework consisting of six building blocks, i.e., leadership and governance, health financing, health workforce, health products, vaccines, and technologies, health information, and service delivery.  The Department of Health (DOH) is the lead agency for Philippine health care. According to its mandate (E.O. No. 119, Sec. 3), the DOH shall be responsible for the (1) formulation and development of national health policies, guidelines, standards, and manual of operations for health services and programs; (2) issuance of rules and regulations, licenses, and accreditations; (3) promulgation of national health standards, goals, priorities, and indicators; and (4) development of special health programs and projects, and advocacy for legislation on health policies and programs. LESSON 3: Primary Health Care and the Philippine Health Care Delivery System Health Care According to the Alma-Ata Declaration 1978, health is a fundamental human right. It states that the most important global goal is for humans to reach the optimal level of their health; this requires nut the action of the health sector but the collaboration among other sectors such as those in the social and economic sectors. Meanwhile, a common concern of many countries, including both developed and developing on is the gross inequality in the people's health status which is not socially, economically, and politic acceptable. Thus, the government of each country has the duty and responsibility to institute adequate measures to promote and protect its people's health, and thus achieve a better quality of life. For better understanding, the following concepts under health care are defined (as cited in DeDios, n.d.): 1. Health care system is defined by Miller & Keane (1987) as “an organized plan of health service.” 2. Health care delivery, as defined by Williams & Tungpalan (1981), is “the rendering of health care services to the people.” 3. Health care delivery system, also as defined by Williams & Tungpalan (1981), is “the network of health facilities and personnel which carries out the task of rendering health care to the people.” Primary Health Care As cited by WHO, the Alma-Ata Declaration defines primary health care as important health care derived from scientifically sound and socially acceptable methods. It must be universally accessible to al individuals and is based on what the community and country can provide.  As an approach the primary health care (PHC) deals with social policy which targets health equity. PHC has the essential elements and objectives that ensure attainable better health services for all. The ultimate goal of primary health care is better health for all. WHO has identified five key elements to achieve this goal. These are 1. universal coverage to reduce exclusion and social disparities in health, 2. service delivery organized around people's needs and expectations, 3. public policy that integrates health into all sectors, 4. leadership that enhances collaborative models of policy dialogue, and 5. increased stakeholder participation. Essential Elements of Primary Health Care Below are the eight (8) elements of primary health care: 1. Education concerning prevailing health problems and the methods of identifying, preventing, controlling them 2. Locally endemic disease prevention and control 3. Expanded program of immunization against major infectious diseases 4. Maternal and child health care including family planning 5. Essential drugs arrangement 6. Nutritional food supplement, an adequate supply of safe and basic nutrition 7. Treatment of communicable and non-communicable disease and promotion of mental health 8. Safe water and sanitation Other elements of primary health care include: 1. Expanded options of immunization 2. Reproductive health needs 3. Provision of essential technologies for health 4. Health promotion 5. Prevention and control of non-communicable diseases 6. Food safety and provision of selected food supplements Principles of Primary Health Care A conceptual shift in health care calls attention to the fact that primary health care should be integrated, and its principles guide the functions of the system as a whole. Having a systems perspective bridges the conflict between primary health care as a distinguished level of care and as a holistic approach to the provision of health services.  The health system should also consider the principles of the Alma-Ata Declaration and other intersectoral approaches. It should cover broader health issues of populations while reinforcing public health functions. It should come up with programs that provide care and prevent diseases and provision for services especially for the poor and marginalized groups. Finally, it should be able to monitor programs for continuous improvement. The basic objectives to launch and sustain primary health care as part of the comprehensive health system are as follows: 1. Improve the level of health care of the community 2. Promote favorable population growth structure 3. Reduce the morbidity and mortality rates especially among infants and children 4. Reduce prevalence of preventable, communicable, and other diseases 5. Improve basic sanitation 6. Extend essential health services especially to the underserved sectors 7. Develop the capability of the community to become self-reliant 8. Encourage the contribution of other sectors to the social and economic development of the community 9. Provide equitable distribution of health care 10. Ensure community participation and monitor adequacy and distribution of health worker are supported locally and at the referral levels 11. Recognize that the formal health sector needs other sectors in the promotion of health (multi-sectoral approach) 12. Use the appropriate technology which are accessible, feasible, affordable, and culturally acceptable to the community Management of Primary Health Care Health care managers usually carry out the following functions in the process of management: 1. Planning - This means setting priorities and determining performance targets. Managers are usually required to set a direction and determine what needs to be accomplished. 2. Organizing - This refers to designing the organization or the specific division, unit, or service for which the manager is responsible. Furthermore, it means designating reporting relationship and intentional patterns of interaction, determining positions and teamwork assignments, distributing authority and responsibility. 3. Staffing - This function refers to acquiring and retaining human resources, and developing and maintaining the workforce through various strategies and tactics. 4. Controlling - This function refers to monitoring staff activities and performance and taking the appropriate actions for corrective actions to increase performance. 5. Directing - This focuses on initiating action in the organization through the effective leadership motivation, and communication of managers.  Below are the management principles in relation to organizing: 1. Authority, responsibility, and accountability a. Authority refers to the formal and legitimate right of a manager to issue orders, make decisions, and allocate resources to achieve desired outcomes of the organization. b. Responsibility is the duty of the employee to perform the assigned tasks and activities. c. Accountability means reporting and justification of task outcomes to higher management by those people with authority. 2. Types of authority a. Line authority managers issue orders to their subordinates and are also responsible for the results. b. Functional authority is for managers that have power only over a specific set of activities. c. Staff authority is given to specialists in their areas of expertise. The staff manager simply advises, recommends, and counsels. 3. Centralization, decentralization, and formalization a. Centralization refers to the concentration of planning and decision-making to the top of the organization. b. Decentralization refers to the delegation of planning and decision-making to the lower branches of the organization. c. Formalization refers to a written documentation provided for the direct control of the employees. 4. Staffing As regards to the process of staffing, here is the list of functions of the manager: a. Assign individuals to respective positions identified in the management plan b. Assess required competencies through  identification of the key result areas (KRAS) per major activity  determination of the competencies and qualifications c. Recruit qualified personnel d. Improve existing services and programs by  reviewing and adjusting the requirements accordingly  matching the competency requirements vis-à-vis the responsible personnel assigned to the activity The Philippine Health Care System According to Dizon (1977), the Philippine health care system is “a complex set of organizations interacting to provide an array of health services.” It has progressed due to challenges encountered over time. In 1991, the local government units (LGUS) took over the management of health service delivery but the issue of fragmentation has not been absolutely addressed. Health workforce has to deal with the pressing issues of underemployed workers, limited resources, and unequal distribution. Meanwhile, the private sector which is said to comprise 50% of the overall health system is strongly involved in improving the delivery of health services, but the government's power to regulate should be optimized. The Department of Health Mandate As specified in Executive Order No. 119. Sec. 3, the Ministry of Health (now Department of Health (DOH)) has the responsibility to create, plan, implement, and systematize national health policies, advocacies, and programs. Its primary function is to promote, protect and preserve or restore people's health by giving health services and by monitoring and motivating health service providers. Moreover, it is responsible for the issuance of health-related licenses and accreditations and disseminating information about national health indicators. Vision DOH vision by 2030 states A global leader for attaining better health outcomes, competitive and responsible health care system, and equitable health financing Mission DOH mission states To guarantee equitable, sustainable and quality health for all Filipinos, especially lead the quest for excellence in health Levels of Health Care Facilities Below are the levels of health care facilities according to Williams & Tungpalan (as cited in DeDios, n.d.): 1. Primary Level of Health Care Facilities The primary level of health care facilities refers to the following: a. Units operated by the DOH which include the rural health units, their respective sub-centers chest clinics, malaria eradication units, and schistosomiasis control units; b. Puericulture center operated by the League of Puericulture Centers; c. Units operated by the Philippine Tuberculosis Society such as the tuberculosis clinics and hospitals; d. Clinics operated by the Philippine Medical Association; e. Clinics operated by large industrial firms for their employees; f. Health centers and community hospitals Commission, and operated by the Philippine Medical Care Commission; and  g. Other health facilities operated by voluntary religious and civic groups. 2. Secondary Level of Health Care Facilities The secondary level of health care facilities includes the smaller and non- departmentalized hospitals. These are emergency and regional hospitals where adequate treatments are offered for patients with symptomatic stages of diseases. 3. Tertiary Level of Health Care Facilities Included in the tertiary level are specialized national hospitals which offer highly technological and sophisticated services. Patients who are afflicted with life- threatening diseases requiring highly technical and specialized knowledge, facilities, and personnel are treated here. Levels of Primary Health Care Workers 1. Grassroot or Village Health Workers a. They are the initial links of the community to health care. b. They provide preventive health care measures and simple curatives to promote a healthy environment. c. They encourage programs/activities such as food production programs to improve the socio-economic level of the community. d. They are the volunteers, community health workers, or traditional birth attendants. 2. Intermediate Level Health Workers a. They are the first source of professional health care. b. They attend to health problems which are already beyond the competence of the village workers. c. They provide supervision, training, supplies, and services that provide support to front-line health workers. d. They are medical practitioners, nurses, and midwives. 3. First-Line Hospital Personnel a. When hospitalization is required, they serve as the backup health service providers. b. The intermediate level health workers or village health workers are in close contact with them. c. They are the physicians with specialty, nurses, dentist, pharmacists, and other health professionals. The categories of health workers are affected by certain factors such as 1. the availability of health manpower resources, 2. the presence of health care concerns and needs of the locality, and 3. the issue of financial and political feasibility. Key Points to Remember  Health is a fundamental human right as cited in the Alma-Ata Declaration of 1978.  Reaching the highest possible level of health is important worldwide.   Primary health care (PHC) is essential health care made universally accessible through full participation of health care providers and at a cost that the community and the country can afford.  The ultimate goal of primary health care is better health for all. The principles of primary health care should guide the functions of the system as a whole.  Management of primary health care includes planning, organizing, staffing, controlling, and directing  Health care facilities are categorized into primary, secondary, and tertiary levels. Primary health care workers are categorized as grassroot or village health workers, intermediate level health workers, and first-line hospital personnel.  The Philippine health care system has progressed due to many challenges through time. The private sector has been strongly engaged but government regulation should be optimized.  The primary function of the Department of Health (then Ministry of Health) indicated in EO no. 119 is to promote, protect, preserve, or restore people's health by giving health services and monitoring health service providers. LESSON 4: Overview of Health Informatics Health Information Technology The dawn of the information age has resulted in the generation of huge amounts of routine data, particularly in health care, which can become perplexing to process and analyze. This is the challenge for health Informatics--to make sense of large amounts of data while ensuring that the processes are valid and secure. The transition from a manual to a more advanced health information system is an overarching issue for providers of health care managers, policymakers, researchers, and patients alike. While there are benefits, there are also undeniable disadvantages. One innovation that manages health information better service delivery is health information technology. Rouse (2016) defines health Information technology (HIT) as "the area of IT involving the design development, creation, use, and maintenance of information systems for the health care industry. Automated and interoperable health care information systems are expected to improve medical care, lower costs, increase efficiency, reduce error, and improve patient satisfaction while also optimizing reimbursement for ambulatory and inpatient health care providers.” Health information technology vows to provide innovation to health care delivery and connection among users and stakeholders in the e-health market. Systems such as electronic health records, decision support systems, and personal health records are promising and are becoming widely deployed worldwide (Kushniruk & Borycki, 2017). Health Care Software Systems Rouse (2016) enumerates the following types of health information technology: An electronic health record (EHR) is also called an electronic medical record (EMR). It is one of the fundamental components of health information technology infrastructure EHR is the patient's official health record in digital form and this information is shared across multiple health care providers and agencies. The other key elements are the personal health record (PHR) and the health information exchange (HIE). A PHR 5 person's self-maintained health record while the HIE is the health data clearinghouse which is comprised of health care organizations with interoperability pact to share data among their health information technology systems. In the United States, since the inception of the HITECH Act of 2009, the use and implementation of EHR systems have increased dramatically. Hospitals and physicians using the government-certified EHR systems meet the meaningful use criteria and are qualified to receive incentives. The said criteria is regulated under the Office of the National Coordinator (ONC) for health IT which certifies approved IT technology use under the federal reimbursement program and Centers for Medicare & Medicaid Services (CMMS). However, meaningful use is changing due to the Medicare Access and Children's Health Insurance Plan Reauthorization Act (MACRA) which is a law on value-based reimbursement system passed by the US Congress in 2015. There are two widely used types of health information technology, the picture archiving and communication systems (PACS) and vendor neutral archives (VNA). These two help manage and store the patients' medical images. PACS and VNAs integrate radiology into the main hospital workflow. Radiology used to be the primary repository for medical images. Presently, other specialties such as cardiology and neurology are also among the large-scale producers of clinical images VNAs can also be installed for the purpose of merging stored imaging data from various departments into a multi-facility health care system. Health Information Ecosystem The Healthcare Information and Management Systems Society (2017) defines a health interoperability ecosystem as a composition of individuals, systems, and processes that share, exchange, and access all forms of health information, including discrete, narrative, and multimedia. Individuals, patients, providers, hospital/health systems, researchers, payors, suppliers, and systems are potential stakeholders within such an ecosystem. Each is involved in the creation, exchange, and use of health information and/or data. An efficient health interoperability ecosystem provides an information infrastructure that uses technical standards, policies, and protocols to enable seamless and secure capture, discovery, exchange, and utilization of health information. Health Informatics in the Cloud The role of cloud technology is undeniably significant in our everyday lives. Currently, 83 percent of health care organizations are making use of cloud-based applications, and it is changing the landscape of the health care system and health informatics. However, both benefits and threats exist (University of Illinois, 2014). Advantages of Cloud Technology 1. Integrated and Efficient Patient Care Cloud technology offers a single access point for patient information which allows multiple doctors to review laboratory results or notes on patients. Physicians can spend more time deciding and performing patient treatment instead of waiting for information from different departments. 2. Better Management of Data The accumulation of electronic health records will allow more meaningful data mining that can better assess the health of the general public. More data can mean more opportunities to identify trends in diseases and crises. Disadvantages of Cloud Technology 1. Potential Risks to Personal Information The strength of cloud technology is also the very same characteristic that makes it vulnerable to data breaches. The information contained within medical records may be subjected to theft or other violations of privacy and confidentiality. Fortunately, safeguards may be put in place to minimize such threats such as encryption, proper data disposal, and other security features. 2. Cloud Setup Seems Cumbersome The transition from a traditional to an automated system might be difficult for some members of health care organizations that may not be familiar with cloud technology. This technology, however, will be adopted by more institutions in the future. With proper education and illustration of its function, hesitant practitioners may be able to see its advantages. Health Informatics in the Philippines Health informatics is the application of both technology and systems in a health care setting. It has been loosely practiced in the Philippines since the 1980s. Practitioners who had access to IBM (International Business Machines Corporation) compatible machines used word processors to store patient information. Since then, significant milestones in health informatics have occurred over the years, one of which is the Community Health Information Tracking System (CHITS), a Linux, Apache. MySQL, PHP-based system released under the general public license (GPL). CHITS was named finalist at the Stockholm Challenge 2006 and one of top three e-government projects in the Philippines by the Asia Pacific Economic Cooperation (APEC) Digital Opportunity Center (ADOC). CHITS is an electronic medical record (EMR) developed through the collaboration of the Information and Communication Technology community and health workers, primarily designed for use in Philippine health centers in disadvantaged areas. It is currently utilized in 111 government health facilities. What used to be manually done, eg., looking up a patient's record for four to five minutes, can now be executed within a couple of seconds. The implementation of CHITS has indeed resulted in higher efficiency rate among health workers since more time can be spent in providing patient care (Philippine Council for Health Research and Development, 2012). Despite the development, health informatics in the Philippines still suffers from various issues that hamper progress, one of these is the lack of interest in the field. Health informatics is seen more as a novelty rather than as a profession. When professional and economic constraints come into play, priorities shift towards clinical responsibilities at the expense of health informatics as a discipline. Another issue is that many decision-makers do not use the benefits of information technology in the health sector. The large initial expenditure for a health information system remains another barrier to the integration of IT in the Philippine health care system (Marcelo, 2012). Key Points to Remember  Health information technology (HIT) involves the development and management of health information for improved health service delivery.  The electronic health record (EHR) is the central component of the HIT infrastructure.  Picture archiving and communication systems (PACS) and vendor neutral archives (VNAs) are two widely used types of HIT that help health care professionals store and manage patients' medical images.  An efficient health interoperability ecosystem provides an information infrastructure that uses technical standards, policies, and protocols to enable seamless and secure capture, discovery exchange, and utilization of health information.  The advantages of health informatics in the cloud are integrated and efficient patient care and better management of data.   Despite the development, health informatics in the Philippines still suffers from various issues that hamper progress, such as the lack of interest in the field. Another issue is that the benefits of information technology do not seem apparent to many decision- makers in the health sector. LESSON 5: Health Information Systems Health Information Systems Health informatics is the application of both technology and systems in a healthcare setting. While health information technology focuses on tools, health information systems cover the records, coding, documentation, and administration of patient and ancillary services. Concerns about the cost and quality of health care are among the motivating factors why health information systems are increasingly implemented across health industries all over the world. The combination of elements in a health information system enables the provision of more efficient and effective health care services. The components of a health information system are correlated and translated into harmonious operations. The health information system (HIS) cover different systems that capture, store, manage, and transmit health-related information that can be sourced from individuals or activities of a health institution. These include disease surveillance system, district level routine information systems, hospital patient administration system (PAS), human resource management information systems (HRMIS), and laboratory information system (LIS). The information collected from a well-functioning HIS is very useful in policy making and decision-making of health institutions and becomes the basis in creating program action. This translates to efficient resource allocation at the policy level, and improvement of the quality and effectiveness of health at the delivery level. HIS should be sustainable, user-friendly, and economical. Health care personnel should be educated on the use of the routine data collected from the system and the significance of good quality data in improving health (Pacific Health Information Network, 2016). Role and Function of Health Information Systems Sheahan (2017) defines health Information system (HIS) as a mechanism which keep track of all data related to the patient such as patient's medical history, contact information, medication logs, appointment schedule, insurance information, and financial account inducing billing and payment. The roles that a well-implemented HIS can perform in improving health services are follows: 1. Easier to files The systems have revolutionized the collection and management of patient information. The need for hard copy of the patient's medical records becomes optional as the systems are electronic.  2. Better control Only authorized personnel can have access information on the patient's health. Doctors may be given permission to update patient information while a receptionist may only have the authority to update a patient's appointments. 3. Easier update After creation of the record, patient information can be accessed and reviewed any time and copies can be printed or released to the patient upon request. 4. Improved communication HIS assist communication among doctors and hospital. However, medical professional must adhere to regulation on patient privacy and security to ensure that information is kept confidential and safe from unauthorized access. A good health Information system delivers accurate information in a timely manner, enabling decision-makers to make informed choices about the different aspects of the health institution, from patient care to annual budgets. It also upholds transparency and accountability due to easier access to information. Components of Health Information Systems The Health Metrics Network (HMN), in its Framework and Standard for Country Health Information Systems (2008), defines health information systems as consisting of six components. 1. Health information system resources These include the framework on legislation, regulation, planning, and the resources required for the system to be fully functional (e.g. personnel, logistics support, financing, ICT, and the component's coordinating mechanisms). 2. Indicators The basis of the HIS plan and strategy includes indicators and related targets such as the determinants of health; health system inputs, outputs, and outcomes; and the health status.  3. Data sources Data sources are divided into two main categories: (1) population-based approaches such as civil registration, censuses and population surveys and (2) institution-based data such as individual records, resource records, and service records. Occasional health surveys, research and information produced by community-based organizations may not be directly classified under the main categories, but they may provide useful information. 4. Data management Data management refers to the handling of data, starting from collection and storage to data flow and quality assurance, processing compilation, and data analysis. 5. Information products Data is transformed into useful information that serves as evidence and provides insight crucial to shaping a health action. 6. Dissemination and use HIS enhances the value of health information by making it readily available to policymakers and data users. These six components of health information systems can be categorized into inputs, processes, and outputs. Inputs refer to the health information system resources. These resources include health, institutional coordination and leadership, health information policies, financial and human resources, and infrastructures. The indicators, data sources, and data management form the process in HIS. Core indicators are needed as bases for program planning, monitoring, and evaluation. Population- and institution-based sources are also essential for decision-making as they provide guide to health service delivery. Importantly, these data must be accessible and understandable by users and policymakers. Outputs refer to the transformation of data into information that can be used for decision-making and to the dissemination and use of such information. Different Data Sources for Health Information Systems Donaldson and Lohr (1994) explain that a comprehensive database for health information systems include the following:  1. Demographic data refers to the facts about the patient which include age and birthdate, gender, marital status, address of residence, race, and ethnic origin. Information on educational background and employment is also recorded along with information on immediate family members to be contacted during emergency. 2. Administrative data includes information on services such as diagnostic tests or out-patient procedures, kind of practitioner, physician's specialty, nature of institution, and charges and рауments. 3. Health risk information records the lifestyle and behavior (e.g. use of tobacco products or engagement in strenuous activities) of a patient and facts about his or her family's medical history and other genetic factors. This information is used to evaluate the patient's propensity for different diseases. 4. Health status refers to the quality of life that a patient leads which is crucial to his or her health. This shows the domains of health which include physical functioning, mental and emotional well being, cognitive functioning, and social functioning. It also shows one's perception of his or her health in comparison with that of his or her peers. 5. Patient medical history gives information on past medical encounters like hospital admissions, pregnancies and live births, surgical procedures, and the like. It also includes previous illnesses and family history (e.g. alcoholism or parental divorce). 6. Current medical management reflects the patient's health screening sessions, diagnoses, allergies (especially on medications), current health problems, medications, diagnostic or therapeutic procedures, laboratory test, and counseling on health problems. 7. Outcomes data presents the measures of aftereffects of health care and of various health problems. These data usually show the health care events (e.g. readmission to hospital, unexpected complications or side effects) and measures of satisfaction with care. Outcomes directly reported by the patient after treatment will be most useful. Key Points to Remember  Health information systems (HIS) refer to systems that capture, store, manage and transmit health related information that can be sourced from individuals or activities of health institutions.  HIS improves the delivery of health services because it ensures easier file access, better control, easier update, and improved communications.  The components of health information systems are health information system resources (inputs): indicators, data sources, and data management (processes); and transformation of data into information, and its dissemination and use (outputs).  The different data sources are demographic data, administrative data, health risk information, health status, patient medical history, current medical management, and outcomes data. LESSON 6: Health Management Information System Health Management Information System Traditionally, health care administrations have been managed manually, starting from patient registration to consultation. The creation of documents proved o be time-consuming and posed the risk of having duplicate records. Improper storage of these documents was also a concern because of difficulty in retrieval and the high cost of maintaining proper storage. Getting an overview of the number of patients visiting the hospital, or consolidating the nature of problems that need immediate action, and providing pertinent reports were very difficult to achieve. Tools such as snapshots and dashboard which are necessary in the analysis of the performance of hospitals were unavailable. Hospitals using the traditional manual process do not have real-time data and delays the receipt of data pose a challenge to evidence-based program management. Accurate and real- time records of equipment and drugs could not be obtained in a timely manner resulting in problems in accountability, monitoring of expiry dates, stocks, and auto indenting. Inventory of medicine and equipment was a tedious task due to lack of standards in filling names and codes in the institution. The need to enhance the management of health care services and to have real-time data to monitor the hospital performance thus calls for a health information management system that will address these concerns. As defined by the World Health Organization (2004), health management information system (HMIS) is "specially designed to assist in the management and planning of health programmes, as opposed to delivery of care." The health component of HMIS refers to clinical studies to understand medical technologies, clinical procedures, data base processes; management refers to the principles that help administer the health care enterprise; and information system refers to the ability to analyze and implement applications for efficient and effective transfer of patient information. An HMIS is one of the six building blocks essential for health system strengthening. It is a data collection system specifically designed to support planning, management, and drugs decision-making in health facilities and organizations. HMIS is a set of integrated components and procedures organizesd with the objective of generating information that will improve health care management decisions math all levels of the health system. It is a routine monitoring the system that evaluates the process with the intention of providing warning signals through the use of indicators. At the health unit level, HMIS is used by the health unit in-charge and the Health Unit Management Committee to plan and coordinate health care services in their catchment area. HMIS was developed within the framework of the following concepts (Republic of Uganda Ministry of Health Resource Centre, 2010):  The information collected is relevant to the policies and goals of the health care institution, and to the responsibilities of the health professionals at the level of collection.  The information collected is functional as it is to be used immediately for management and should not wait for feedback from higher levels.   Information collection is integrated for there is one set of forms and no duplication of reporting.  The information is collected on a routine basis from every health unit. Roles of HMIS The major role of HMIS is to provide quality information to support decision-making at all levels of the health care system in any medical institution. In addition to encouraging the use of health information in hospitals, it also aims to aid in the setting of performance targets at all levels of health service delivery and to assist in assessing performance at all levels of sector (Republic of Uganda Ministry of Resource Centre, 2010). An HMIS needs to be complete, consistent, clear, simple, cost-effective, accessible, and confidential (Janneh, 2002). It should be complete with all information but avoiding duplication and consistent in assigning definitions to similar information from various sources. It should also be simple to use and clear as to what is measured by the elements. The eligible users must have access and should be able to use the system with ease. The confidentiality of patient information and data privacy should always be a top priority. While providing all these benefits, the system must prove its cost-effectiveness through its operations. Functions of HMIS The information from an HMIS can be used in planning, epidemic prediction and detection, designing interventions, monitoring, and resource allocation (Republic of Uganda Ministry of Health Resource Centre, 2010). Historically, all information systems, including HMIS, are built upon the conceptualization if three fundamental information-processing phases: data management, and data output. Each phase comes with elements (Tan, 2010) that perform specific functions. 1. Data Input includes data acquisition and data verification. a. Data acquisition refers to the generation and collection of data through the input of standard coded formats (e.g., bar codes) to assist in the faster mechanical reading and capturing of data. b. Data Verification involves data authentication and validation. The authority, validity, and reliability of the data sources help ensure quality of gathered data. 2. Data management, also called processing phase, includes data storage, data classification, data update, and data computation. a. Data storage includes preservation and archiving of data. It is advisable that data which are no longer actively used should be archived. At times, it is mandatory and part of legislation. b. Data classification is also called data organization which sets the efficiency of the system. Key parameters should be used for data classification schemes for easier data search.  c. Data computation requires various forms of data manipulation and data transformation (e.g., mathematical models, linear and nonlinear transformation, statistical and probabilistic approaches, and other data analytic process). This function allows data analysis, synthesis, and evaluation so that data can be used not only for decision-making but also for other tactical and operational use. d. Data update facilitates new and changing information and requires constant monitoring. For HMIS, the mechanism for data maintenance must be in place for updating changes for manual or automated transactions. 5. Data output includes data retrieval and data presentation. a. Data retrieval pertains to the processes of data transfer and data distribution. The transfer process consider the duration of transmittal of required data from the source to the appropriate criterion. b. Data presentation is the reporting if the interpretation of the information produced by the system. Summary tables and statistical reports are expected but the use visuals is encouraged especially for high-level managerial decision- making because they provide a better intuitive perspective of the data trend. List of Functions of HMIS Listed below are the possible functions in an HMIS with the corresponding type of information that can be captured and tracked in the system (Behavioral Health Collaboration Solutions, 2006). 1. Client data relates to all the information of the client which is related to his or her transactions, reports, and other information such as client billing data, clinical data l, and other client data. 2. Scheduling is observed to distribute resources to areas that need them. An example is linking the schedule to the billing of the entity. 3. Authorization tracking focuses on monitoring of the authorized personnel and their use of the authorized unit. 4. Billing refers to the notification of the charges for the patient and other related documents such as the compliant electronic claim. 5. Accounts receivable (A/R) management ensures that costumers are properly notified about their bill and will settle it accordingly. Data for A/R management include tracking aging of unpaid services, tracking reasons for denials, and aged receivable report by payer source. 6. Reporting refers to reports issued by the entity which could be basic reports or report writer. 7. Medical record, also called electronic health record (EHR), is a collection of digital information about a patient. Aside from patient registration, the data could include assessment, treatment plan, and progress/encounter notes. 8. Compliance refers to procedure that should be followed for the improvement of the condition of the patient or the service provided such as treatment plan and progress note.  9. Financial data refers to information relating to the performance of the entity collected for administering purposes. These include financial reports, general ledger, payroll, and accounts payable. Determinants of HMIS Performance Area The determinants affecting the performance of an HMIS may be behavioral, organizational, and technical. Behavioral determinants The data collector and users of the HMIS need to have confidence, motivation, and competence to perform HMIS tasks in order to improve the routine health information system (RHIS) process. The chance of the task being performed is affected by the individual perceptions on the outcome and the complexity of the task (Aqil, Lippeveld, & Hozumi, 2009). Lack of motivation and enough knowledge on the use of the data has been found to be a major drawback in the data quality and information use. Changing people's attitude towards data collection and analysis is necessary in order to maximize the performance of the RHIS process (Routine Health Information Network, 2003). Organizational determinants The important factors that affect the development of the RHIS process are the structure of the health institution, resources, procedures, support services, and the culture within the organization (Aqil, Lippeveld, & Hozumi, 2009). However, other factors which include lack of funds, human resources, and management support contribute to the determinant of the RHIS process. Having a system in place which supports data collection and analysis and transforms it into useful information will help in promoting evidence-based decision-making. Thus, all components within the system are ideal in making the RHIS perform better. And improved RHIS performance means an effective organizational culture that promotes information use by collecting, analyzing, and using information to accomplish the organization's goals and mission (Sanga, 2015). Technical determinants Technical factors involve the overall design used in the collection of information. It comprises the complexity of the reporting forms, the procedure set forward in the collection of data, and the overall design of the computer software used in the collection of information (Sanga, 2015). PRISM Framework The Performance of Routine Information Systems Management (PRISM) is a conceptual framework that broadens the analysis of HMIS or RHIS by including the three determinants of HMIS performance, namely:  Behavioral determinants - knowledge, skills, attitudes, values, and motivation of the people who collect and use data,  Organizational/environmental determinants - information culture, structure, resources, roles, and responsibilities of the health system and key contributors at each level, and  Technical determinants - data collection processes, systems, forms, and methods. This framework identifies the strengths and weakness in certain areas, as well as the correlation among these areas. This assessment aids in designing and prioritizing interventions to improve RHIS performance, which in turn improves the performance of the health system. The PRISM framework founded on performance improvement principles, defines the various components of the routine health information system and their linkages to produce better quality data and continuous use of information, leading to better health system performance and, consequently, better health outcomes (Aqil, Lippeveld, & Hozumi, 2009). Key Points to Remember  A health management information system (HMIS) is "specially designed to assist in the management and planning of health programs, as opposed to delivery of care (WHO, 2004)."  The major role of HMIS is to provide quality information to support decision-making at all levels of the health care system in any medical institution.  Historically, all information systems, including HMIS, are built upon the conceptualization of three fundamental information-processing phases: data input, data management, and data output. Each phase comes with elements that perform specific functions. The eight elements are data acquisition, data verification, data storage, data classification, data computation, data update, data retrieval, and data presentation.  The determinants affecting HMIS performance are behavioral, organizational, and technical.  The PRISM (Performance of Routine Information Systems Management) framework defines the various components of the routine health information system (RHIS) and their linkages to produce better quality data and continuous use of information, leading to better health system performance and consequently, better health outcomes. LESSON 7: HMIS Monitoring and Evaluation HMIS Monitoring and Evaluation A health management information system aims primarily at assisting in the planning and management of a national health strategy plans; thus, continuous monitoring and evaluation is necessary for it to be effective. By definition and function, monitoring and evaluation are complimentary. Monitoring refers to the collection, analysis, and use of information gathered from programs for the purpose of learning from the acquired experiences, accounting the resources used both internal and external, and obtaining results and making decisions. These purposes correspond to three functions: learning, monitoring, and steering. Meanwhile, evaluation is the systematic assessment of completed programs or policies. The objective is to gauge the effectiveness of the program so that the adjustments can be made in areas that need improvement. An evaluation has both a learning function in which the lessons learned need to be incorporated into future proposals, and a monitoring function which means that the concerned parties review the implementation of policy based on the objectives and resources. Purpose of M&E A robust monitoring and evaluation (M&E) system is required to access the effect of an integrated service delivery. Appropriate indicators, data collection systems, and data analysis to support decision-making help guide the successful implementation of integrated services and measure the effect on both service delivery and use of service (FP/Immunization Integration Working Group, n.d.). M&E Framework A general framework of M&E of health system strengthening (HSS) was developed by various global partners and countries. Derived from the Paris Declaration on aid harmonization and effectiveness and the International Health Partnership (IHP+), this framework places health strategy and related M&E processes of each country at the center. The strengthening of a common country platform for the M&E of HSS is the core of the framework. In doing so, there is better alignment and the monitoring of fundings for health systems is easy. There are four components of the framework as provided by WHO, namely, the indicator domains, data collection, analysis and synthesis, and communication use, intended for achieving greater health impact. For monitoring medical services, indicators should be tracked to assess processes and results associated with the various indicator domains. In this way, the strengths and weaknesses of implementation are provided and can be used for troubleshooting in the system. In terms of outcomes and impact indicators, the changes may not be directly caused by service delivery efforts for there are other factors to consider. However, these data are still useful in understanding the current health status and context within a country (FPI/Immunization Integration Working Group, n.d.).  It should be noted that shifts in outcome and impact indicators may not be directly attributable to integrated service delivery efforts, as there are many other factors which influence these indicators. However, where possible, it can be useful to collect these data in order to understand the broader health context within a country, and the ways in which packages of interventions can lead to impact over time (FPI/Immunization Integration Working Group, n.d.). M&E Plan An M&E plan addresses the components of the framework and establishes the foundation for regular reviews during the implementation of the plan for the national level. Local M&E systems generate information for global monitoring based on the health sector review processes which are considered key factors in monitoring the progress and performance of the entire system. Medical institutions are monitored and evaluated through the assessment of reports, surveys, HMIS, and other evaluation studies. Specifically, the National Health Mission of India identifies strategies which help in the successful implementation of the framework. The framework should (1) be localized, (2) address the needs for multiple users and purposes, (3) facilitate the identification of indicators and data sources, and (4) be able to use the M&E in disease-specific programs. M&E and HMIS Indicators An indicator is a variable which measures the value of the change in units that can be compared to past and future units. The focus is on a single aspect of a program such as input, output, among others. HMIS uses various indicators to monitor key aspects of health system performance. The United States Agency for International Development (USAID) classifies these indictors (Table 7.1) into five broad categories, namely, reproductive health, immunization, disease prevention and control, resource utilization, and data quality. Table 7.1 Categories of HMIS Key Indicators Key Performance Area Key Indicator 1. Family planning acceptance rate 2. Antenatal care coverage 3. Proportion of deliveries attended by Reproductive Health skilled health personnel 4. Proportion of deliveries attended by HEW‟s 5. DPT-3 (Pentavalent-3) coverage (>1 child) Immunization 6. Measles Immunization coverage (>1 child) Disease Prevention and Control 7. Malaria case fatality rate among  patients under 5 years of age 8. New malaria cases per 1,000 population 9. New pneumonia cases among children under 5 per 1,000 population of < 5 yrs 10. TB cases detection rate 11. TB cure rate 12. Clients receiving VCT services 13. PMTCT treatment completion rate 14. PLWHA currently on ART 15. Trace drug availability (in stock) 16. OPD attendance per capita Resource Utilization 17. In-patient admission rate 18. Average length of stay (in-patient) 19. Bed occupancy rate Data Quality 20. Reporting completeness rate 21. Reporting timeliness rate Source: HMIS Information Use Training Manual (USAID, 2013) Table 7.2 provides specific indicators, data sources, and purposes for tracking each indicator for monitoring family planning and immunization service delivery and assessing the integration of services. This table includes a variety of quantitative indicators coupled with qualitative techniques in order to better understand the basics of the integration processes and solicit feedback on the approach. Table 7.2 Quantitative indicators for monitoring family planning/immunization integration Indicator Data Source Purpose INPUTS Vaccines stockouts in a single month (YES/NO, by the type HMIS, Service statistics Monitor vaccine stockouts. of vaccine) Contraceptive stockouts in a Monitor contraceptive single month (YES/NO, by HMIS, Service statistics stockouts. type of contraceptive) Monitoring reach of EP/FP Number of service providers integration training as an input trained in provision of EPI/FP Training records for effective integrated service integrated services delivery. OUTPUS Number of service delivery Service statistics and Coverage of integrated points offering integrated FP Supervision service delivery and immunization services Number of days per month Service statistics and Availability of co-located when both immunization and Supervision (Observation + FP/immunization services family planning services are Interviews) offered at the same site Supplemental tracking column Number/percent of women that can be added to existing attending routine child Quality/continuity of immunization register immunization services who implementation of integrated [Monitored for received information on family service delivery demonstration/pilot programs planning from a vaccinator only] Number/percent of women Supplemental tracking column (with children