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Provision and evaluation of health services

  • Page updated onMarch 10, 2025
Provision and evaluation of health services
Photo: Bruno Abarca

A good health system must be able to offer the population the services it needs, in the way and in the place that is most effective. To do so, it must employ all its resources, from its funding to the personnel and the medicines and health supplies. All these inputs are necessary for the first output that the system produces: quality health services.

In humanitarian emergencies it is necessary to adapt the approach of humanitarian action in health to the existing situation. Therefore, it is key to understand how health services may be affected by the crisis and know how to assess their capacity, performance and real needs. In addition, it is usual that, at least temporarily, cooperation efforts should be focused on the health services that are considered a priority.

Humanitarian crises affect and disrupt health services

What is the usual service provision like?

The provision of health services refers to the package of services that the health system offers, the modalities for doing so, and the infrastructure needed to do so. It is the immediate result of introducing resources into a functional health system. In addition, it also includes the way in which all this is organized, coordinated and managed.

Under normal conditions, and despite the variations that exist between health systems, it is usual for a health system to offer services of all types. This includes diagnosis and treatment of health problems, preventive services such as routine childhood immunization or prenatal follow-up, palliative and rehabilitation services, and health promotion.

In a good system, moreover, these services are offered at different levels of care. Thus, there must be a strong community-based and equitable access to primary care centers that constitute the heart of the system, together with second- and third-level hospitals. This network must be articulated with a good referral and counter-referral system. The centers must be sufficient, well distributed, and ensure a complete package of services with sufficient personnel, ensuring broad coverage. In addition, it is important that there is continuity of care, focusing attention on the patient throughout his or her life cycle. All this requires proper management and strong district coordination to facilitate collaboration between the different health care providers.

A humanitarian emergency can interrupt or deteriorate health services.

In complex emergencies and humanitarian crises, the health system and service delivery can collapse. When this happens, the health system loses the ability to secure the resources needed to deliver the usual package of services. Health personnel are forced to abandon their posts, infrastructure is damaged and equipment maintenance is diminished, the supply of medicines is hampered, referral and counter-referral systems are weakened, and access to services for the population (sometimes displaced or trapped in areas of high insecurity) becomes difficult.

In addition, new risks and disease patterns may appear as a result of the impact of the crisis on living conditions or access to water and sanitation, among other factors. At times, this ends up causing an overload of health services that do not have the capacity to cope with it.

Health services must adapt to the new humanitarian context

In a humanitarian crisis, new actors and modalities of health services appear

The humanitarian actors must contribute to ensure, in one way or another, that the affected population has access to the health services they need. According to the Sphere standards, it is recommended to set the target of an 80% of the population with access to primary health care services on foot (no more than one hour walking) and an 80% of facilities offering the priority services. It is not enough for services to be available, they must also work. Therefore, even in the most difficult conditions, it is necessary to ensure and maintain constant monitoring of a sufficient network of health centers at different levels, to ensure minimum standards of quality and access, and to identify support needs for these services.

In these contexts, when support to existing weakened health services is not sufficient (or when there are no services to support), temporary alternative service provision mechanisms emerge. The most common is to deploy emergency medical teams or mobile clinics. In most cases, these teams depend on humanitarian organizations, which come in to temporarily cover a critical need. However, they may do so with different service packages to the pre-existing one, different payment regimes (generally at no direct cost to the users), independent information systems (which may hinder continuity of care in populations on the move) and sometimes wide differences in quality with respect to what was previously available.

The diversity of interventions with mobile teams is enormous, depending on the capacity of the actors or the needs. However, since 2010 efforts have been made to systematize and establish minimum standards for Emergency Medical Teams, both national and international. This has to some extent facilitated their deployment and coordination and thus health system governance during the crisis, despite the multiplicity of actors.

The health care package should be tailored to cover the essentials and priorities

In many humanitarian contexts it may be necessary to adapt and define a new essential package of health services to make prioritization of the most important health problems feasible. The global health cluster defines Essential Package of Health Services as "A detailed list of interventions/services (preventive, promotive, curative, rehabilitative and palliative) at different levels of care, endorsed by the government at the national level, or agreed upon by a substantial group of actors when services are to be provided in areas outside government control. These interventions must be available to all, safe, person-centered and quality-assured to be effective. They should be funded by the government, with or without donor support, and to the extent possible, should be provided without user fees at the point of service delivery during the emergency."

Having a package of services adapted to the crisis allows the development of a strategy around it, supported by political commitments, which facilitates the work of planning, resource mobilization and management of these services. At the same time, it can serve as a basis for the provision of services by all the actors involved in the crisis, reducing fragmentation, increasing equity, and even facilitating the implementation of common health information system tools and common reporting mechanisms.

How to define which health services are essential and a priority?

Developing a package of essential health services, however, is no easy task. In addition to preliminary coordination between actors, it requires expert work to select the services to be included according to international recommendations and, above all, the local burden of disease and the specific priorities of the intervention context.

To prevent the proposed package of services from remaining a utopian aspiration, a thorough analysis of the feasibility of the proposed package given the existing capacity of the system and its services, as well as a study of the cost it could entail, must also be carried out. As usual, including more services may seem positive but may be unfeasible when resources are scarce or not guaranteed.

WHO and the global health cluster have led a collective work with many more organizations in 2024 for the development of a guide to develop high-priority health services for humanitarian response (H3) packages, from community to second-level hospitals. It is based on an analysis of the burden of disease and capacity of services typically found in humanitarian settings, but always allowing (and encouraging) adaptation to each specific context. Within the essential services package are included services classified as core for their high impact, cost-effectiveness and feasibility of implementation and services classified as widespread for requiring medicines not found in the usual inter-agency kits or specialized training of health personnel.

To support health services in a crisis, they must be assessed first

Analyzing the situation of health services makes it possible to identify intervention priorities

In the same way that humanitarian action always starts with an analysis of the context and needs, practically all health cooperation interventions, especially those focused on support to the health services network, start with an assessment of the situation of the health units. This makes it possible to know such important aspects as their level of functionality or availability, as well as the aspects that need support as a higher priority. These aspects, when implementation begins, should also be part of the monitoring and evaluation work.

There are many different tools for this purpose. Some are aimed at carrying out a quick review in acute emergency or difficult access contexts to extract basic information, while others are aimed at a more complete evaluation and calculation of monitoring indicators, at evaluating other aspects such as users' opinions about these services, or at analyzing specific aspects of a health problem to guide more vertical actions. 

In the last two decades there have been efforts aimed at the development of numerous tools for the assessment of health units and their mapping in a geographic area in humanitarian contexts or for system strengthening,more or less standardized for coordinated action.

There are numerous methods and tools for the evaluation of health services.

Every humanitarian organization, practically, has developed its own tools for the situation analysis of health services. In fact, every professional in the sector probably has a folder on his or her computer full of lots of versions and adaptations of small questionnaires for more or less rapid assessments. All of them are usually quite similar, with minor differences resulting from continuous modifications. Even so, every time it is necessary to analyze health needs and identify a possible intervention, there is an appetite -almost irrepressible- to make a new readaptation.

Some needs assessment tools are multi-sectoral and designed for rapid use in emergencies. These include IASC's Multi-Sector Initial Rapid Assessment (MIRA), UNHCR's Needs Assessment for Refugee Emergencies (NARE), or OCHA's more recent Joint and Intersectoral Analysis Framework (JIAC 2.0).

However, in addition to this, some humanitarian health and global health actors have tried to propose complete, more or less standardized toolkits for large-scale health services assessment, mostly under a health systems strengthening framework but also with a possible early capacity recovery approach. Efforts in this direction by the World Bank, USAID and WHO are worth noting.

  • The World Bank, for example, launched in 2010 and updated in2018 its Service Delivery Indicators (SDI) questionnaires for health, very focused on assessing the quality of health services from the experience of users. However, these are complex tools posed for extensive data collection (over one to two years) at the national level.
  • USAID launched its Service Provision Assessment (SPA) proposal in 2012, developed by ICF International under the Demographic and Health Surveys project. This tool, which was again completely updated in 2022, focuses on assessing the availability and quality of specific services.
  • In parallel to these initiatives, the WHO launched its Service Availability Mapping (SAM) and later, in 2015, a new tool, developed in collaboration with USAID: the Service Availability and Readiness Assessment (SARA). which makes it possible to calculate availability and readiness indices for specific health units and health services.

Evaluating health services requires both a quantitative and qualitative approach

There are two key tools today and for the future: HeRAMS and HHFA.

At present, and despite the coexistence with a myriad of other tools, the two that seem to have the most potential in the future are HeRAMS and HHFA.

The Health Resources Availability Mapping System (HeRAMS) is a collaborative effort led by WHO and the Global Health Cluster that began in 2007 to enable mapping and monitoring of the availability of essential health resources and services in humanitarian settings, to help identify needs, dysfunctionalities, their causes and priorities for decision making. The result of the HeRAMS application is a Master List of health units with information on location and type of health services in a geographic area, as well as data on the general state of infrastructure and equipment, the functionality of the facility, accessibility, how it is being managed, the services it offers and the type of external support it receives.

Its implementation requires solid coordination among health sector actors around its corresponding cluster. Once the information is available it can be displayed on a dashboard or web dashboard and in reports. HeRAMS does not allow for in-depth analysis of all elements of a health system, but it allows for essential monitoring in difficult contexts that can inform decision making in humanitarian action.

In addition, in 2020, WHO launched a new initiative to harmonize the multiple existing health facility assessment tools into one: the Harmonized Health Facility Assessment (HHFA). This initiative, in which USAID and the World Bank also collaborated, culminated in 2022 and 2023 with the publication of a comprehensive set of questionnaires to assess the availability, capacity, management and financing of health units and the provision of services according to quality standards, with a strong focus on primary health care, universal health coverage and the Sustainable Development Goals.

These two tools, although they make a good tandem, cannot cover all the needs of humanitarian or global health organizations. These sometimes need more agile and lightweight tools for isolated use in specific projects. However, HeRAMS and HHFA offer a strong basis for adaptation and, above all, for collaboration between multiple actors for common coordinated monitoring.

The opinion of health service users (and health personnel) matters.

In humanitarian action, haste is the enemy of quality. When there is an emergency, rapid health services assessment actions usually prioritize the use of quantitative tools. These are usually used by health personnel who, during a visit to a health center and an interview with those in charge, complete a model questionnaire.

However, most quantitative tools focus more on the inputs and outputs of the health system and its services. After all, it's good that drugs are available, staff are well trained, the solar panel battery is working, and there are plenty of consultations, right?

When attempting to act urgently, the mistake is often made of paying little attention to the views of the people who use these services. However, they are the people affected and to whom the health system (and the humanitarian actors that support and sustain it) must be accountable. It is therefore urgent to reconsider the importance of dialoguing with these people, who are the ones who can provide the most relevant information on the effectiveness of services to solve their problems, on who is being discriminated against and without access, or on their lack of financial protection against health problems.

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