The problem

Health system strengthening is often judged by what is invested or delivered: health workers trained, facilities built, consultations recorded. These figures matter, but they do not show whether people can reach care, receive good-quality care, stay in care or avoid financial hardship. New facilities change little if they lack staff, essential medicines, electricity or referral links.

What the framework does

PBHI is developing its own framework that connects three functions:

• Measurement: the current state and performance of a health system.
• Evaluation: whether, how and why capabilities and outcomes change.
• Decision support: turning findings into priorities, resource allocation, corrective action and accountability.

We begin with district-level primary health care in sub-Saharan Africa, where PBHI already works with communities, facilities and health authorities. The framework builds on the WHO health system building blocks, the WHO health system performance assessment framework, the WHO and UNICEF primary health care measurement framework, PHCPI Vital Signs Profiles and the OECD DAC evaluation criteria, and treats health systems as complex and adaptive.

Intended contribution

The framework aims to link the measurement of system capabilities with the diagnosis of bottlenecks and the mechanisms behind them. Whether this adds value beyond existing tools will be tested through a structured review before any claim of novelty is made.

The six-layer model

1. Context: political economy, demographics, disease burden, geography, climate, conflict and fiscal space.
2. Resources and structures: financing, workforce, facilities, medicines, technologies, laws and information systems.
3. Functional capabilities: governance, coordination, purchasing, regulation, supply chains and adaptive capacity.
4. Service performance: access, quality, safety, continuity, integration, responsiveness and efficiency.
5. Goals and outcomes: health improvement, coverage, financial protection, equity, trust and people-centred care.
6. Learning and adaptation: performance review, causal investigation, corrective action and resource reallocation.

Equity, resilience, sustainability, accountability and integration run through every layer. The links between layers are hypotheses to be tested, not fixed pathways.

What we will measure

Eight domains: governance and accountability; financing and financial protection; health workforce; service delivery and quality; medicines and health technologies; health information and digital systems; infrastructure and operational readiness; and resilience and community engagement.

Four tiers of indicators: a core set for comparison; domain measures for programme management; context-specific measures for local priorities; and diagnostic measures for research. Every indicator has a full specification, and existing data such as DHIS2 and facility and household surveys are reused wherever possible.

12-month development plan

Evidence review (months 1 to 2), design (3 to 4), consensus (5 to 6), operations (7 to 8), pilot in contrasting districts (9 to 11) and consolidation into a pilot-tested version 1.0 (month 12). Full validation across settings will take longer and depend on partners, data access and funding.

How results will be reported

Results will be reported as indicator values, domain profiles and a whole-system profile, not a single score. This is so that strong results in one area do not hide failure in another, averages do not hide inequality, and better data do not make a system look worse. The framework is for learning and improvement, not for penalising under-resourced systems.

Expected outputs

• A technical framework document, indicator registry and data dictionary
• A field assessment manual, decision-support toolkit and validation protocol
• Four planned papers: a scoping review, a framework development study, a pilot and validation study, and an applied evaluation

Sources

1. WHO. Monitoring the building blocks of health systems: a handbook of indicators. 2010. https://iris.who.int/items/ecbd9a5a-538f-43a7-8050-d18073d51bd4
2. WHO and European Observatory. Health system performance assessment: a framework for policy analysis. 2022. https://eurohealthobservatory.who.int/publications/i/health-system-performance-assessment-a-framework-for-policy-analysis
3. European Observatory. Health system performance assessment: a renewed global framework. Policy Brief 80. 2023. https://eurohealthobservatory.who.int/publications/i/health-system-performance-assessment-a-renewed-global-framework-for-policy-making
4. WHO and UNICEF. Primary health care measurement framework and indicators. 2022. https://www.who.int/publications/i/item/9789240044210
5. Primary Health Care Performance Initiative. Vital Signs Profiles. https://www.improvingphc.org/vital-signs-profiles
6. OECD DAC. Better criteria for better evaluation. 2019. https://www.oecd.org/en/publications/better-criteria-for-better-evaluation_15a9c26b-en.html
7. Alliance for Health Policy and Systems Research. Systems thinking for health systems strengthening. 2026. https://ahpsr.who.int/newsroom/news/item/02-02-2026-systems-thinking-for-health-systems-strengthening-changing-the-frame

Suggested citation: Powered by Health Initiative. The PBHI HSS-MEL Framework: concept note. Version 1.0. Lagos: PBHI; 2026. © 2026 Powered by Health Initiative. All rights reserved.