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Development and Usefulness of a District Health Systems Tool for Performance Improvement in Essential Public Health Functions in Botswana and Mozambique

Bishai, David MD, PhD; Sherry, Melissa MPH; Pereira, Claudia C. PhD; Chicumbe, Sergio MD, MPH, TM; Mbofana, Francisco MD, MIH; Boore, Amy PhD, MPH; Smith, Monica MPH; Nhambi, Leonel BA; Borse, Nagesh N. PhD, MS

Journal of Public Health Management and Practice: November/December 2016 - Volume 22 - Issue 6 - p 586–596
doi: 10.1097/PHH.0000000000000407
Original Articles

Introduction: This study describes the development of a self-audit tool for public health and the associated methodology for implementing a district health system self-audit tool that can provide quantitative data on how district governments perceive their performance of the essential public health functions.

Methods: Development began with a consensus-building process to engage Ministry of Health and provincial health officers in Mozambique and Botswana. We then worked with lists of relevant public health functions as determined by these stakeholders to adapt a self-audit tool describing essential public health functions to each country's health system. We then piloted the tool across districts in both countries and conducted interviews with district health personnel to determine health workers' perception of the usefulness of the approach.

Results: Country stakeholders were able to develop consensus around 11 essential public health functions that were relevant in each country. Pilots of the self-audit tool enabled the tool to be effectively shortened. Pilots also disclosed a tendency to upcode during self-audits that was checked by group deliberation. Convening sessions at the district enabled better attendance and representative deliberation. Instant feedback from the audit was a feature that 100% of pilot respondents found most useful.

Conclusion: The development of metrics that provide feedback on public health performance can be used as an aid in the self-assessment of health system performance at the district level. Measurements of practice can open the door to future applications for practice improvement and research into the determinants and consequences of better public health practice. The current tool can be assessed for its usefulness to district health managers in improving their public health practice. The tool can also be used by the Ministry of Health or external donors in the African region for monitoring the district-level performance of the essential public health functions.

This study describes development and usefulness of a district health systems tool for performance improvement in essential public health functions in Botswana and Mozambique.

Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (Dr Bishai); JHPIEGO, Baltimore, Maryland (Ms Sherry); ENSP, Fiocruz, Rio de Janeiro, Brazil (Dr Pereira); National Institute of Health, Maputo, Mozambique (Drs Chicumbe and Mbofana); CDC, Maputo, Mozambique (Dr Boore); CDC, Gabarone, Botswana (Ms Smith); JHPIEGO, Mozambique (Mr Nhambi); and USAID, Washington, District of Columbia (Dr Borse).

Correspondence: David Bishai, MD, PhD, Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, Baltimore, MD 21205 (

The United States President's Emergency Plan for AIDS Relief (PEPFAR) and Centers for Disease Control and Prevention (CDC) Division of Global HIV/AIDS Health Systems offered grant support for this research.

The findings and conclusions in this paper are those of the authors and do not necessarily represent the views of the CDC or USAID.

The authors declare no conflicts of interest.

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.