Who 2021-01-31 Global-Report-Score TB v2

Global report
on health data
systems and
capacity, 2020
GLOBAL REPORT ON HEALTH DATA SYSTEMS AND CAPACITY, 2020
2
Global report
on health data
systems and
capacity, 2020
Made possible by funding from

Bloomberg Philanthropies
SCORE for health data technical package: global report on health data systems and capacity, 2020
ISBN 978-92-4-001870-9 (electronic version)
ISBN 978-92-4-001871-6 (print version)
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Contents
Foreword by Dr Tedros Adhanom Ghebreyesus, WHO Director-General...................................................................iv

Foreword by Michael R. Bloomberg, WHO Global Ambassador for Noncommunicable Diseases and Injuries................ v
Acknowledgements.......................................................................................................................................vi
Acronyms............................................................................................................................................................ viii
Summary................................................................................................................................................................... x
Introduction........................................................................................................................................................... 1
Survey populations and health risks..................................................................... 8

System of regular population-based surveys..................................................................................................................... 10
Surveillance of public health threats..................................................................................................................................... 16
Regular population census....................................................................................................................................................... 21
Looking forward: policy implications.....................................................................................................................................23
Count births, deaths and causes of death.......................................................24

Full birth and death registration............................................................................................................................................. 26
Certification and reporting of causes of death.................................................................................................................. 32
Looking forward: policy implications..................................................................................................................................... 35
Optimize health service data.................................................................................... 36

Routine facility reporting system with patient monitoring............................................................................................. 38
Regular system to monitor service availability, quality and effectiveness................................................................. 42
Health service resources: health financing and health workforce...............................................................................44
Looking forward: policy implications.....................................................................................................................................48
Review progress and performance...................................................................... 50

Regular analytical reviews of progress and performance, with equity....................................................................... 52
Institutional capacity for analysis and learning..................................................................................................................54
Enable data use for policy and action................................................................ 58

Data and evidence drive policy and planning..................................................................................................................... 61
Data access and sharing...........................................................................................................................................................64
Strong country-led governance of data................................................................................................................................68
Data availability and global health priorities..................................................................... 72

Conclusion............................................................................................................................................................ 75
Annexes.................................................................................................................................................................. 78
Annex 1. SCORE Interventions, elements and indicators............................................................................................................................... 79
Annex 2. SCORE Assessment maturity models for indicators included in scoring.................................................................................84
Foreword | WHO
The COVID-19 pandemic has highlighted the systems, the report highlights some important
importance of strong data and health information findings. It shows for example, that while 68% of
systems that provide timely, reliable and countries have well-developed and sustainable
actionable data. The grounding principle of WHO’s capacity to detect public health threats, this varies
transformation is to make a measurable impact in between regions. Although there is good coverage
countries. WHO’s Triple Billion targets – one billion of basic national level data, this is not the case in all
more people benefitting from universal health countries. Similarly, there is high availability of data
coverage, one billion more people better protected on immunization, tuberculosis and HIV; however,
from health emergencies, and one billion more coverage of other critical health issues such as
people enjoying better health and well-being – is a noncommunicable diseases, including mental
pathway to achieve this vision. health and cancer, is very limited.
Even before the pandemic, health systems were The SCORE for Health Data Technical Package
already over-stretched, and the world was not includes this report and its accompanying
on track to meet the health-related Sustainable Assessment methodology, Assessment instrument
Development Goals (SDGs). COVID-19 has shown and Online Data Portal along with the recently
that even the most advanced and resilient systems launched Essential interventions and Tools and
have faced significant disruption across multiple standards. This is a unique, one-stop-shop of
sectors. We can only build back better with robust essential interventions, recommended actions,
data and health information systems in every tools and resources. We encourage all countries
country and every community. and partners to use this global report and the
SCORE Assessment instrument to urgently identify
Despite progress in recent years, high-quality
gaps, prioritize investments, and accelerate
data are not routinely collected in all settings,
progress towards achieving the SDGs and the
major health challenges are not adequately
Triple Billion targets to promote health, keep the
monitored, and effective interventions are not
world safe and serve the vulnerable.
directed to the right people, at the right time
and at the right place. This impacts policies and We would like to express our sincere gratitude to
programmes and consequently, the health of Member States for their engagement, to Bloomberg
entire populations. Similarly, in order to meet Philanthropies for funding this truly collaborative
the shared SDG commitment to “leave no-one work, and to all Data for Health Initiative partners
behind”, we need disaggregated data to ensure who played a role in bringing the SCORE global
equitable health outcomes. report and technical package to fruition.
This means we must strengthen comprehensive
data systems, collaborate with other sectors, and
apply innovative digital technologies to collect,
analyse and use data to make informed decisions
and deliver impact.
The publication of the SCORE Global report on
health data systems and capacity, 2020 therefore
comes at a particularly relevant time. As the first
global assessment of the status and capacity
of health information systems in 133 countries,
covering 87% of the global population, it identifies
gaps and provides guidance to precisely and
rapidly improve the quality, availability, analysis,
accessibility and use of data.
Using the innovative SCORE (Survey, Count,
Dr Tedros Adhanom Ghebreyesus
Optimize, Review, Enable) Assessment instrument to
measure the status of data and health information Director-General, World Health Organization
iv
Foreword | Bloomberg
Philanthropies
Good data is essential to good decision- from noncommunicable diseases around the
making. Fortunately, for a growing number of world, we search out the best data and use it
governments around the world, “Follow the Data” to help our partners develop the most effective
is the motto driving their work to strengthen strategies for success. To cite one example: Since
public health. With more timely and accurate 2015, through our Data for Health programme,
data in hand – ranging from basic birth and death we have helped countries around the world
records, to detailed evidence on risk behaviours strengthen their health data systems – and we
like tobacco use – policymakers can then make look forward to enhancing our impact.
smart, targeted investments in improving public
Together with the World Health Organization, we
health and saving lives.
encourage our partners in government to continue
To help more countries do just that, Bloomberg following the data – and putting it to immediate
Philanthropies teamed up with our longtime use, in crafting policies that save and improve their
partner the World Health Organization and residents’ everyday lives.
developed the SCORE package. SCORE is a set of
essential, standardized tools, which boil down to:
Survey, Count, Optimize, Review, and Enable. While
there is still much work to be done, our results so
far are encouraging.
Most significantly, this SCORE report is the first to
gauge countries’ progress in producing sustainable
health data. The report’s findings come from over
130 countries, representing nearly 90 percent of the
global population. While no country has achieved
perfect marks in each of SCORE’s five categories,
one important fact is clear now. All countries, across
income levels, have the capacity to fill gaps in their
health data. By pinpointing those gaps, we hope
this report leads countries not just to produce more
data, but to take policy action.
At Bloomberg Philanthropies, that kind of Michael R. Bloomberg
data-driven approach informs all our work to WHO Global Ambassador for
help protect and advance global public health. Noncommunicable Diseases and Injuries
Whether we are responding to the urgent needs
of the COVID-19 pandemic, or expanding our
Founder, Bloomberg LP
longstanding efforts to reduce preventable deaths and Bloomberg Philanthropies
v
Acknowledgements
The WHO SCORE Global report on health data Escoto; Peru: Elizabeth Zulema Tomas Gonzales;
system and capacity, 2020 is the result of close Saint Kitts and Nevis: Delores Stapleton Harris;
collaboration between individuals within WHO, Saint Lucia: Feix St. Hill; Saint Vincent and the
Member States and external partners, without Grenadines: Cuthbert Knights; Trinidad and
whom this work would not be possible. This Tobago: Asif Ali; Venezuela: Jose Manuel Garcia
report was coordinated by the Division of Data,
Analytics and Delivery for Impact at WHO. EASTERN MEDITERRANEAN REGION
Afghanistan: Attaullah Sayeedzai, Ahmad Nawid
We would like to thank all partner institutions, UN Shams; Bahrain: Safa Sayed Ali Majed; Djibouti:
statistical division, participating Member States, Saleh Banoita Tourab; Egypt: Ibtesam Mostafa
WHO colleagues and leadership of WHO countries, Zakzouk; Iraq: Hisham Jasim Abed, Raoof Tareq
territories and areas for their contributions Raoof; Jordan: Kareman Al-Zain; Lebanon: Hilda
and inputs to this report. We would also like to Harb; Libya: Mohamed Ibrahim Saleh Daganee;
thank the Bloomberg Philanthropies Data for Oman: Omar Al Farsi, Halima Al Hinai, Ahmed
Health Initiative. WHO is a proud partner of the Al Qasmi, Badar Awlad Thani; Palestine: Jawad
Bloomberg Philanthropies Data for Health Initiative Bitar; Saudi Arabia: Mawyah Alatassi; Somalia:
which works with governments to strengthen Abdullahi Hashi Ali; Sudan: Amal Abass, Amal
their public health data to inform improved policy Alamin, Khalid Almardy, Wiam Bushra
decisions and public health investments.
EUROPEAN REGION
MEMBER STATES Austria: Jeannette Klimont; Belgium: Lieven
De Raedt, Francoise Renard, Timmy Van Dijck;
AFRICAN REGION
Cyprus: Vasos Scoutellas; Germany: Philip
Benin: Midodji Hervé Djossou; Botswana: Baile Wahlster, David Herr; Netherlands: Polanen
Moagi; Burundi: Anaclet Nahayo; Cameroon: Petel, Wendy Loorbach-van Zutphen, Bruin, A.
Gnigninanjouena Oumarou; Côte d’Ivoire: de (Agnes), Mariken Tijhuis, Peter Achterberg;
Joseph Acka; Ethiopia: Biruk Abate; Ghana: Nana Poland: Karolina Konarzewska; Portugal: Jose
Kwabena Adjei-Mensah; Guinea: Sekou Conde; Martins; San Marino: Elena Sacchini, Gabriele
Guinea-Bissau: Orlando Lopes; Madagascar: Rinaldi, Andrea Gualtieri, Mauro Sammaritani;
Harisoa Julie Norovoahangy; Malawi: Issac Slovakia: Bukšárová Daniela, Urbanová Gabriela,
Oambula; Namibia: Ben Nangombe; Nigeria: A. Greisigerová Dominika, Pauhof Ján; United
M. Abdullani; Sierra Leone: Amara Jambal; South Kingdom: Sion Ward
Africa: GV Andrews; Zimbabwe: A. Mahomva
SOUTH-EAST ASIA REGION
REGION OF THE AMERICAS
Bangladesh: Habibur Rahman; Indonesia:
Antigua and Barbuda: Joon Corrott; Argentina: Didik Budijanto; Maldives: Aishath Samiya,
Cintia Speranza, Alejandro Osornio, Daniel Rizzato Sofoora Kawsar Usman; Nepal: Kehav Raj Pandit;
Lede, Carlos Guevel; Bahamas: Delon Brennen; Thailand: Walaiporn Patcharanarumol, Cha-aim
Costa Rica: Adriana Salazar González; Cuba: Pachanee; Timor-Leste: Elia A A dos Reis Amaral
Jose Angel Portal Miranda; Guatemala: Carlos
Enrique Soto Menegazzo; Haiti: Jean Partrick WESTERN PACIFIC REGION
Alfred; Honduras: Karla Yadira; Jamaica:
Australia: Sami Iohara; Brunei Darussalam:
Andriene Grant, Karen Webster-Kerr; Nicaragua:
Rudy bin Haji Harun, Haji Shamsul Bahrine bin
Carolina Davila Murillo; Paraguay: Luis Roberto
vi
Haji Sabtu; China: Min Cai, Yue Cai; Japan: Yuuta The following experts and reviewers were part
Yokobori; Laos: Chansaly Phommavong, Founkham of the conceptual development and finalization
Rattanavong; Malaysia: Chansaly Phommavong, of the report. We are grateful for their expertise,
Founkham Rattanavong, Christopher Lee Kwok contributions and critical review to produce a
Choong, Chen Chaw Min, Muna Zahira Mohd timely and impactful resource for health systems
Yusoff, Nur Shahadah Zakaria; Mongolia: strengthening:
Bayasgalan Dashnyam, Amarjargal Yadamsuren;
Technical Experts and Reviewers
Republic of Korea: Sunmi An, Jeongwoo Shin;
Carla Abouzahr, Ties Boerma, David Boone,
Solomon Islands: Seraphina Elisha, Rodley Ruskin;
Jennifer Ellis, Fern Greenwell, Adam Karpati,
Vanuatu: Rachel Takoar, Posikai Samuel Tapo;
Manish Kumar, Francesca Perucci, Adrienne
Viet Nam: Phan Le Thu Hang
Pizatella, Robert Pond, Heidi Reynolds, Philip
Setel, Kavitha Viswanathan
WORLD HEALTH ORGANIZATION
HEADQUARTERS This document was edited by Prudence Smith.

Adewale Akinjeji, Oluwaseun Aladesanmi, Samira
The SCORE technical package is made possible by
Asma, Azza Badr, Philippe Jean-Pierre Boucher,
funding from Bloomberg Philanthropies.
Somnath Chatterji, Anh Chu, Dida Connor, Doris
Ma Fat, Gabriela Flores, Ahmad Hosseinpoor,
Robert Jakob, Nenad Kostanjsek, Muriel Levy,
Benjamin Gutierrez Lobos, Kathryn O’Neill, Alyssa
Palmquist, Amit Prasad, Amani Siyam, Chelsea
Taylor, Tamitza Toroyan, Pavel Ursu, Luhua Zhao
REGIONAL OFFICES
African Region: Benson Droti, Humphrey Cyprian;
Region of the Americas: Marcelo Jose D’Agostino,
Vilma Gawryszewski; Eastern Mediterranean
Region: Henry Doctor, Arash Rashidian; European
Region: Stefania Davia, David Novillo Ortiz;
South-East Asia Region: Mark Landry, Rakesh
Mani Rastogi; Western Pacific Region: Mengjuan
Duan, Jun Gao
vii
Acronyms
AFR WHO African Region
AMR WHO Region of the Americas
ART Antiretroviral Therapy
CRVS Civil Registration and Vital Statistics
DFI Delivery for Impact
DHS Demographic and Health Survey
DTP Diphtheria-tetanus-pertussis
EMR WHO Eastern Mediterranean Region
EUR WHO European Region
HDC Health Data Collaborative
HHFA Harmonized Health Facility Assessments
HIS Health Information System
HMIS Health Management Information System
HRHIS Human Resource Health Information System
HRSDG Health-Related Sustainable Development Goals
ICD International Classification of Diseases
IHR International Health Regulations
LSMS Living Standards Measurement Study
M&E Monitoring and Evaluation
MICS Multiple Indicator Cluster Surveys
MoH Ministry of Health
NHA National Health Accounts
NHO National Health Observatories
NHSP National Health Sector Strategic Plan
viii
NHWA National Health Workforce Accounts
OPD Outpatient Department
PES Post Enumeration Survey
SCORE Survey, Count, Optimize, Review, Enable
SDG Sustainable Development Goal
SEAR WHO South-East Asia Region
SHA System of Health Accounts
SPAR State Party Self-Assessment Annual Reporting
UHC Universal Health Coverage
UNDESA United Nations Department of Economic and Social Affairs
UNSD United Nations Statistical Division
WHO World Health Organization
WPR WHO Western Pacific Region
ix
Summary
Data and information that help governments The results of the global assessment are published
prioritize health challenges and allocate in this SCORE Global report on health data systems
necessary resources rely on strong country health and capacity, 2020. Accompanying the global
information systems. These systems identify report is the SCORE Assessment methodology
health care availability as well as access and which provides details of the indicators and
quality of care issues that prevent the attainment methodologies applied in the assessment and
of universal health coverage (UHC). The same subsequent analyses.
country health information systems also provide
133
important data for global monitoring for the
Sustainable Development Goals (SDGs) and other
donor reporting.
To meet the increasingly complex demands on country health information

countries for health information, the new SCORE systems were assessed,
for Health Data Technical Package brings together, covering
87%
for the first time, a set of the most effective
interventions and tools for addressing critical data
gaps and strengthening country health data for
planning and monitoring health priorities.
of the global population.
The package is based on five key interventions,
represented by the acronym SCORE (Figure 1). This report is particularly timely and highlights
Interventions S, C and O focus on improving how important it is to strengthen a country’s
critical data sources, their availability and health information system to meet data needs.
quality; while R and E aim to enhance the Among several key findings, the income divide
synthesis, analysis, access and use of health between high and low-income countries is
data for action. Key components of the SCORE reflected in the lack of health information system
package were launched in August 2020 – SCORE capacity to address fundamental areas such as the
Essential interventions for strengthening country registration of births, deaths and causes of death.
health information systems and SCORE Tools While some countries have achieved sustainable
and standards. Together, these documents capacity in some key areas, no country has a fully
provide an overview of health information mature system capable of meeting their evolving
systems, the context and indicators of each needs for health information.
intervention, examples of actions needed to
strengthen different aspects of the system and The report provides recommendations for
a summary of the best tools and standards countries to prioritize investments in health
to do so. An additional key component of the information system and is published during one
SCORE package is the Assessment instrument of the most data-strained public health crisis
which was developed to evaluate a country’s responses ever - that of the COVID-19 pandemic.
health information system according to the five As countries’ health information systems have had
SCORE interventions. One hundred and thirty- to track COVID-19, they have also had to continue
three country health information systems were tracking other health priorities. This challenge
assessed, covering 87% of the global population, underlines the demand to improve countries’
with the data collected between 2013 and 2018. health information system to meet current and
x
future data needs. While the global report’s No single country assessed achieves sustainable
assessment predates the COVID-19 pandemic, the capacity across all five interventions, nor meets
results remain relevant, highlighting the key gaps best practice guidelines across the full spectrum
and challenges countries face around the world. of the health information system. Therefore,
all countries could benefit from understanding
the gaps in their system and follow SCORE
recommendations for improvement.
All countries have the potential
to realise stronger data systems
OVER
50%
The report assesses the five SCORE interventions
that determine if a country has a fully mature
health information system with the capacity
to meet a country’s evolving data needs. Up to of countries have
60% of the countries have a well-developed or moderate or better
sustainable capacity for reviewing progress and capacity for each of the
performance of their health sector and more five SCORE interventions,
than half have a well-developed or sustainable respectively.
capacity to survey populations and health risks
(Figure I). Fewer countries reach such capacity for
the other three interventions, but over half of all
countries have moderate or better capacity for
each of the five interventions, respectively.
xi
FIGURE I
DISTRIBUTION OF SCORE CAPACITY BY SCORE INTERVENTIONS*
Percentage of countries
1%
20% 11% Number of Percentage of
countries world population
Sustainable 26 51%
Well-developed 45 24%
35% Moderate 47 11%

SURVEY 34%
populations and Limited 14 1%
health risks
Nascent 1 0%
16%
Number of Percentage of
28% countries world population
Sustainable 21 7%
27%
Moderate 18 22%
COUNT
births, deaths and 16% Limited 21 12%
causes of death 14% Nascent 37 14%
4% 2%
Sustainable 5 3%
32% Well-developed 42 62%
Moderate 57 17%
OPTIMIZE
health service data Limited 26 4%
43% Nascent 3 1%
5%
27% 8% Number of percentage of
Sustainable 36 55%
28%
Moderate 37 10%
REVIEW
progress and Limited 10 1%
performance 33%
Nascent 6 0%
5%
8%
27% 22% Sustainable 7 6%

Moderate 51 21%
ENABLE
data use for Limited 29 4%
policy and action 38%
Nascent 10 1%
*Data from 133 countries either validated or approved for use are included in analysis.
xii
More disaggregated data will and sustainable capacity, respectively.
enhance countries ability to Similar differences can be seen across other
interventions: while 100% of high-income
monitor inequalities
countries and 91% of upper-middle-income
Of the 673 total surveys conducted between countries have well-developed or higher capacity
2013 and 2018 that are analysed as part of for counting births, only 58% of lower-middle-
the SCORE assessment, 91% of them present income and 23% of low-income countries have
data disaggregated by sex and 83% by age, the same capacity. For counting deaths, the
but less than 75% collect disaggregated data differences are even more marked. While 97%
by education, rural- urban status, and wealth. and 82%, respectively, of high-income and upper-
Similarly, while 90% of countries have published middle-income countries have well-developed
an analytical report within the last five years, and higher capacity for death registration, only
only 56% examine inequality by sex and even 27% of lower-middle-income countries and no
fewer (38%) by socioeconomic status. This lack of low-income countries achieve the same capacity.
disaggregated data can also be seen in data from
Country wealth also affects the capacity to enable
health facilities and data on health workers. Data
data use for policy and action; 63% of high-income
of higher quality are often available at national
countries have well-developed or sustainable
level; this may mask the lack of disaggregated data,
capacity for data use compared to 32%, 19%, 15%
creating the perception that systems are stronger
of upper-middle income, lower-middle income, and
than they really are. Therefore, relying solely on
low-income countries, respectively.
data at national level to monitor the strength of
a country’s health information system may lead
Some of these differences can be explained by
to biased conclusions, and some subpopulations
how health information systems are funded
being overlooked.
in countries. The SCORE assessment collected
information on funding sources for nationally
51%
representative population-based surveys.
The results show that between 2013-2018
low-income countries had a higher average
of countries have number of annual surveys compared to upper-
disaggregated population middle-income countries (0.9 surveys compared
projections. to 0.7 surveys). However, only 6% of surveys in
lower-middle-income countries and low-income
countries are funded solely by the national
High-income countries have
government. This situation has both advantages
stronger health information and disadvantages for countries. There is a
systems. Sustainable solutions need for countries to be less reliant on external
are needed to improve all assistance to monitor their health priorities. As
countries’ systems evidence shows, upper-middle-income countries
fall into the gap between being aided by external
There is a marked difference between the high- donors and being able to adequately fund
income countries and countries in other income surveys themselves. This can have implications
groups when it comes to health information for other areas of data collection and highlight
system. An estimated 66% of high-income the need for progressive country solutions that
countries have well-developed or sustainable lead to greater sustainability.
capacity for surveying populations and health
risks, while countries in the upper-middle-
income, lower-middle-income and low-income
groups, have 47%, 51% and 50%, well-developed
xiii
Equitable investment across all Effective governance of data
health programmes strengthens management and use will
a country’s reporting system maximise return of investment
in health information systems
Focused spending on key programme areas
such as immunization and tuberculosis, has Timely, reliable, actionable data is essential for
improved their data availability but has not delivering interventions to improve the health
uniformly strengthened the reporting system. For of populations. Translating data to policies
example, less than 50% of countries have data and actions requires effective investment in
available for mental health disorders compared mechanisms which focus on using data to
to almost 100% of countries which have data formulate policy (such as dedicated units within
for immunization and tuberculosis. There are the ministry of health or another ministry);
promising shifts however, and a greater focus mechanisms which ensure data can be accessed
now on overall health system strengthening, and shared openly (such as national health data
rather than supporting only specific programmes. observatories); and country-led governance of
data (policies or regulations which guide the
management and use of a country’s data).
Improving data quality is essential While 84% of countries have a central unit
for policy and planning or function to translate data and evidence to
policy, the functionality of these units is not very
Data availability does not automatically translate clear. Over 60% of countries have a national
into availability of the quality data needed for health observatory or portal. However, these
policy, planning and patient health care. Data portals are not updated frequently (only 25% of
quality is a critical issue for health facilities with countries updated them more than once a year)
about 40% of countries not showing clear evidence and only 26% of countries have portals with full
that data quality assurance processes have been coverage of health statistics. Similarly, 74% and
followed for their published health facility data. 62% of countries, respectively, have a national
Census data provide benchmark population data monitoring and evaluation plan and a national
for many health statistics. With less than 50% of digital or eHealth strategy. However, these plans
countries conducting post-enumeration surveys, do not usually meet recommended standards, an
there is legitimate concern about the quality of index for good governance of data. For example,
census data. The quality of cause-of-death data only 21% of countries have a monitoring and
could also be an issue. Only 28% of countries have evaluation plan that meets 85% of the standards,
less than 10% ill-defined cause-of-death codes. and another 21% for eHealth strategy.
The remaining 72% either do not record cause-
of-death data using International Classification High-income countries have stronger systems for
of Diseases (ICD) codes, or have more than 10% translating data to policy and action compared
ill-defined cause-of-death codes. Furthermore, to countries in other income groups. It is worth
many countries require technical support and/or noting that the disparity between low-income,
funding to ensure that the data collected through middle-income and upper-income countries is not
all aspects of their health information systems are very wide though low-income countries overall
of sufficient quality to be useful. face more barriers in using data and evidence to
drive policies.
xiv
Introduction
Unprecedented demand for data
Monitoring progress: Monitoring progress

national and subnational towards the SDGs,
health priorities UHC, health emergency
Countries need data to inform national-level
protection and healthier
planning and management at programme, populations
subnational and facility levels. Health ministry
officials, district and facility managers, as well There are 59 health and health-related SDG
as individual providers, legislative bodies, (HRSDG) indicators, including 27 indicators under
communities, citizens and the media need the overarching health goals that countries
accessible, high-quality health information to: need to consider and monitor in national health
strategies and policies, and additional 32 health-
• better target health programming related indicators that fall within other SDGs.
to reach all people; Some of the 59 indicators rely on non-health
sector data sources such as civil registration
• increase the monitoring of populations
and vital statistics systems (CRVS), satellite
at greatest risk;
data, air-quality monitors for air pollution, and
• provide early warning on potential police data for suicide, homicide and road traffic
public health threats; mortality. Countries have primary responsibility
• efficiently adjust programming to monitor progress made in implementing the
to meet evolving needs; SDGs, which requires high-quality, accessible and
timely data collection and analysis, to ensure that
• improve the quality and efficiency
no one is left behind.
of health care;
• support global monitoring; Underpinning SDG 3 - ”to ensure healthy lives

and promote well-being for all at all ages” - is
• effectively plan and advocate for resources
a pledge by countries to provide UHC – a
both within and beyond the health sector;
commitment that everyone will receive the
• hold health institutions and government high-quality health interventions they need
authorities to account for resource use and without incurring financial hardship. Monitoring
health outcomes. UHC requires information about both financial
protection and effective coverage of health
interventions. Effective coverage requires both
measurement of access to health services, and
the quality of the services received.
Meeting the HRSDGs requires health

emergencies protection and healthier
populations based on indicators such as
sanitation, nutrition and environment.
1
Emergency protection means preparedness, In addition:

prevention and the ability to detect and respond
quickly to public health threats. Each of these 1. Many health facility recording and reporting
depends on effective early warning systems systems lack the capacity to measure the
based on reliable data. No single data source quality and outcomes of the services provided.
can meet all information needs; therefore, Facility assessments and population-based
a multisectoral approach to monitor overall surveys may provide insights, but they are not
progress towards the SDGs is essential. conducted routinely. Furthermore, absence of
reporting from private sector facilities means
that coverage of certain services cannot be
accurately reflected at population level.
Data is essential to
ensure equity 2. Data systems and workers are often burdened
by requirements to collect and report on
The “leaving no one behind” imperative of the an excessive number of data elements and
SDGs implies that countries must significantly indicators.
increase their efforts to ensure that marginalized
3. CRVS systems are often incomplete and paper-
populations achieve equitable health outcomes.
based and thus do not provide timely and
Thus, disaggregation of health data by inequality
reliable information for public health decisions
dimensions such as sex, age, economic status,
education, place of residence and other context- 4. Health inequality data are not fully collected,
specific population subgroups, is important for analysed and reported.
the achievement of this objective.
5. Integration and use of data from other
sectors are often piecemeal, especially those
concerning risks to health (for example,
Health information environmental risks and road traffic
systems do not meet the accidents). The same is true for data on
coverage of preventive interventions to reduce
data needs of countries those risks.
Despite the increasing demands for data and 6. Ministries of health and national public health
evidence, the health information systems institutions may lack the technological and
(HIS) currently in place in many countries are analytical capacity to cope with the increase in
inadequate. High-quality data are not routinely data demands related to the SDGs.
collected in sufficient detail to allow regular
computation of levels, trends and inequalities in
health outcomes. Major health challenges are
not adequately measured and monitored, thus
affecting programme implementation at national
and local levels and, consequently, the health
status of the population.
2
INTRODUCTION
WHO’s SCORE for Health

Data Technical Package
The SCORE for Health Data Technical Package use and accessibility of data in countries. This
was developed by WHO and partners to assist package is not intended to replace existing detailed
Member States in strengthening country data guidance on implementing various components of
systems and capacity to monitor progress a health information system. Instead, it provides
towards the health-related SDGs, UHC, and other a coherent framework for countries to focus on
national and subnational health priorities and priority interventions and elements, and points
targets. It provides a coherent framework that countries towards best practices and universally
enables national policymakers and planners to: accepted standards and tools. It is intended that
the SCORE for Health Data Technical Package will
1. focus investments on priority interventions evolve over time to incorporate new and innovative
(“best buys”) – proven to be effective, feasible, tools, approaches and country experiences.
affordable, scalable, and sustainable;
The SCORE for Health Data Technical Package
2. access recommended/best practice actions, is based on five key interventions (Figure
tools and standards; 1.1) represented by the acronym SCORE.
Interventions S, C and O focus on improving
3. identify critical gaps and needs and allow for
critical data sources and their availability and
continuous monitoring, based on a set of
quality, while interventions R and E aim to
simple, standardized, verifiable core indicators.
enhance the synthesis, analysis, access and use
of health data for action.
The SCORE package represents the most effective
strategies and interventions for strengthening
The package includes the following components
country health data systems. The package
which complement this Global report on health
encourages stakeholders to invest in a select
data systems and capacity, 2020:
number of interventions that synergistically have
greatest impact on the quality, availability, analysis,
Assessment
Methodology,
2020
SCORE Essential SCORE Tools SCORE Assessment SCORE Assessment

Interventions: and Standards: Instrument: Methodology, 2020:
A description of five A list of up-to-date A data collection A technical explanation
SCORE interventions resources for each instrument with of the scoring methods
with underlying intervention. accompanying user used in the Global report
elements and indicators, guide to assess health for quantifying SCORE
and examples of actions information systems indicators, elements and
for assessing and and identify gaps. interventions.
strengthening health
information systems.
3
FIGURE 1.1
FIVE ESSENTIAL INTERVENTIONS FOR STRENGTHENING COUNTRY
HEALTH DATA SYSTEMS AND CAPACITY
Survey Count Optimize Review Enable

populations births, deaths health progress and data use for
and health and causes service data performance policy and
risks of death action
4
INTRODUCTION
About this report
This Global report on health data systems and

capacity, 2020 represents the results of country
Process
health information system assessments A multi-step process was undertaken to assess
conducted by WHO between 2018 and 2020 using country health information systems. These steps
the WHO SCORE assessment tools. included:
• Expert consultation: Multiple consultations
Scope with different stakeholders were held to define

a core set of simple, measurable indicators.
The SCORE Assessment instrument measures the These indicators formed the basis of the
status of a country’s health information system SCORE Assessment instrument.
and its suitability for use as a basis for country • Data collection: Each intervention was
planning. The Assessment instrument is not measured against the indicators and
intended to conduct a comprehensive diagnosis of attributes identified in the SCORE Assessment
all aspects of a country health information system, Instrument for each country. Reviewers
but it triggers more specialised and in-depth included HIS experts who undertook desk
assessments based on gaps and identified needs. reviews and examined published and grey
literature as source documents for each
The objective of this report is to:
country to complete the tool. They also
triangulated country data with data collected
• Provide an overview of the status of health
from global databases such health workforce,
information systems in Member States around
health expenditures, etc.
the world using a comparable methodology;
• Review and preliminary validation:
• Identify gaps in health information systems
The preliminary desk review results were
and CRVS systems which can guide
shared with country counterparts in regional
investments and action;
consultations for feedback. Review and
• Provide baseline information and data that validation were also carried out by country HIS
allow monitoring of progress towards the focal points.
SDGs, UHC and other national and
• Final validation: Final results were shared
international targets;
with the country for further validation, final
• Guide international investments and actions review and sign-off
and track improvements in the health
• Data analysis: Global level data analyses
information system over time.
were performed on 133 countries,
representing 87% of the world population,
with either fully validated or approved
assessments.
5
• Results presentation: The majority of the Figure I.2 shows the global map of the
results in this report include the 133 validated countries that participated in the SCORE
and approved countries. In some cases, only assessment.
a sub-set of countries are included in the
analysis due to data availability. For indicators
collected from published and validated
sources (for example, results from State Party
Self-Assessment Annual Reporting (SPAR)), all
countries with available data were included,
even though countries may not have validated
data in other areas.
FIGURE 1.2
MAP OF COUNTRY PARTICIPATION IN SCORE ASSESSMENT
Validated country profiles for publication Validated and approved desk review assessment Not included in report
Distribution of countries, by status of participation in SCORE Assessment
Validated country Validated and

profiles for approved desk Not included
publication review assessment in report
Number of countries 99 133 62
Share of world population 61% 87% 13%
6
ABOUT THIS REPORT
Survey populations
and health risks
to know what makes
people sick or at risk
KEY ELEMENTS
S1. SYSTEM OF REGULAR

POPULATION-BASED SURVEYS
112
surveys conducted annually.
S2. SURVEILLANCE OF
PUBLIC HEALTH THREATS
NEARLY
70%
of countries achieve a well-
developed or higher capacity
for indicator and event-based
surveillance.
S3. REGULAR POPULATION CENSUS
51%
of countries have disaggregated
population projections.
8
SURVEY POPULATIONS AND HEALTH RISKS
Information about a population’s health and that are critical for resource allocation and
health risks is the cornerstone of disease and targeting interventions. It is recommended that
disability prevention. Population-based surveys a population census is conducted once every
are one of the main sources (and sometimes the 10 years. A population registry may include
only source) of this information, providing critical basic characteristics such as date and place
insight into factors affecting the population such of birth, sex, date and place of death, date of
as poverty, education, water and sanitation, living arrival/departure in the country, citizenship(s)
conditions, nutrition, air quality and security. and marital status. It also provides essential
Surveys are the most important instrument for population statistics that are often used in
assessing inequality and are a prominent source population-based surveys for population
of data for many HRSDG indicators. They are also adjustment and calibration.
the main source of health data disaggregation
especially in low-and middle-income countries, Figure S.1 shows that overall 68% of countries
given that they collect information both for a have well-developed or higher capacity for
large number of health indicators as well as surveying populations and health risks. Further
inequality dimensions like economic status, analysis indicates that while an estimated 66%
education, place of residence, age and sex and of high-income countries have well-developed
other context-specific population subgroups. or higher capacity for surveying populations
and health risks, only 47%, 51% and 50%,
A population and housing census (or population respectively, of upper-middle-income, lower-
registry) is an important data source for health middle-income and low-income countries,
and other sectors. It provides information on achieve the same capacity (numbers not shown
population size, geographical distribution, and in the figure).
social, demographic and economic factors
FIGURE S.1
NUMBER AND PERCENTAGE OF COUNTRIES (N=133), AND COUNTRY
POPULATION AS A PERCENTAGE OF WORLD POPULATION, BY COUNTRY
CAPACITY TO SURVEY POPULATIONS AND HEALTH RISKS
1%
20% 11%
Sustainable 26 51%
Moderate 47 11%
34% 35% Limited 14 1%
Nascent 1 0%
9
S1. System of regular population-

based health surveys
112
In many low- and middle-income countries
population-based surveys are the main source
of information on population health, particularly
in the absence of well-functioning CRVS and population-based surveys
population registries. Surveys can capture are conducted annually.
information that complements CRVS and
registries, and thus play important roles in tracking
population health and identifying priority areas for
Upper-middle-income countries
improvement even in countries where CRVS and
population registries are in place.
fall between being aided by
external donors and funding
Population-based health surveys are a significant survey systems adequately
source of data for many HRSDGs and UHC themselves
indicators. For a number of indicators that
measure health-related behaviours and risk Representative population surveys verify
factors, such as breastfeeding practices, tobacco information that is collected through routine
use prevalence and some measures of mental systems and show us where there are gaps.
health, they are often the only data source. The 133 countries included in this report
Similarly, surveys can provide critical information conducted a total of 673 surveys between
from non-health sectors (such as education, 2013 and 2018 (an average of 112 per year). On
water and sanitation, living conditions, nutrition, average, countries conducted about one survey
security) that impact health and are among per year. The lowest number of surveys were
the data sources used to determine out-of- conducted in upper-middle-income countries.
pocket expenditure in national health accounts. These countries are often not supported by
Household surveys can provide data for 29 of international donor agencies in conducting
the 57 HRSDG1; an upcoming WHO publication surveys, but are also limited in their ability to
indicates that the Demographic and Health fund and conduct their own surveys.
Survey (DHS), Multiple Indicator Cluster Survey
(MICS), and Living Standards Measurement Study
(LSMS) are able to measure the highest number
of HRSDG indicators.
A survey programme should identify strategic

priorities, periodicity and scope of data collection.
It also should enforce quality assurance, ethical
practices, transparency and data sharing in
accordance with stringent confidentiality protocols
and international standards for measurement
to ensure comparability of results between
populations and over time.
Asma S, Lozano R, Chatterji S, Swaminathan S, de Fátima Marinho M, Yamamoto N, Varavikova E, Misganaw A, Ryan M, Dandona L,
1
Minghui R, Murray CJL. Monitoring the health-related Sustainable Development Goals: lessons learned and recommendations for improved
measurement. Lancet. 2020 Jan 18;395(10219):240-246. doi: 10.1016/S0140-6736(19)32523-1. Epub 2019 Nov 22. PMID: 31767190.
10
FIGURE S1.1
AVERAGE NUMBER OF SURVEYS CONDUCTED PER YEAR IN 133
COUNTRIES, BY COUNTRY INCOME GROUP, 2013-2018
High Income 1,3

(n=32)
Upper-middle income 0,7
(n=34)
Lower-middle income 1,1
(n=41)
Low income 0,9
(n=26)
0 0,2 0,4 0,6 0,8 1 1,2 1,4
Coverage of key topics primary data source, 2) indicators that can be

best captured through other sources, but surveys
in surveys conducted can provide valuable information if other sources
Good coverage of topics in are insufficient or unavailable, 3) indicators that
may only apply in certain countries; for example,
surveys conducted, but some key
malaria is not endemic in all countries so these
topics are still being missed countries will not collect malaria data through
household surveys.
While over 70% of countries captured tobacco
use, child weight/height, and family planning In calculating the percentage for certain topics,
(Figure S1.2), in at least one survey since including those that are either not relevant
2013; less than half of countries captured (e.g. malaria parasite in non-malaria endemic
cervical cancer screening, catastrophic health countries) or are usually collected by non-survey
expenditure, and HIV prevalence. While a few methods in given countries (e.g. child mortality
high-income countries do measure some of these in countries with strong CRVS systems), the
topics through population-based surveys, many denominators are accordingly adjusted. In other
of these topics such as child weight or height, words, the number of countries included in the
family planning, and child immunization are less calculation may vary by indicator. For example,
likely to be included in their surveys compared only 8 out of 32 high-income countries collected
to other countries. This is likely because 1) much child mortality data through surveys; the others
of this information can be captured by the well- measured mortality through other means, such
functioning CRVS in most high-income countries, as the CRVS systems. To avoid misunderstanding,
2) the majority of these countries have sound child mortality and a few other indicators are
health care systems that can provide data in not considered applicable in Figure S2.1 for high-
some areas without resorting to surveys. income countries.
Box S1.1 shows, with examples, three types of

topics or indicators that are commonly included
in health-related surveys. These three types
include 1) indicators that use surveys as the
11
BOX S1.1
USE OF HOUSEHOLD SURVEYS TO MEASURE HEALTH PRIORITIES
Indicators using other

means as primary source
Family planning
Deliveries
Immunization
Child mortality
Indicators using surveys
Cervical cancer screening
as primary data source
TB prevalence
Tobacco use
HIV
Child anthropometry
Blood pressure Indicators depending
Blood glucose on epidemiology
Health expenditure Malaria
12
FIGURE S1.2
PERCENTAGE OF COUNTRIES (N=133) THAT CAPTURED RELEVANT
HEALTH TOPICS IN AT LEAST ONE SURVEY, BY COUNTRY INCOME GROUP,
2013-2018
Global Average (GA) High income Upper-middle income Lower-middle income Low income
85%
88%
Tobacco use 82%
93%
73%
79%
Delivery/Skilled birth not applicable
70%
attendance 90%
81%
74%
68%
Child weight/height 65%
90%
69%
73%
55%
Family planning 67%
90%
73%
69%
not applicable
Child mortality 55%
85%
65%
68%
30%
Child immunization 68%
90%
77%
60%
Prevalence of raised 69%
55%
blood pressure 59%
58%
53%
Prevalence of raised 53%
50%
fasting blood glucose 59%
46%
47%
Cervical cancer 55%
48%
screening 46%
35%
42%
Malaria parasite not applicable
prevalence among 24%
36%
children 73%
40%
Catastrophic health 50%
31%
expenditure 46%
31%
40%
not applicable
HIV prevalence 42%
41%
62%
28%
not applicable
Tuberculosis 23%
prevalence 27%
35%
0 20% 40% 60% 80% 100%
13
Understanding wealth-related However, while most surveys disaggregate data

inequality is essential, yet by age and sex, fewer surveys apply urban-rural
or wealth disaggregation. Sex and age are the
less than 60% of all surveys
most commonly-used inequality dimensions
disaggregate based on wealth
(included in over 80% of surveys overall and at
least 75% of surveys across all income groups),
Population-based surveys are among the most
followed by education (74%), place of residence
important instruments for assessing equality,
(70%) and subnational units (67%). Economic
since they can be designed deliberately to
status is least likely to be collected (58%) in
provide relevant disaggregated data (e.g.,
surveys overall (Figure S1.3).
including sex, age, economic status, education
and geographic location).
FIGURE S1.3
PERCENTAGE OF HEALTH SURVEYS CONDUCTED IN 133 COUNTRIES
THAT INCLUDED INEQUALITY MEASUREMENT, BY COUNTRY INCOME
GROUP, 2013-2018
Global Average High income Upper-middle income Lower-middle income Low income
91%
95%
Sex 92%
87%
89%
83%
88%
Age 87%
79%
76%
74%
84%
Education 74%
67%
68%
70%
Urban-rural 63%
70%
72%
81%
67%
66%
Subnational 65%
68%
70%
58%
74%
Wealth 53%
49%
55%
0 20% 40% 60% 80% 100%
14
ONLY
8%
of surveys in low-and
middle-income countries
are funded by government.
Heavy reliance on external funding creates challenges

for building sustainable approaches to measure
population health
While there is partial government funding support for survey implementation

in low- and lower-middle income countries, only 3% and 8%, respectively,
of the surveys, are fully-funded by the government. This has significant
implications for a country’s ability to control their own survey programme and
the long-term sustainability of surveys (Figure S1.4).
FIGURE S1.4
PERCENTAGE OF HEALTH SURVEYS IN 133 COUNTRIES THAT ARE FULLY
FUNDED BY GOVERNMENT, BY COUNTRY INCOME GROUP, 2013-2018
Global (n=133) 33%
High income
(n=32) 78%
Upper-middle income
(n=34) 35%
Lower-middle income
(n=41) 8%
Low income
3%
(n=26)
0 20% 40% 60% 80% 100%
15
S2. Surveillance of public

health threats
The International Health Regulations (IHR) 2005 • effective communication and
require countries to maintain an integrated collaboration across sectors and between
national system for public health surveillance subnational, national and international
and response and have set out the core national authorities on surveillance of events of
capacities they should achieve to meet the public health significance;
required standards for surveillance and response.
• strong country and intermediate level/
regional capacity to analyse and link data
As part of the IHR commitment, countries use the
from and between strengthened, real-time
SPAR tool to self-assess their core IHR capacities
surveillance systems, including interoperable,
and report the results to WHO1. This SCORE
interconnected electronic reporting systems.
element used the validated SPAR results sent
by 180 countries to WHO in 2018. The 13 core
capacities in SPAR are measured by 24 indicators
with each core capacity being measured by 1-3
Capacity to detect
indicators. Indicators are further broken down public health threats
into attributes, which further define the indicator.
Two of the 13 SPAR core capacities were used as
tracers to measure the surveillance element as
part of the SCORE assessment. These two core
capacities are 1) IHR coordination and national IHR
focal point functions and, 2) surveillance. Together
these two core capacities indicate that for
countries to detect public health events requiring
ABOUT
rapid investigation and response and ensuring
timely action and control they should have: TWO
• a strong indicator and event-based surveillance
system that can detect events of significance
THIRDS
of countries have well-developed
for public health, animal health and health or higher capacity to detect public
security (these are the two main channels of health threats.
information for public health surveillance);
1
International Health Regulations (2005) State Party Self-assessment Annual Reporting Tool. Geneva: World Health Organization; 2018.
Licence: CC BY-NC-SA 3.0 IGO.
16
FIGURE S2.1
PERCENTAGE OF COUNTRIES (N=180), BY CAPACITY TO SURVEY PUBLIC
HEALTH THREATS AND COUNTRY INCOME GROUP*
Nascent Limited Moderate Well-developed Sustainable
Global (n=180) 7% 25% 41% 27%

1%
High Income
13% 39% 44%
(n=54) 4%
Upper-middle income
8% 18% 41% 31%
(n=51) 2%
Lower-middle income
9% 33% 43% 15%
(n=46)
Low income
7% 48% 38%
(n=29) 3% 3%
0% 20% 40% 60% 80% 100%
*There are 15 countries that do not have a SPAR result, and thus, are not included in the analysis.
Figure S2.1 reveals that 83% of high-income However, only 8% of the 180 countries with SPAR
countries have well-developed and sustainable data had limited or less capacity to detect public
capacity to detect public health threats health threats – overall a positive picture for the
compared to 58% of lower-middle-income global health security agenda (Figure S2.2).
counties and 41% of low-income countries.
17
FIGURE S2.2
PERCENTAGE OF COUNTRIES (N=180), BY CAPACITY TO SURVEY PUBLIC
HEALTH THREATS AND WHO REGION
Global 7% 25% 41% 27%

1%
AMR 26% 39% 32%

3%
AFR 13% 47% 34%

4% 2%
EMR 19% 52% 29%
EUR 15% 40% 40%

4%
SEAR 9% 18% 55% 18%
WPR 9% 9% 39% 43%
0% 20% 40% 60% 80% 100%
Distribution of countries, by level of capacity and WHO region

Nascent Limited Moderate Well-developed Sustainable Total
AMR 0 1 8 12 10 31
AFR 2 6 22 16 1 47
EMR 0 0 4 11 6 21
EUR 0 2 7 19 19 47
SEAR 0 1 2 6 2 11
WPR 0 2 2 9 10 23
GLOBAL 2 12 45 73 48 180
Stark regional variations exist in country capacity

to survey population health threats
In the WHO African region, only 1 out of 47 countries has sustainable

capacity for public health surveillance. In addition, of the 14 countries that
have only limited or less capacity, eight are in the African region.
1 47
Countries in WHO African
OUT region has sustainable
OF capacity for public health
surveillance.
18
Countries have good early warning However, Figure S2.3 also shows that what really
systems but are weaker in ability differentiates the high-income countries from
the others is the coordination mechanism that
to respond to threats
exists within the country to be able to respond
Each SPAR indicator is scored between 1-5 based to the public health threat (the national IHR
on the level of capacity of a country. This score coordination function). In addition, there is also
is translated into a percentage. For example, if some difference between high-income and
a country gets a score of 4 (level 4), it has a 80% low-income countries in their ability to respond
capacity. Figures S2.3 and S2.4 present variations to early detection of public health threats, as
in the scores for surveillance by country income measured by mechanisms for event management.
levels and WHO regions by showing the average These same patterns play out even more acutely
percentage capacity of the 3-tracer indicators within the WHO African region which faces key
as well as showing them individually. Figure S2.3 challenges in maintaining robust functions for
shows there is not much difference between the coordination and response. Having real time
various income-level groups in their overall ability information to make the right decisions is critical
to detect threats – the early warning function – for managing public health threats.
with scores ranging from 75-83%.
FIGURE S2.3
AVERAGE SCORES OF SPAR TRACERS FOR SURVEILLANCE OF PUBLIC
HEALTH THREATS IN 180 COUNTRIES, BY COUNTRY INCOME GROUP*
71%
79%
Overall SPAR 72%
66%
62%
69%
National IHR Focal Point 82%
functions under IHR 69%
63%
54%
79%
Early warning function: indicator 83%
and event-based surveillance 79%
75%
75%
65%
Mechanism for event management
71%
(verification, risk assessment, 67%
analysis investigation) 60%
56%
0% 20% 40% 60% 80% 100%
*There are 15 countries that do not have a SPAR result, and thus, are not included in the analysis.
19
FIGURE S2.4
AVERAGE SCORE OF SPAR TRACERS FOR SURVEILLANCE OF PUBLIC
HEALTH THREATS, BY WHO REGION
Overall SPAR
National IHR Focal Point functions
Early warning function
Mechanism for event management
71%
69%
Global (n=180)
79%
65%
57%
53%
AFR (n=47)
69%
49%
75%
77%
AMR (n=31)
83%
65%
76%
73%
EMR (n=21)
83%
70%
77%
75%
EUR (n=47)
80%
75%
71%
69%
SEAR (n=11)
82%
62%
77%
74%
WPR (n=23)
85%
71%
0% 20% 40% 60% 80% 100%
20
S3. Regular population census

All countries should have regular censuses every
10 years, or equivalent population registries
Census conducted
that provide information on population in last 10 years with
and socioeconomic characteristics by small population projections
geographical area, conducted in line with
United Nations Department of Economic and
for subnational units
Social Affairs (UNDESA) standards2. Information
Most countries have conducted
generated by a census or population registry
provides critical demographic data that are used
a census in the last 10 years or
to determine denominators for the computation maintain a population registry
of many health indicators, especially in the
Most countries in the world have conducted
absence of reliable data from CRVS systems.
a census or maintain a population registry.
In addition to assessing the availability of a However, some regional differences still exist
recent census or a population registry, this in the conducting of decennial census or
element, also examines if the census or registry continuous population registry. The Eastern
meet some minimum standards. These include: Mediterranean Region has the lowest availability
of a recent census. Several countries in this
• Census has been conducted within the region are in conflict or have had persistent
last 10 years conflict for the past 10 years or more, making it
difficult to conduct a full census.
• A post-enumeration survey (PES) has been
carried out for the most recent census, and
• Population projections with all disaggregation

are available for the current year.
86%
conducted a census
in the last 10 years.
Principles and Recommendations for Population and Housing Censuses, Revision 3. New York: United Nation; 2016
2
21
FIGURE S3.1
PERCENTAGE OF COUNTRIES THAT CONDUCTED AT LEAST ONE CENSUS
WITHIN LAST 10 YEARS, BY WHO REGION*
Global (n=189) 86%
SEAR (n=11) 100%
WPR (n=21) 100%
EUR (n=53) 96%
AMR (n=35) 89%
AFR (n=47) 77%
EMR (n=22) 55%
0% 20% 40% 60% 100%
* Data collected between 2018 and 2020 in 189 countries.
While availability of a census is questionnaires, not conducting the PES can raise
high, countries need support in questions on the quality of the census data. Only
46% of countries with a census conducted a PES.
conducting quality censuses
Disaggregated population projections are among
While most countries are conducting a census, a
the most important analytical outputs from the
much smaller percentage are conducting post-
census (Figure S3.2); only 51% of countries had
enumeration surveys (PES). As the PES is critical
disaggregated population projections.
in ascertaining the degree of coverage error for
the census as well as assessing item errors in
FIGURE S3.2
PERCENTAGE OF COUNTRIES THAT HAVE CONDUCTED A CENSUS IN
LAST 10 YEARS WITH SELECTED ATTRIBUTES*
Census in last 10 years 86%
Post enumeration survey done 46%
Population projection available 85%
Disaggregation for population

51%
projections available
0% 20% 40% 60% 80% 100%
*Data collected between 2018 and 2020 in 189 countries.
22
Looking forward: policy

implications
• There has been increased investment in • Countries need event-based surveillance and
surveys overall but it has been uneven in mechanisms that capture public health events
distribution, with some health topics well from a variety of sources
supported and others neglected. International
surveys have played an important role in • Most countries have undertaken an annual
securing good health data SPAR report to measure country capacity
for ensuring health security, based on IHR
• Data disaggregation is improving but is still requirements
lacking with regard to monitoring inequality
dimensions in many countries • Censuses, including small-area identifiers,
should be done every 10 years and provide
• More investment is needed to establish a comprehensive demographic data, including
more synergized and coordinated approach consideration of migrant populations,
to surveys which meet country needs, where relevant
and ensures the relevant equality issues
are captured • Ensure national capacity to produce
small-area population projections based
• Countries need a systematic and coordinated on census data
approach to population surveys
• Implementation of PES is necessary to ensure
• Indicator-based surveillance (i.e. the routine the quality of censuses
reporting of cases of disease), including an
early warning function, is needed to detect
unusual disease patterns
23
Count births, deaths
and causes of death
to know who is born and
what people die from
KEY ELEMENTS
C1. FULL BIRTH AND DEATH REGISTRATION
NEARLY
40%
of the world’s deaths are
not registered.
C2. CERTIFICATION AND REPORTING

OF CAUSES OF DEATH
ONLY
8%
of reported deaths in low-income
countries show causes of death.
24
COUNT BIRTHS, DEATHS AND CAUSES OF DEATH
Civil registration is the continuous recording of systems, that in many countries, provide the
vital events in an individual’s life (such as birth, proof of legal identity required to access health
marriage, death and cause of death). An effective and other services. Several health and health-
CRVS system is critical for recording these events, related SDGs require either all-cause or cause-
as well as for tracking public health trends, specific reporting of deaths. In addition, CRVS
planning interventions to improve population systems provide the population denominators
health and evaluating policy effectiveness. required for the calculation of many SDG and
UHC indicators. Development of a CRVS system
CRVS is the optimal system for producing fertility is a fundamental responsibility of government
and mortality statistics, while birth registration is and requires collaboration among multiple
the foundation of individual identity management stakeholders across multiple sectors.
FIGURE C.1
PERCENTAGE OF COUNTRIES (N=133) BY COUNTRY CAPACITY TO COUNT
BIRTHS, DEATHS AND CAUSES OF DEATH
16%
28% Number of Percentage of

Sustainable 21 7%
Moderate 18 22%
27% Limited 21 12%
Nascent 37 14%
16%
14%
25
C1. Full birth and death

registration
All countries should have a well-functioning assessed register at least 90% of births in their
CRVS system that registers all births and countries. On the other hand, less than 40% of
deaths, issues birth and death certificates, the countries register at least 90% of deaths in
and compiles and disseminates vital statistics, their countries.
including cause-of-death data. It may also record
marriages, divorces and adoptions.
ABOUT
Completeness of birth
and death registration
50%
of countries register
at least 90% of births.
Countries are stronger at
birth registration than death
registration NEARLY
Figure C1.1 describes country capacity to achieve
complete birth and death registration, defined
as having at least 90% of births or/and deaths
registered. About half of the 133 countries
40%
of countries register
at least 90% of deaths.
FIGURE C1.1
PERCENTAGE OF COUNTRIES (N=133) BY CAPACITY TO ACHIEVE FULL
BIRTH AND DEATH REGISTRATION
Nascent: No data on birth (death) registration completeness

Limited: <50%
Moderate: 50-74%
Well-developed: 75-89%
Sustainable: ≥90%
Full birth and death

10% 26% 11% 15% 38%
registration system
Completeness of 15% 14% 19% 51%

birth registration 1%
Completeness of
29% 14% 5% 13% 40%
death registration
0% 20% 40% 60% 80% 100%
26
Significant disparity exists, between high-and

low-income countries, in registering births, deaths
and causes of death
There is considerable disparity in coverage of birth registration by country

income level. While over 90% of high-income countries have complete
registration of births (defined as over 90% of births registered), less than 10%
of low-income countries have such complete registration (Figure C1.2).
FIGURE C1.2
PERCENTAGE OF COUNTRIES (N=133), BY CAPACITY TO ACHIEVE
COMPLETENESS OF BIRTH REGISTRATION AND COUNTRY INCOME GROUP
Nascent: No information on birth registration completeness
Limited: <50%
Moderate: 50-74%
Sustainable: ≥90%
Global (n=133) 15% 14% 19% 51%

1%
High Income 97%

(n=32) 3%
Upper-middle income 9% 26% 65%

(n=34)
Lower-middle income 22% 20% 24% 34%

(n=41)
Low income 42% 31% 19%

(n=26) 4% 4%
0% 20% 40% 60% 80% 100%
27
A similar pattern is seen in death registration. Whereas more than one third of
countries – predominantly high-income nations – register at least 90% of their
deaths (Figure C1.3), most low-income countries either have no data, or report
registration completeness below 50%.
FIGURE C1.3
PERCENTAGE OF COUNTRIES (N=133), BY CAPACITY TO ACHIEVE
COMPLETE DEATH REGISTRATION AND COUNTRY INCOME GROUP
Nascent: No information on death registration completeness

Limited: <50%
Moderate: 50-74%
Sustainable: ≥90%
Global (n=133) 29% 14% 5% 13% 40%
High Income
6% 91%
(n=32) 3%
Upper-middle income
9% 9% 29% 53%
(n=34)
Lower-middle income
32% 32% 10% 12% 15%
(n=41)
Low income 81% 19%

(n=26)
0% 20% 40% 60% 80% 100%
However, the relationship between income group A number of upper-middle-

and death registration completeness is by no income countries have death
means uniform. Several lower-middle-income registration levels
countries have levels of death registration
BELOW
75%
completeness in excess of 90%. Conversely, a
number of upper-middle-income countries have
death registration levels below 75%.
28
There are fewer effective incentives for the

registration of deaths compared with births.
The following are considered
For example, although some countries make
important prerequisites for a
death registration a condition for permission to
strong CRVS system:
dispose of the body, this only works in settings
where burial or cremation is regulated by law
A legal framework for CRVS –
and enforcement measures are applied. In
adequate and enforced legislation
some settings, such as Bangladesh, permission
which states that registration of
to dispose of a body is not required. In other
births and deaths is compulsory.
jurisdictions there are local, informal ways of
burying a body, including family burial plots. In Existence of a functioning CRVS
Brazil, Ghana, and Liberia, for example, there are intersectoral coordination
unregulated cemeteries where burials take place mechanism
without any legal documentation. Elsewhere,
permission to bury is given by local cemetery Registration Infrastructure
managers who are not required to report burial (offices and registrars) in adequate
details to the civil registrar. numbers to ensure easy access
for registration.
There is often a lack of recognition that a death
certification is an important document for the Business processes for notification
family of a deceased person, in particular for and registration of births and
children (who may be able to benefit from services deaths, and other vital events,
for orphans) and for widows(ers) who need that enable timely and reliable
the death certificate in order to claim spousal reporting.
pensions and benefits, as well as the right to marry
in settings where monogamy is the law. In addition, Health sector exercises a strong
a death certificate is required for surviving family role in notification of births and
members to claim inheritance or access to deaths, including causes of death.
resources and property of the decedent.
Availability of a system for
Although incentives such as these can encourage notification of births, deaths and
death registration, for many people, especially vital events that takes place in
the poorest, there is little to inherit following the community (including verbal
the death of a loved one and there is little autopsy methods for reporting
understanding of how a death certificate can probable cause of death in the
help establish eligibility for certain benefits. absence of medical certification).
Sometimes, the family only become aware of
the need for a death certificate some years after Physicians that are well trained in
the death when legal issues arise in relation to medical certification of deaths.
transfer of property or land. By then, it may be
Coders that are well trained in ICD
too late to register the death and penalties for
mortality coding of cause of death.
late registration may be a major barrier.
Statisticians that can analyse vital
This situation has enabled the identification of key
events and produce vital statistics.
prerequisites of a functioning CRVS system. These
prerequisites can be considered as intermediate
indicators of progress and will be important in
leading to improved and well-functioning CRVS
systems in the future.
29
Few countries meet all for interagency collaboration (that has oversight
recommended standards for a role, includes key stakeholders, meets regularly)
and having a comprehensive electronic system
functioning CRVS system
for sharing information between local, regional
In the 75 countries (covering 70% of the world and central locations.
population) where details were available
about the cause-of-death attributes, only
ONLY
20%
20% met at least 80% of the eleven standards
for a functioning CRVS system. Of the eleven
standards examined, countries were most
likely to be able to demonstrate they have legal
frameworks, business processes, and standard of countries with cause-of-
operating procedures in place and that the death data meet
80%
country is fully covered with locations for citizens
to register births and death, including rural and
hard-to-reach areas. The standards that countries
were least likely to meet included having a system of CRVS standards.
FIGURE C1.4
PERCENTAGE OF COUNTRIES (N=75) THAT MEET RECOMMENDED
STANDARDS FOR FUNCTIONAL CRVS SYSTEM, BY KEY INDICATORS*
Legal framework 85%
Access to registration offices 81%
Interagency collaboration 68%

oversees CRVS planning
Interagency collaboration 61%
meets regularly
Adequate training of registrars 60%
Data quality and analysis 56%
Performance monitoring 48%
Interagency collaboration includes

47%
key stakeholders
Frequency of reports 43%
Electronic exchange of data 39%
Formal CRVS interagency collaboration 28%
Meets at least 80% of standards for

20%
functional CRVS system
0% 20% 40% 60% 80% 100%
*Recommended standards for a functional CVRS system were examined in 75 countries where reliable information was collected.
30
Where are the missing millions?
36 million babies born each

year are unregistered.
Globally, just over 70% of births each year are registered. This means that
36 million babies born each year go unregistered. Only 44% of children
born in the WHO African region are registered, while birth registration
completeness is highest in the European and Americas regions, where
over 90% of births are registered.
Approximately 62% of deaths are registered every year. Only 10% of

deaths in the African region are registered while in the European and
Americas regions, over 90% of deaths are registered.
TABLE C1.1
NUMBER OF REGISTERED BIRTHS AND DEATHS BY WHO REGION*
Global AFR EMR EUR AMR SEAR WPR
Number of births 126 423 36 067 16 045 2 708 11 670 36 327 23 607
Number of registered births 90 574 15 950 11 006 2 661 11 154 28 326 21 476
Percentage of
72% 44% 69% 98% 96% 78% 91%
registered births
Global AFR EMR EUR AMR SEAR WPR
Number of deaths 47 749 9 285 3 701 2 592 5 173 13 762 13 236
Number of registered deaths 29 463 921 2 033 2 535 4 718 8 390 10 866
Percentage of
62% 10% 55% 98% 91% 61% 82%
registered deaths
*Based on most recent data available from 133 countries; all numbers of births and deaths are in thousands.
31
C2. Certification and reporting

of causes of death
All countries should have the capacity to
generate good quality, recent mortality statistics
Completeness of deaths
to describe levels and trends of mortality, and with cause of death
identify and track changes in the burden of
disease in different population groups. Countries with cause-of-death
completeness greater than 90%
Low-income countries are almost all high or upper-
record cause of death in middle income countries
ONLY
8%
While high-income countries record cause
of death for 95% of their reported deaths,
low-income countries only record cause of death
for 8% of their reported deaths.
of reported deaths.
FIGURE C2.1
PERCENTAGE OF DEATH REGISTRATION WITH CAUSES OF DEATH
AMONG ALL DEATH REGISTRATION, BY COUNTRY INCOME GROUP*
Global (n=94) 58%
High income
95%
(n=31)
Upper-middle income
(n=31) 78%
Lower-middle income
(n=28) 26%
Low income
(n=4) 8%
0% 20% 40% 60% 80% 100%
*Data are from 94 out of 133 countries that have death registration information.
32
FIGURE C2.2
PERCENTAGE OF COUNTRIES (N=133), BY CAPACITY TO REGISTER CAUSE
OF DEATH, AND COUNTRY INCOME GROUP
Nascent: No standardised system

Limited: <30% of deaths medically certified
Moderate: 30-69% of deaths medically certified
Well-developed: 70-89% of deaths medically certified
Sustainable: ≥90% of deaths medically certified
Global 30% 14% 8% 13% 35%
High income 13% 84%

3%
Upper-middle income 12% 18% 29% 38%

3%
Lower-middle income 44% 27% 10% 7% 12%
Low income 69% 23% 8%
0% 20% 40% 60% 80% 100%
Distribution of countries, by level of capacity and country income group

Nascent Limited Moderate Well-developed Sustainable Total
High income 0 1 0 4 27 32
Upper-middle income 4 1 6 10 13 34
Lower-middle income 18 11 4 3 5 41
Low income 18 6 0 0 2 26
Global 40 19 10 17 47 133
85%
There are 47 countries where the percentage of
death registration with cause of death is higher
than 90%. More than 85% of these 47 countries
are in upper-middle-income and high-income
of countries that have
groups. Less than 15% are in lower-middle-
causes of death for
90%
income and low-income groups. (Figure C2.2).
or more of their registered

deaths are upper-middle or
high-income countries.
33
Quality of cause-of- Ensuring that deaths are medically certified

and coded reliably is a particular challenge in
death data countries where most deaths occur outside of
health facilities. In such cases, verbal autopsies
Quality of cause-of-death data is can provide information on probable cause
problematic in many countries of death. A verbal autopsy is where a trained
interviewer uses a questionnaire to collect
Even when deaths are medically certified by information about the signs, symptoms, and
a physician, there can be quality problems demographic characteristics of a recently
that limit the usefulness of the cause-of-death deceased person from an individual familiar with
information. The quality of cause-of-death the deceased and translates this information
information can be improved using international into a probable cause of death.
standards to correctly code cause of death.
The International Classification of Diseases 10 th Only 28% of countries have less than 10%
revision (ICD-10) is a standardized classification ill-defined cause-of-death codes. While around
of diseases that allows causes of death to be 50% of high-income countries have less than
comparable across time and across populations. 10% ill-defined cause-of-death codes, about a
Standardized cause- of-death information third of lower-middle income and low income-
helps inform public health decisions and equips countries do not use ICD-10 to code causes of
policymakers to prioritise health challenges and death and therefore do not have quality cause-
investments and monitor progress. of-death data.
FIGURE C2.3
PERCENTAGE OF COUNTRIES, BY QUALITY OF DEATH REGISTRATION
AND COUNTRY INCOME GROUP*
Nascent: No data
Limited: ≥30% ill-defined or unknown causes
Moderate: 20-29% ill-defined or unknown causes
Well-developed: 10-19% ill-defined or unknown causes
Sustainable: <10% ill-defined or unknown causes
Global (n=94) 17% 12% 19% 24% 28%
High income
(n=31) 13% 32% 55%
Upper-middle income
(n=31) 16% 13% 13% 29% 29%
Lower-middle income
(n=28) 36% 18% 32% 14%
Low income
(n=4) 25% 50% 25%
0% 20% 40% 60% 80% 100%
*Data are from 94 out of 133 countries that have death registration information.
34

implications
This global snapshot of CRVS systems suggests • The key to a strengthened CRVS system
significant room for improvement, however, the is improved governance, improved
examination of completeness of registration is notification processes, capacity building, the
the end stage of a process and ignores progress establishment of collaborative partnerships
that is already taking place further “upstream” that involve stakeholders from across
by many governments that are investing in CRVS government sectors and capacity building for
systems. Policymakers in a number of low- and certification of death and ICD mortality coding
middle-income countries have taken bold steps
to strengthen their national CRVS systems – steps • WHO is investing in strengthening CRVS
that have led to greatly improved birth and death systems and has developed the WHO CRVS
registration coverage and cause-of-death data. Strategy and Implementation Plan 2020-2023.
Nevertheless: This aims to empower Member States to more
effectively mobilize their health sector to lead
• Accurate information on births, deaths CRVS system strengthening efforts in order
and causes of death is essential for health to ensure maximum benefit from routine data
policymakers to prioritise health challenges, systems for policy and development
guide investments and ensure optimal
resource allocation • WHO is also collaborating with many partners
and donors to accelerate CRVS system
• Civil registration records are the best source strengthening through the Health Data
of vital statistics needed for tracking progress Collaborative (HDC) platform which was
towards achieving national and international established in 2017. The HDC platform aims to
health targets: the ability to monitor progress ensure alignment of investments and activities
towards achievement of the SDGs will be of CRVS partners and donors
strongly influenced by the availability of
comprehensive Civil Registration and Vital
Statistics systems
35
Optimize health
service data
to ensure equitable,
quality services for all
KEY ELEMENTS
O1. ROUTINE FACILITY REPORTING SYSTEM

WITH PATIENT MONITORING
ONLY
31%
of countries report subnational
facility data on severe mental
health disorders.
O2. REGULAR SYSTEM TO MONITOR

SERVICE AVAILABILITY, QUALITY
AND EFFECTIVENESS
ALMOST
50%
of countries have limited or less
capacity for systematic monitoring
quality of care.
O3. HEALTH SERVICE RESOURCES: HEALTH

FINANCING AND HEALTH WORKFORCE
89%
of countries report public
health expenditures.
36
OPTIMIZE HEALTH SERVICE DATA
Health service data are generated through many ONLY
4%
data subsystems, including routine facility and
community reporting systems, health facility
surveys and various health resource data
systems such as health workforce and health
financing information systems. of participating countries
have sustainable capacity
These subsystems should ideally be integrated to optimize health
or interoperable to facilitate comprehensive service data.
analysis of health services to support patient
management, facility management, disease
surveillance, sector planning, monitoring and
management at all levels. Data generated in
health facilities contribute to a number of health
SDG and UHC monitoring indicators.
FIGURE O.1
NUMBER AND PERCENTAGE OF COUNTRIES (N=133), COUNTRY
POPULATION AS A PERCENTAGE OF WORLD POPULATION, BY CAPACITY
TO OPTIMIZE HEALTH SERVICE DATA
4% 2%
20% Number of Percentage of

Sustainable 5 3%
Moderate 57 17%
Limited 26 4%
Nascent 3 1%
43%
37
O1. Routine facility reporting

system with patient
monitoring
Data routinely reported by health facilities are Results from the examination of a set of
not fully representative of population health and tracer indicators collected show that many
they may be incomplete or of uneven quality. health issues are being tracked nationally but
Nonetheless, these data have several advantages these results vary greatly between indicators.
over those collected through surveys and special Examining availability of data from 2013 onwards
studies. They are available close-to-real-time and show high availability of data for HIV, TB and
they are available for every service delivery unit. immunization but lower availability for the other
As such, these data can be used for client/patient tracer indicators (Figure O1.1).
management, health service management at
facility and higher levels and disease surveillance.
Data generated by health facilities contribute to
the monitoring of a number of health SDG and
UHC indicators, including tuberculosis incidence
DATA
DISPARITY
and treatment success, malaria incidence,
coverage of essential health services (UHC EXISTS
tracer indicators with facility data component), due to unevenly resourced
percentage of people living with HIV currently health programmes.
receiving antiretroviral therapy and hospital beds
per capita.
This high availability of data for HIV, TB and
immunization reflects the impact of many years
of intensive support for these programmes
Availability of key through large funding mechanisms, including
indicators derived from support for monitoring and reporting. Other
facility data indicators do not benefit from the same type

of support, and this shows in the results. Less
More action needed to than 50% of countries can demonstrate data
availability for mental health, for example.
strengthen routine facility
reporting - only selected
diseases or areas measured
The limitations of the data routinely reported

by health facilities are well recognized, including
the lack of comprehensive representation of a
population’s health, data incompleteness, and
low data quality. Nonetheless, these data have
a couple of advantages over data from other
sources: they are available close-to-real-time and
they are available for every service delivery unit.
38
Measuring inequality in Access to, and availability of, services can vary in
service delivery is critical, yet different parts of the country or be different for
men, women and different age subgroups. Where
countries often don’t report
relevant, it is also important to disaggregate data
disaggregated data
by appropriate population subgroups to determine
the magnitude and patterns of inequality in the
Disaggregation of programme data allows planners
delivery of health services.
and programme managers to assess inequality in
the delivery of services and treatment outcomes.
FIGURE O1.1
PERCENTAGE OF COUNTRIES (N=133) WITH DATA MEASURING FACILITY-
BASED INDICATORS*
National Subnational
98%
Tuberculosis treatment success rates sub-national not applicable
Diphtheria-tetanus-pertussis 97%
(DTP)/Penta3 83%
92%
Antiretroviral therapy (ART) coverage sub-national not applicable
84%
Outpatient department (OPD) visits
70%
Hospital admission/discharge 80%

rate by diagnosis 66%
Low birth weight prevalence 74%

among institutional births 51%
72%
Institutional maternal mortality ratio
54%
68%
New cancer diagnosis by type
44%
Hospital deaths by major 60%

diagnostic category (use ICD) 46%
50% 59,4%
Surgical interventions by type
38%
48%
Severe mental health disorders
31%
0% 20% 40% 60% 80% 100%
39
In Figure O1.1, the disaggregated data is only less than 50% of countries have data
examined for a set of 10 indicators among the disaggregated at subnational level, respectively.
countries that collect data at national level. Data When looking at sex and age, for eight indicators,
disaggregation is most commonly available at the percentages of countries are all under 50%
subnational level; however, for four indicators, (Figure O1.2).
FIGURE O1.2
PERCENTAGE OF COUNTRIES (N=133) REPORTING DISAGGREGATED
FACILITY DATA, BY SELECTED INDICATORS*
Subnational Sex Age
Diphtheria-tetanus-pertussis 83%
sex not applicable
(DTP)/Penta3 age not applicable
sub-national not applicable

Antiretroviral therapy (ART) coverage 84%
80%
70%
Outpatient department (OPD) visits 38%
45%
Hospital admission /discharge 65%

rates by diagnosis 38%
42%
Institutional maternal 54%

mortality ratio sex not applicable
age not applicable
Low birthweight prevalence 51%

25%
among institutional births age not applicable
Hospital deaths by major 45%

36%
diagnostic category (use ICD) 38%
44%
New cancer diagnosis by type 49%
44%
38%
Surgical interventions by type 20%
20%
31%
Severe mental health disorders 26%
26%
0% 20% 40% 60% 80% 100%
40
Good data quality practices systems of documented quality checks for

produce reliable data facility data in both primary care facilities and
hospitals. Over 40% (42% in primary care facilities
Where countries collect facility-based data, the and 45% in hospitals, Figure O1.3) either do not
quality of these data are often not assured. There have data quality checks or could not provide
should be documented processes for checking any documentation about the process. The
the completeness, consistency and accuracy of representativeness and reliability of the facility
the data and adjustment of the statistics based data is highly dependent upon the completeness
upon such findings; however, fewer than one-in- of reporting from facilities, which varies by facility
five countries reported having comprehensive type (Figure O1.4).
FIGURE O1.3
PERCENTAGE OF COUNTRIES (N=133) WITH DOCUMENTATION ON
QUALITY CHECKS FOR HEALTH FACILITY DATA, BY FACILITY TYPE
None or unknown Partial Comprehensive
Primary care facilities 42% 39% 19%
Hospitals 45% 36% 19%

0% 20% 40% 60% 80% 100%
FIGURE O1.4
PERCENTAGE OF COUNTRIES (N=133) THAT REPORT FACILITY DATA
WITH DOCUMENTATION, BY FACILITY TYPE
No documentation available <25% 25-75% >75%
Primary care facilities 27% 5% 12% 56%
Public hospitals 34% 12% 52%

2%
Private hospitals 54% 9% 20% 16%

0% 20% 40% 60% 80% 100%
41
O2. Regular system to monitor

service availability, quality
and effectiveness
Universal access to quality services is a necessary
precondition to achieving universal health
Well-established system
coverage1. Hence, the importance of a system to independently monitor
for monitoring service availability and readiness2 health services
as well as the quality and effectiveness of care.
Countries are at different levels of monitoring Quality health services are critical
quality of care: at the simplest level, facility yet, systematic assessment still
assessments can be used to capture information
a challenge
that is not routinely reported, such as availability
of essential equipment, supplies and human All countries should have in place an
resources; compliance with clinical guidelines; independent, objective, comprehensive
quality of care; and client experience. Facility system for external review, through to
assessments are also used to validate data regularly monitoring health service availability,
reported through the routine system. More readiness, quality and effectiveness. Findings
mature systems, present in many high-income were interpreted in terms of maturity levels
countries, involve accreditation. which assumes that, as health systems mature,
monitoring of health service availability and
readiness will evolve to regular independent
monitoring of quality of care.
ALMOST
50%
of countries have limited
or less capacity for
systematic monitoring
quality of care.
1
Evans DB, Hsu J, Boerma T. Universal health coverage and universal access. Bull World Health Organ 2013; 91: 546-546A http://dx.doi.
org/10.2471/BLT.13.125450 pmid: 23940398.
2
O’Neill K, Takane M, Sheffel A, Abou-Zahr C, Boerma T. Monitoring service delivery for universal health coverage: the Service Availability
and Readiness Assessment. Bull World Health Organ. 2013 Dec 1;91(12):923-31. doi: 10.2471/BLT.12.116798. Epub 2013 Sep 30. PMID:
24347731; PMCID: PMC3845262.
42
Standards and methods for assessing Provision Assessment (SPA), Service Delivery
the quality of health services Indicator (SDI) survey, the Harmonized
Health Facility Assessment (HHFA) go
A service is available if it is offered by a health beyond assessment of readiness to more
facility. A health facility is ready to offer the robustly assess the quality of services.
service if it has the trained staff, diagnostic
capacity and medicines required to provide Accreditation is a systematic process of
the service. Availability, readiness and quality review that requires health facilities to
of care can either be measured through recurrently demonstrate their ability to meet
independent facility surveys or through a official standards, unlike a survey approach,
system of accreditation. which typically assesses a sample of
availability and readiness. At a more mature
WHO’s Service Availability and Readiness stage, health systems should introduce
Assessment (SARA) has been used to assess monitoring of the quality of services, based
availability and readiness at a representative either upon appropriately designed facility
sample of health facilities. Other health surveys or a system of accreditation of all
facility survey methodologies (e.g. Service health facilities.
FIGURE O2.1
PERCENTAGE OF COUNTRIES (N=133) THAT HAVE A REGULAR SYSTEM
TO MONITOR SERVICE AVAILABILITY, QUALITY AND EFFECTIVENESS
Global (n=133) 26% 24% 8% 10% 33%
High Income
19% 6% 6% 6% 63%
(n=32)
Upper-middle income
32% 15% 9% 9% 35%
(n=34)
Lower-middle income
32% 37% 5% 7% 20%
(n=41)
Low income
15% 38% 12% 19% 15%
(n=26)
0% 20% 40% 60% 80% 100%
Quality of care is critical to achieve effective upon a system of accreditation. However, this
universal health coverage. Globally, almost 50% was not the case with countries in other income
of the countries had limited capacity to monitor levels where a large percentage of countries
quality of care (Figure O2.1). The majority of high- demonstrated no, or limited, capacity to monitor
income countries demonstrated comprehensive quality of care.
and regular monitoring of quality of care based
43
O3. Health service resources:

health financing and health
workforce
All countries should have comprehensive health spending in a country, providing a common
databases for tracking health financing and framework for enhancing comparability of health
human resources for health. Systems of expenditure data over time and among countries.
national health accounts (NHA) and national
health workforce accounts (NHWA) should be Over 40% of countries are not
maintained according to international standards. tracking catastrophic health
expenditures – a fundamental
measure of UHC
Availability of latest
The SHA provides a framework for examining
data on national health public and private health expenditures, based
expenditures on a set of international standards. While almost
90% and 80% of countries have tracked public
The aim of having a sustainable method to and private health expenditures, respectively,
track health expenditures is for all countries in the last five years, they are not always
to systematically measure the flow of funds tracked according to international standards.
in their health system using NHA, based on Approximately, only 60% of countries have tracked
international standards. An electronic system public and private health expenditures according
for tracking public expenses at all levels of to international standards, such as SHA, since
government is desirable to enable effective 2013. However, tracking of catastrophic spending is
monitoring of subnational health expenditures. lower overall, with only 56% of countries doing any
tracking, and only 32% meeting SCORE standards
NHAs provide national decision-makers with
(Figure O3.1). Data that is not based on standards
essential financial information to inform policy
is difficult to compare within a country across time
choices, budgetary planning and resource
and between countries. Higher-income countries
allocation and to monitor accountability. NHA
are more likely to be collecting expenditure data
information includes: the share of health
according to the standards. There is both the need
expenditure within an economy, the financial
to increase the tracking of catastrophic health
burden of health spending on households,
expenditures and the need to use international
the magnitude of external financing in health
standards for the collection of public, private and
expenditure and the share of spending on
catastrophic expenditures.
different levels of care (e.g. hospitals, primary care
facilities) and on different diseases or conditions.
NHAs are produced using the System of

Health Accounts (SHA) 2011, an internationally
recognized methodology that tracks the flow
of expenditures in the health system. The SHA
89%
of countries report public
generates consistent, comprehensive data on all health expenditures.
44
FIGURE O3.1
PERCENTAGE OF COUNTRIES (N=133) THAT COLLECT EXPENDITURE
DATA, BY TYPE OF EXPENDITURE AND COUNTRY INCOME GROUP
89%
Any public health 91%
expenditure 94%
93%
73%
Public health 59%

75%
expenditure based on 74%
International standards 51%
35%
78%
Any private health 84%
expenditure 82%
80%
62%
Any private health 59%

75%
expenditure based on 71%
International standards 54%
31%
56%
Any catastrophic 63%
spending 50%
66%
42%
32%
Catastrophic spending
56%
based on International 32%
standards 24%
12%
0% 20% 40% 60% 80% 100%
private sectors). Given the importance of placing

Annual data on health sustained focus on achieving intra-country equity,
worker density and countries should disaggregate data to inform
distribution policy-making on the density and distribution
of the health workforce3. The implementation of
Health workers are the backbone of strong, NHWAs provides a systematic and progressive
resilient health systems. UHC and any guarantees approach to the improvement in the availability
of global health security are only possible with and quality of human resources data.
investments targeting inequities in access to
skilled health workers within countries (between
urban and rural areas and between public and
3
Working for health and growth: investing in the health workforce. Report of the High-Level Commission on Health Employment and
Economic Growth. Geneva: World Health Organization; 2016.
45
Only 55% of countries provide sex, subnational and managing authority (public
disaggregated data on the health or private)). When examining all five occupations
combined, 55% of countries have sub-national
workforce by subnational units
data, 39% have data on age, 43% have data
Five health workforce occupations were the focus on sex and 34% report data on managing
of the data availability assessment: Physicians, authority (by public/private sector). These subtle
pharmacists, dentists, nurses and midwives. differences in the availability of disaggregated
While 71% of the 133 countries surveyed had data for the health workforce distribution limits
capacity to report aggregate data on the five the development of effective plans and policies at
occupations combined nationally (Figure O3.2), the national and subnational level.
the same was not the case in terms of the
recommended disaggregation (namely by age,
FIGURE O3.2
PERCENTAGE OF COUNTRIES (N=133) THAT REPORT HEALTH
WORKFORCE DENSITY AND DISTRIBUTION, BY OCCUPATION
National Age Sex Subnational Private/public
95%
58%
Physicians 65%
76%
46%
88%
45%
Pharmacists 51%
66%
44%
86%
44%
Dentists 50%
64%
44%
94%
56%
Nurses 62%
73%
46%
78%
41%
Midwives 48%
62%
40%
71%
Five occupations 39%
43%
combined 55%
34%
0% 20% 40% 60% 80% 100%
46
Some key indicators of a functional human resources information system

(HRHIS) were assessed in 65 countries (Figure O3.3). Although a high
proportion of these countries were able to meet some of these key criteria
in their reporting, only 29% of the 65 countries met 80% or more of the
standards required for a functional HRHIS. In implementing NHWAs,
countries can progressively improve their data reporting on many aspects
which are reflected by these indicators.
FIGURE O3.3
PERCENTAGE OF COUNTRIES (N=65) THAT MEET ACCEPTED STANDARDS
FOR A FUNCTIONAL NATIONAL HRHIS, BY KEY INDICATORS*
Subnational level data

80%
of active health workers
Demographic distribution of
77%
active health workers
Number of graduates from education

68%
and training institutions
Number of active stock

66%
(people) on the labour market
Number of entrants
57%
to the labour market
Information on foreign-born and/ or

43%
foreign-trained health workers
Number of exits from

40%
the labour market
Meets at least 80% of the standards

29%
for functional HRHIS system
0% 20% 40% 60% 80% 100%
*The standards for a functional national human resources information system (HRHIS) are examined in 65 countries where reliable
information was collected.
47
Looking ahead: policy

implications
Data from health facilities and health resources middle-income countries which may have
data are essential for management of health the resources to adopt such an approach.
services and a key requirement for monitoring Nationally representative health facility
progress towards UHC. Some key policy assessments provide an interim strategy for
implications that emerge include: monitoring service availability, readiness and
quality. However, most countries employing
• Standards need to be promoted for country this strategy need to conduct such surveys
statistical reports to specify the completeness more regularly which will necessitate the
of data and describe processes for data mobilization of considerably more resources
quality assurance
• Countries should develop a harmonized
• Standards need to be reinforced for annual programme for health facility surveys, based
publication of core health statistics based on international standards and adapted to
upon routine health data. To meet the need country context and needs, that reduces
for policy, planning and management, these duplication and includes details on content,
statistics need to be recent and appropriately funding and execution as part of the
disaggregated (by geographic region, sex and monitoring and evaluation plan of the national
age subgroups). Methods for assuring the health sector
quality of data must be adequately described
in statistical reports and any limitations noted • Standards need to be reinforced for the
dissemination of basic information on
• Based on the models established for the health workforce. Statistics for the
reporting on immunization and care for TB previous year should be published annually
and HIV, global support needs to be extended with disaggregation by health district.
to tracking the delivery of essential services Global advocacy and aligned investments,
(antenatal and delivery care, mental health particularly through supporting the NHWA
care, cardiovascular disease care, cancer implementation in countries, will build
diagnoses, etc) as well as for monitoring country capacity to strengthen existing
health system utilization (outpatient visits, HRH information systems (and subsystems
admissions, major surgeries) that belong to professional associations
and the private sector) to produce timely,
• For many countries there is a pressing need
disaggregated quality data needed to
to strengthen the monitoring of quality
address complex policy questions for health
of care. Where practical, accreditation
workforce development
programmes could be taken to scale
and better documented – particularly for
48
49
Review progress
and performance
to make informed
decisions
KEY ELEMENTS
R1. REGULAR ANALYTICAL REVIEWS

OF PROGRESS AND PERFORMANCE,
WITH EQUITY
ONLY
38%
of countries review health
sector performance by socio-
economic status.
R2. INSTITUTIONAL CAPACITY FOR

ANALYSIS AND LEARNING
ABOUT
50%
of countries have well-developed
or higher capacity
50
REVIEW PROGRESS AND PERFORMANCE
The use of data and information for periodic of these analyses are interpreted in the light
health sector progress and performance reviews of national strategies, plans and policies and
is critical to understanding what is working and take into account international developments
what is not working. The output of a review as well as contextual changes. Engagement of
process (based on standards and including the national academic, public health and research
highest-possible quality data and indicators) will institutions will foster broader institutional
support decision-making at all levels and help capacity to improve the analysis and use of
generate consensus on where action is needed, health-related data.
including guiding resource allocation. Assessing
equity dimensions, system performance against Within the SCORE intervention, “Review progress
targets, and enablers and barriers to effective and performance”, there are two elements:
access to, and utilization of, health care services
1. regular analytical reviews of progress and
are key components of a review.
performance, with equity, and
Progress and performance reviews are part of
2. institutional capacity for analysis and learning.
national and local governance mechanisms, and
scorecards or dashboards are tools that have Overall, 60% of countries demonstrated
tremendous potential for regular annual or more well-developed or higher capacity for this
frequent assessment of progress. Mid-term intervention (Figure R.1).
and end-of-plan reviews are also common
and should be more extensive. The results
FIGURE R.1
NUMBER AND PERCENTAGE OF COUNTRIES (N=133), COUNTRY
POPULATION AS A PERCENTAGE OF WORLD POPULATION, BY CAPACITY
TO REVIEW PROGRESS AND PERFORMANCE IN HEALTH SECTOR
5%
27%
17%
Number of percentage of
Sustainable 36 55%
Moderate 37 10%
28% Limited 10 1%
Nascent 6 0%
33%
51
R1. Regular analytical reviews

of progress and performance,
with equity
Countries should assess and monitor progress Inequality analyses are critical
and performance of their NHSP, including the in health systems review, yet
extent to which equity in access to, and availability
only 38% countries include
of, health care has been achieved. Health sector
disaggregated data by socio-
performance assessments should adhere to
international standards for content and rigor, and economic status
lead to action to improve performance towards
While most countries (91%) have produced an
targets. Essential elements for performance
analytical report of the health sector strategy
assessments include the use of multiple data
within the last 5 years, only 25% of countries had
sources (for example, routine health information
reports that met at least 80% of recommended
system data as well as periodic population-
standards (Figure R1.1). Common aspects that
based surveys, and CRVS, etc.). They should
were lacking included comparative analyses
assess progress against targets for core health
(comparisons with similar countries) and
indicators, and assess coverage and access with
subnational rankings (for example, comparisons
regard to equity (sex, across socioeconomic
of performance between districts within
strata, and subnational units). It should include an
the same country). Measures of inequality,
assessment of efficiency by comparing progress
particularly socioeconomic, also were lacking;
relative to expenditures. Finally, it should compare
comparisons of health sector performance
progress towards targets among different types
among different socioeconomic strata were
of health care providers (that is hospitals vs.
included in only 38% of surveyed countries,
primary health care units) and among different
while comparisons of health sector performance
subnational units to identify well performing and
for men and women were included in 56% of
poorly performing areas of the country. Finally,
countries and subnational administrative units
comparisons should be made for national results
(70%) were included more often.
against the performance of similar countries
(external comparison).
ONLY
56%
of countries report
inequality measurement
by sex.
52
FIGURE R1.1
PERCENTAGE OF COUNTRIES (N=133) THAT REGULARLY PUBLISH
ANALYTICAL REPORTS IN COMPLIANCE WITH RECOMMENDED
STANDARDS, BY KEY INDICATORS
Analytical report published

91%
in last 5 years
All data sources used 85%
Shows progress against target 74%
Inequality - subnational 70%
Links findings to policy 67%
Linking performance to health inputs 59%
Inequality - sex 56%
Performance of hospitals included 53%
Subnational rankings 40%
Inequality - socioeconomic 38%
Comparative analysis 23%

0% 20% 40% 60% 80% 100%
MORE THAN
70%
of countries measure
progress against targets.
53
R2. Institutional capacity for

analysis and learning
All countries should have national institutional of the countries (Figure R2.2). Such involvement
capacity for health data and statistics generation, helps to build institutional capacity to improve
synthesis, analysis, dissemination and use. Sources the analysis and use of health-related statistics.
of institutional capacity include the ministry of However, this is seen much more in high-income
health (and other line ministries), the national countries than in other countries.
statistical offices, public health institutes, schools
of public health, and non-governmental and other The national statistical offices are shown to have
civil society organizations. Capacity should also comparatively greater capacity for data analysis
be available subnationally, for example at regional for all wealth groups than ministries of health or
or district level health ministry units. Overall, public health institutions. This is an encouraging
about 50% of countries (n=133) had at least well- sign for the management of SDG monitoring
developed institutional capacity for analysis and which remains with national statistical offices.
learning (Figure R2.1). Given the complex health challenges, such as
the global pandemic of COVID-19, it is critical to
Strong engagement with national strengthen the analytical capacity of ministries of
academic, public health and health as well as other institutions, especially in
low-income countries.
research institutions is critical
Engagement of national academic, public health

and research institutions in the review process is
well-developed or sustainable in only about 35%
FIGURE R2.1
PERCENTAGE OF COUNTRIES (N=133) WITH INSTITUTIONAL CAPACITY
FOR ANALYSIS AND LEARNING, BY LEVEL OF CAPACITY
9% 14% 26% 16% 35%
0% 20% 40% 60% 80% 100%
54
FIGURE R2.2
PERCENTAGE OF COUNTRIES (N=133) WITH INSTITUTIONAL CAPACITY
OR INVOLVEMENT IN DATA ANALYSIS, BY COUNTRY INCOME GROUP
53%
Strong capacity at 72%
national statistical offices 41%
46%
54%
42%
Strong capacity at 56%
national MoH 44%
24%
50%
26%
Strong subnational
34%
capacity in MoH or 29%
independent institutions 20%
23%
35%
Strong involvement
50%
from public health 38%
institutions 24%
31%
0% 20% 40% 60% 80% 100%
42%
of countries have strong
capacity at national
ministry of health.
55

implications
• While the vast majority of countries are • Institutional capacity for data analysis needs
conducting regular health sector performance to focus on two fronts:
reviews, the reviews are not always of the
highest quality, often missing important 1. It is essential to foster collaborations
elements to promote equity with private entities such as public
health institutes, universities, and
• Comparisons of health sector performance non-governmental organizations to
by socioeconomic strata, sex, and subnational support the review process
units can help identify underperforming areas,
improve access and uptake of services among 2. In addition, there is critical need to
disadvantaged groups, thereby enhancing improve the institutional capacities of
equity in health service delivery ministries of health to face complex health
challenges
• Countries should make efforts to reform
the processes and content of health sector
performance reviews and ensure the inclusion
of these essential elements
56
57
Enable data use for
policy and action
to accelerate improvement
in health
KEY ELEMENTS
E1. DATA AND EVIDENCE DRIVE

POLICY AND PLANNING
40%
of countries include health system
strength analysis in strategic plans.
E2. DATA ACCESS AND SHARING
25%
of countries update their global
health portal more than once a year.
E3. STRONG COUNTRY-LED

GOVERNANCE OF DATA
74%
of countries have an M&E plan
and a national eHealth strategy.
58
ENABLE DATA USE FOR POLICY AND ACTION
An enabling environment is critical for ensuring the effective use of health

data, the bedrock of sound national health service plans. Accessible,
credible data from multiple sources must be made available to a broad
group of users to improve health system performance. This user
group include decision-makers at all levels, health service funders and
implementers, academic institutions, the media and the public. It must also
be accessible to those who hold the government accountable.
WHO Delivery for Impact (DFI) • The DFI Knowledge Hub was launched
Knowledge Hub with eight countries, ensuring
representation from all WHO regions
• The DFI Knowledge Hub is, - Ethiopia, Mauritius, Oman, Pakistan,
focused on supporting country- Paraguay, Philippines, Sri Lanka, and
level implementation efforts to Ukraine. The programme is organized
accelerate progress towards the around Country Teams comprised of
Triple Billion targets1. priority leads and project members
• The programme is based on a hybrid in charge of implementation. Each
learning model including webinars, team includes representation from the
workshops, 1:1 facilitator-led sessions, Member State governments, regional
and independent and group work. offices, and country offices.
• The online learning portal will also • The “Delivery of the Triple Billion” WHO
allow participants to review delivery Academy course will further promote
content, download key tools, take an impact-focused culture by explicitly
self-guided courses, and interact with linking country implementation plans
their peer community and network of and efforts to the WHO GPW 13
participating countries. (Thirteenth General Programme for
Work) impact measures and strategy2.
Mechanisms that enable data use include: • and an open and transparent policy
on data access.
• sound health sector strategic plans which
Policy-relevant data analyses, evidence synthesis
include a plan for monitoring and evaluation,
and structured expert review processes are
• annual high-quality statistical reports with needed to translate this knowledge to inform
priority analyses policy-making and legislative proposals, and to
• national health observatories or portals enable monitoring of progress towards UHC and
that are easy to access and use and contain the HRSDGs.
relevant content,
World Health Organization. Thirteenth General Programme of Work, 2019–2023. 2019. Geneva.
1
Thirteenth General Programme of Work (GPW13): methods for impact measurement. Geneva: World Health Organization; 2020.
2
59
Overall, about 30% of 133 countries have well- compared to 42% for “Data access and sharing”;
developed or higher capacity for this intervention. capacity for “strong country-led governance of
For the key element “Data and evidence drive data” was the least developed among the three
policy and planning”, almost 60% of countries elements – only 25% of countries were found to
have well-developed or higher capacity, have well-developed or higher capacity.
FIGURE E.1
PERCENTAGE OF COUNTRIES (N=133) WITH CAPACITY TO ENABLE
DATA FOR POLICY AND ACTION, BY KEY CAPACITY ELEMENTS
Overall Capacity 8% 22% 38% 27% 5%
Data and evidence

drive policy and 6% 14% 21% 42% 17%
planning
Data access and 24% 18% 16% 24% 18%
sharing
Strong country-led
21% 26% 28% 17% 8%
governance of data
0% 20% 40% 60% 80% 100%
60
E1. Data and evidence

drive policy and planning
All public health policies and planning should be and their contents using a set of standards, as
driven by data and evidence. Governments at all well as determining the presence of a central
levels need data to budget and allocate resources, unit or function in the ministry of health that is
and monitor and track progress. Quality data can responsible for data to policy development. About
provide effective feedback for course correction, 60% of countries have well-developed or higher
enhance performance and improve accountability. capacity to use data and evidence for policy and
planning, with 75% of high-income countries and
Most countries have good capacity less than 50% of low-income countries achieving
for using data and evidence to this level (Figure E1.1). Up to 41% of high-income
drive policy and planning countries reported sustainable capacity in this
area, while 4% of low-income countries and 12%
It is difficult to measure a country’s capacity to use of upper-middle-income countries reported the
data and evidence to drive policy and planning. same level of capacity, suggesting that country
This measurement is approximated by examining wealth levels influence how well health policy and
the availability of national plans and policies planning are driven by data and evidence.
FIGURE E1.1
PERCENTAGE OF COUNTRIES (N=133) WITH CAPACITY TO HAVE DATA AND
EVIDENCE DRIVE POLICY AND PLANNING, BY COUNTRY INCOME GROUP
Global (n=133) 6% 14% 21% 42% 17%
High income
9% 13% 34% 41%
(n=32) 3%
Upper-middle income
12% 12% 24% 41% 12%
(n=34)
Lower-middle income
17% 24% 49% 10%
(n=41)
Low income
27% 23% 42%
(n=26) 4% 4%
0% 20% 40% 60% 80% 100%
61
Figure E1.2 shows the distribution of key

NEARLY
ALL
indicators or standards that are used to evaluate
health sector performance. Nearly all countries
produced a publicly available national plan for
the health sector, but the quality of the plan
varied. A review of past performance was present countries have a national
in 40% of countries, while a burden of disease health sector strategic plan.
analysis was only found in 38% of countries. A
health system strength analysis was found in the
strategic plans of 50% of countries.
FIGURE E1.2
PERCENTAGE OF COUNTRIES (N=133) WITH A PUBLICLY AVAILABLE
NATIONAL HEALTH SECTOR STRATEGIC PLAN THAT MEETS
RECOMMENDED STANDARDS, BY KEY INDICATORS
Health sector plan publicly available 95%
Presence of a central unit or function

in MoH for data and evidence to 84%
policy translation
Coordination function between MoH

56%
and external partners exists
National health plan/policies include

50%
review of past performance (trends)

health system strength analysis 40%
(response strength)

38%
burden of disease analysis
At least quarterly output of a central

unit or function in MoH for data and 14%
evidence to policy translation
0% 20% 40% 60% 80% 100%
62
To ensure that data are analysed critically, and decisions are taken to
better align the health system to meet the needs of the population, the
responsibility for translating evidence into policy should be assigned to a
discreet entity, such as a working group or unit within the ministry of health.
The vast majority of countries (84%) reported having such a unit (Figure E1.3).
However, the strength and utility of these units is difficult to gauge; only 14%
of countries indicated quarterly outputs from these policy units, with less
frequent output from lower-income countries (8%).
FIGURE E1.3
PERCENTAGE OF COUNTRIES (N=133) WITH A COORDINATION UNIT FOR
DATA AND EVIDENCE TO POLICY TRANSLATION, BY KEY INDICATOR,
AND COUNTRY INCOME GROUP
84%
Central unit or function in
88%
MoH for data and evidence to 71%
policy translation 88%
92%
56%
Coordination function between MoH 53%
44%
and external partners exists 68%
58%
At least quarterly output of a central 14%

28%
unit or function in MoH for data and 9%
evidence to policy translation 10%
8%
0% 20% 40% 80% 100%
84%
of countries have a
data to policy unit.
63
E2. Data access and sharing

All countries should make health data accessible administrative framework is essential to enable
to decision-makers at all levels, including data access and sharing, in accordance with global
subnational and local communities, and to standards for confidentiality and data security.
all constituencies, including the public, with
appropriate disaggregation dimensions to The potential for data sharing is greatly enhanced
address inequality among subpopulations. by the establishment of a data warehouse or
Although data access and sharing has improved national health observatory (NHO). The health
overall, data are not yet accessible to all who observatory concept of gathering, analysing,
need it, and not yet shared extensively. synthesizing and sharing timely and reliable
information on population health and health
Once data have been collected and analysed services has become increasingly popular since
according to the highest standards, the methods the 1970s.
for data collection and compilation — and the
data themselves — should be made available to The main objectives of NHOs are to improve and
all potential users. This encourages openness encourage the utility of health data, including
and transparency, an essential element of health status, health trends and their social
accountability and good governance. determinants, to inform policy, national health
strategies and planning.
The most commonly shared data are aggregated
data. However, there is also great value in sharing
individual records or microdata with bona fide OVER
40%
users such as researchers, as long as there
are solid mechanisms to ensure data privacy,
confidentiality and security. Data sharing has
numerous advantages; it permits analysts and of countries have well-
researchers to conduct in-depth analyses, study developed or higher capacity
historical trends, and draw out correlations and for data access and sharing.
relationships that enhance the policy value of
the information collected. A supportive legal and
64
A country’s capacity of enabling data access sharing (Figure E2.1), and 24% of countries have
and sharing is approximated by examining the only nascent capacity. Wealth appears to play an
publication of health statistics using a set of important role in a country’ ability to make data
standards, including the availability and contents available. Nearly 60% of low-income countries
of the NHO. Just over 40% of countries have well- have limited or less capacity compared to 22% of
developed or higher capacity for data access and high-income countries.
FIGURE E2.1
PERCENTAGE OF COUNTRIES (N=133) WITH CAPACITY FOR DATA ACCESS
AND SHARING, BY COUNTRY INCOME GROUP
Global (n=133) 24% 18% 16% 24% 18%
High income
13% 9% 16% 19% 44%
(n=32)
Upper-middle income
29% 12% 9% 29% 21%
(n=34)
Lower-middle income
20% 29% 20% 29%
(n=41) 2%
Low income
38% 19% 19% 15% 8%
(n=26)
0% 20% 40% 60% 80% 100%
Figure E2.2 shows the availability of NHOs and statistics, while the coverage declined for each
their quality attributes by country income. More subsequent country income group. A similar
than 60% of countries were found to have an disparity was seen in the NHO’s user friendliness.
NHO or tools that function like NHOs. More NHOs were found to be easy to navigate in 59%
than 75% of high-income countries have NHOs of high-income countries, but only in 21-31% of
compared to only 59% of lower-middle-income, countries in lower-income groups.
62% of upper-middle-income and 50% of
low-income countries. High-income countries are
25%
also better at regularly updating their NHOs; 41%
of them update more than once a year, while only
20% of lower-middle-income countries, and 23%
of low-income countries could say the same.
of countries update their
global health portal more
Figure E2.2 shows that the content of the NHOs
than once a year.
is also influenced by a countries’ wealth; 50% of
high-income countries had full coverage of health
65
FIGURE E2.2
PERCENTAGE OF COUNTRIES (N=133) WITH HEALTH PORTAL THAT MEET
RECOMMENDED STANDARDS, BY COUNTRY INCOME GROUP
62%
Existence of 78%
62%
health portal 59%
50%
34%
Health portal easy 59%
21%
to navigate 27%
31%
Health portal has full 26%

50%
coverage of health 24%
statistics 17%
15%
Health portal 25%

41%
updated more than 18%
once per year 20%
23%
0% 20% 40% 60% 80% 100%
Another aspect of data access and sharing is the Most countries (84%) reported to have produced
regular production of statistics on the operations at least one national statistical report in the
of the health system. Figure E2.3 shows the past 10 years. Annual publication of statistical
publication frequency of statistical reports and reports was found in 57% of the countries (66%
quality indicator–the inclusion of appropriate of high-income, 42% of low-income countries).
disaggregation, by income. More frequent The inclusion of appropriate disaggregation in
production of the statistical report means the statistical reports was found in 63% of high-
information is more relevant (describing current income countries, but only in 46-50% of countries
health status and health system functioning). in other income groups.
Data disaggregation permits the assessment
of inequity of population health and health
care, particularly with regard to vulnerable
sub-populations.
66
FIGURE E2.3
PERCENTAGE OF COUNTRIES (N=133) WITH HEALTH STATISTICS REPORTS
THAT MEET RECOMMENDED STANDARDS, BY COUNTRY INCOME GROUP
84%
Health statistics
84%
report published in 76%
last ten years 88%
88%
57%
Statistical report 66%
published annually 47%
68%
42%
51%
Statistical
63%
report includes 47%
disaggregation 46%
50%
0% 20% 40% 60% 80% 100%
About one-third of the countries offer bona fide data policy in government for health data. In
users access to health management information comparison, the percentage of countries in other
system (HMIS) data, and almost 40% offer access income groups that provide access to survey data
to health survey data (Figure E2.4) while almost half ranges from 31% to 37% as opposed to 8%-38% for
have an open data policy in government. Among HMIS. The availability of an open data policy ranges
high-income countries, 53% provide access for from 56% in upper-middle-income countries to
both HMIS and survey data; 78% have an open 23% for low-income countries.
FIGURE E2.4
PERCENTAGE OF COUNTRIES (N=133) WITH HEALTH DATA ACCESS
POLICIES THAT MEET RECOMMENDED STANDARDS, BY COUNTRY
INCOME GROUP
49%
Open data policy in 78%
government exists 56%
37%
23%
39%
Broad access to 53%
35%
health survey data 37%
31%
33%
53%
Broad access to HMIS* 38%
29%
8%
0% 20% 40% 60% 80% 100%
*HMIS: Health management information system.
67
E3. Strong country-led

governance of data
Countries need to A strong M&E plan is comprehensive, addressing

the goals and objectives of the NHSP and
improve the supporting the selection of a balanced set of
mechanisms for health core indicators with well-defined baselines and
targets based on accepted standards. The plan
data governance also details ways to address data gaps and
weaknesses in the various data systems, specifies
Successful implementation of the SCORE
analytical outputs, defines communication and
interventions and progress towards a well-
dissemination mechanisms and outlines plans for
functioning country health information system
institutional capacity building. In many countries,
requires a sound policy and institutional
the M&E plan is accompanied by a comprehensive
environment. This includes robust governance
national HIS strategy and implementation plan that
policies and legal frameworks for data as well as
provides additional details for strengthening the
multi-stakeholder coordination mechanism.
country HIS. The M&E plan and its relationship to
A clear legal framework and associated regulations the NHSP provide the basis for multi-year costing
should underpin policy and planning for health and investment in the HIS by both government
information systems. Data policies should and partners.
be based on the principles of accountability,
transparency and participation of multiple
stakeholders at different levels, promoting the
open use of data at all levels. Furthermore, policies Take advantage of
must make explicit provision to assure ethical digitalization
data use, and protection of individual privacy
and confidentiality. Countries should also have Digitalization of health data has become an
effective governance structures for country-led integral component of country HIS. The use of
coordination mechanisms (including defined roles digital health data should be strategic, support
and responsibilities of different stakeholders) for national health goals and be closely linked to the
monitoring, evaluation and review for the entire national M&E and HIS plans. A national strategy
HIS policy framework, including those concerning for digital health data may be embedded within
monitoring of the many health-related SDGs. the HIS strategy. Within the context of the NHSP,
information and communication technologies
A key focus is investment in a country-led HIS (ICT) require effective governance, investment
system that meets all country data needs and in infrastructure and adoption of standards for
enables monitoring of progress towards UHC, information systems at all levels. Furthermore,
and the HRSDGs, with high-level commitment and national information policies and regulations
aligned investments by countries and partners. should ensure security of digital data and
This requires one strong country-led M&E, as consistent management of data protection,
an integral component of NHSP and related privacy, confidentiality and consent.
sub-sectoral plans.
68
FIGURE E3.1
PERCENTAGE OF COUNTRIES (N=133) WITH COUNTRY-LED GOVERNANCE
OF DATA, BY KEY INDICATORS
E3.1 National monitoring and

evaluation (M&E) plan
M&E plan available 74%
Includes core indicator list 41%
Specifies use of data for

29%
policy and planning
Specifies dissemination of data 26%
Includes specification
25%
on data collection
Specifies resource requirements 23%
Includes analysis and review 23%

process specifications
Includes data quality 20%
assurance mechanisms
M&E plan meets at least 21%
85% of the standards
0% 20% 40% 60% 80% 100%
E3.2 National digital/

eHealth strategy
Digital/eHealth strategy available 62%
Includes discussion
29%
of health data architecture
Specifies alignment
29%
with national HIS strategy
Includes handling
26%
of data security issues
Includes specifications for
26%
confidentiality and storage
Includes description of
25%
health data standards
Specifies access to data 25%
Digital/eHealth strategy meets at 21%

least 85% of the standards
0% 20% 40% 60% 80% 100%
69
Figure E3.1 displays the quality of tracer items eHealth is dependent upon information and
for country M&E plans. Of the 133 countries computer technology. As such investments can
included in this assessment, 74% reported the be costly, the capacity and quality of eHealth
existence of a national M&E plan. Core indicators strategies often rely on countries’ financial ability.
with baselines and targets were present most Figure E3.2 shows the countries’ capacity to
frequently (41%), while data quality assurance develop sound national eHealth strategies by
mechanisms were only referenced in the M&E country income groups. While almost 50% of
plans of 20% of countries. Only 21% of countries high-income countries have sustainable capacity
have M&E plans that meet 85% or more of to have eHealth strategies that meet standards,
recommended standards. only 7-19% of countries in other income groups
have such capacity. It is worth noting that the
Another indicator of good data governance is the
quality of eHealth strategies in low-income
quality of the national digital or eHealth strategy.
countries (19%) is better than lower-middle and
Whereas 62% of countries have a current eHealth
upper-middle-income countries (7% and 15%
strategy, less than 30% have tracer items which
respectively). Technical assistance support, as
can measure the quality and content of these
well as emphasis on availability of key strategies
strategies. The tracer items included data
for required investments by donors, could
standards, access to data, data security, and
potentially explain this phenomenon.
alignment with HIS.
FIGURE E3.2
PERCENTAGE OF COUNTRIES (N=133) THAT HAVE NATIONAL DIGITAL/
eHEALTH STRATEGY BASED ON RECOMMENDED STANDARDS, BY
COUNTRY INCOME GROUP
Global 38% 8% 22% 11% 21%
High income
16% 6% 13% 19% 47%
(n=32)
Upper-middle income
41% 9% 29% 6% 15%
(n=34)
Lower-middle income
54% 10% 20% 10% 7%
(n=41)
Low income
38% 8% 27% 8% 19%
(n=26)
0% 20% 40% 60% 80% 100%
70

implications
• Clearly work remains to be done to achieve do not top to the list of countries with high
sustainable capacity for creating an enabling disease burden and large populations)
environment for data use, particularly in
lower income categories. Nearly half of • For some countries, impediments to data
all countries in the three lower-income access are less structural, or technical, and
categories have “limited” capacity or worse more political. Low confidence in data quality
for enabling data use can inhibit the wider availability of health data.
However, greater access can produce the
• Even when basic elements, such as health pressure, often lacking on health information
sector strategic plans, monitoring and personnel, to make the necessary efforts to
evaluation plans, eHealth strategies, national improve data quality
health observatories, and national statistical
reports are in place, the optimal use of data • The translation from health data to policy
may not be achieved due to lack of quality, change is not guaranteed, even when a
missing key components, and data not being strategy is in place and a mechanism set up
generated nor updated often enough for coordinating and monitoring the process.
Well trained personnel, adequately resourced
• Many countries have taken the initial steps dedicated discreet units, will go some way to
towards establishing a national health ensure that informed decisions are taken to
observatory to provide greater access to better align the health system to meet the
health data and information, and greater needs of the population
transparency and accountability for health
system performance. However, such solutions
can be costly and require external technical
assistance. Donors and international technical
partners are working with countries to
identify and fill needs, but more can be done
to ensure that countries are not left behind
(particularly lower-income countries that
71
Data availability
and global health priorities
How does the strength of issue is that while estimates for indicators may
be available, they are not always derived from
HIS affect global health recent primary data. World Health Statistics 20191
monitoring, including reported that for about one-third of countries,
over half of the indicators had no recent primary
UHC and SDGs? or underlying data2.
Tracking progress towards UHC Figure D.1 shows that the calculation for UHC
and SDG targets is hampered by index (SDG 3.8.1) face major limitations linked to
poor, out-dated data the availability of key indicators. Many countries
do not even have one data point for some tracer
Accurate and timely data are essential for tracking indicators between 2013 and 2018. For the
progress towards achieving the HRSDGs, UHC, and reproductive maternal neonatal child health
national and subnational priorities. This requires (RMNCH) indicators, except for Diphtheria-
comprehensive national health information tetanus-pertussis immunization coverage, the data
systems based on data from CRVS systems, availability was between 58% and 77% for other
nationally representative household surveys, indicators. The availability for non-communicable
administrative data and surveillance systems, disease indicators was particularly low, ranging
and routine health-facility reporting systems. from 50% to 86%. Data on health services are
Methods for measuring many HRSDGs depend on also not as readily available with less than 75%
the availability of accurate cause-of-death data, of countries having at least one data point for
household surveys, and disease registries. hospital beds per 10,000 population and density
of surgeons per 100,000 population
Many of the HRSDGs also require data from
sources beyond the health sector. However, Data availability for other SDG indicators shows
health data are often incomplete, fragmented similar trend with low availability for NCD
or of poor quality. As this report shows, many indicators and indicators measuring mortality
countries lack good data for critical areas such as rates (Figure D.2). These results are demonstrated
access to health services, health workforce and by poor CRVS capacity in low- and middle-
health financing. This affects low- and middle- income countries as well as low capacity in facility
income countries disproportionately. A key reporting systems (see previous chapters).
1
World health statistics 2019: monitoring health for the SDGs, sustainable development goals. Geneva: World Health Organization; 2019.
Licence: CC BY-NC-SA 3.0 IGO.
2
GPW 13 methods for impact measurement 2020. Geneva: World Health Organization; 2020.
72
DATA AVAILABILITY AND GLOBAL HEALTH PRIORITIES
FIGURE D.1
PERCENTAGE OF COUNTRIES (N=133) WITH AT LEAST ONE DATA POINT
SINCE 2013, BY UHC COVERAGE INDEX TRACER VARIABLE
Reproductive Maternal Neonatal Child Health

Diphtheria-tetanus-pertussis (DTP3)
100%
immunization coverage among 1-year-olds
100%
Proportion of married or in-union women of
reproductive age who have their need for family 77% 100%
planning satisfied with modern methods
77%
100%
Antenatal care, four or more visits (ANC4) 73%
77%
73%
77%
Care-seeking behaviour for child pneumonia 58% 73%
0% 20% 40% 58% 60% 80% 100%
73%
0% 20% 40% 58%60% 80% 100%
Non-Communicable Diseases
86%
0% 20% 40% 58%60% 80% 100%
Age-standardized prevalence of tobacco
86%
smoking among persons 15 years and older 0% 20% 40% 60% 80% 100%
67% 86%
Prevalence of normal blood pressure,
67%
regardless of treatment status 86%
59% 67%
Cervical cancer screening among
59%
women aged 30-49 years 67%
50% 59%
Mean fasting plasma glucose (mmol/L) 0% 20% 50%

40% 59%60% 80% 100%
0% 20% 40%
50% 60% 80% 100%
100%
0% 20% 50%
40% 60% 80% 100%
Infectious Diseases
100%
0% 20% 40% 60% 80% 100%
Tuberculosis effective treatment coverage 92%100%
92%
100%
Antiretroviral therapy (ART) coverage 90%
92%
90%
92%
Households with at least access to basic sanitation 84%90%
0% 20% 40% 60% 84%

80% 100%
90%
Population at risk sleeping under insecticide- 0% 20% 40% 60% 80% 100%
84%
treated nets for malaria prevention
100%
0% 20% 40% 60% 84%
80% 100%
100%
Health System and Financing 0% 20% 40% 60% 80% 100%
95%
100%
Average of 13 International Health 95%
100%
Regulations (IHR) core capacity scores
83% 95%
83%
Density of physicians (per 1000 population) 95%
74% 83%
74%
Density of psychiatrists (per 100,000 population) 83%
71%
74%
Density of surgeons (per 100,000 population) 0% 20% 40% 60%71%

74% 80% 100%
0% 20% 40% 60%71% 80% 100%
Hospital beds per 10,000 population 0% 20% 40% 60%71% 80% 100%
0% 20% 40% 60% 80% 100%
73
FIGURE D.2
PERCENTAGE OF COUNTRIES (N=133) WITH AT LEAST ONE DATA POINT
SINCE 2013, BY SELECTED HEALTH-RELATED SDG INDICATORS
2.2.2 Prevalence of overweight children under 5 71%
2.2.2 Prevalence of wasting in children under 5 69%
2.2.1 Prevalence of stunting in children under 5 69%
11.6.2 Annual mean concentrations of fine

100%
particulate matter (PM2.5) in urban areas (µg/m3)
13.1.1 Average death rate due

91%
to natural disasters (per 100 000 population)
7.1.2 Proportion of population with

77%
primary reliance on clean fuels
6.2.1 Proportion of population using

74%
safely managed sanitation services
6.1.1 Proportion of population using

73%
safely managed drinking-water services
16.1.1 Mortality rate due to homicide

57%
(per 100 000 population)
16.1.2 Estimated direct deaths from major conflicts

36%
(per 100 000 population)
17.19.2 Completeness of cause-of-death data 61%

0% 20% 40% 60% 80% 100%
Even when data are available, they may lack

disaggregation or sufficient quality to be useful
Even countries that have UHC or other SDG indicators available at the national
level do not have necessary disaggregation to measure inequalities. The data
availability reported here reflect the bare minimum of a single national data
point over five years. Though not analysed here, one can assume that the
disaggregated data needed to monitor health inequality is scarcer and may
not be collected at subnational or another needed level. Furthermore, the data
quality is often not measured, and may not be of sufficient quality to be useful
in the calculation of global estimates, suggesting that these estimates still
involve significant approximation or modelling.
74
Conclusion
Leave no one behind MICS and others, have underpinned these efforts.
While these surveys have been critical in solving
A robust national health information system that country data needs, there is a need to examine
incorporates inequality monitoring is vital to track how countries can achieve sustainable capacity,
the sustainable development agenda’s central which includes both technical and financial
promise of leaving no one behind. But more independence, over time. For example, results in
importantly, strong national health information upper-middle-income countries showed that they
systems are critical for monitoring national health conducted the lowest average number of annual
priorities as well as for ensuring quality health surveys based on international standards.
services are available to all populations.
Higher income countries performed consistently
The SCORE for Health Data Technical Package better across all the five SCORE interventions,
identifies key interventions that are critical to which was expected. However, the results among
attain robust health information systems capable the other country income groups – upper-middle,
of providing information to all the relevant lower-middle and low-income – did not always
stakeholders. In addition to specifying key data follow the expected trajectory where countries in
sources that need to be strengthened, it also upper-middle-income would perform better than
emphasizes the need to enhance capacity for countries in lower-middle-income group, which
analysis and use of data, as well as having strong in turn would perform better than countries in
governance structures that support and promote the low-income group. This divide between high-
the collection and use of data. income countries and others, demonstrates the
importance of national wealth but also shows the
The SCORE assessment provides a rich overview need to focus on other context-specific levers that
of the health information systems landscape drive improvement in health information systems.
globally. Data from 133 Member States were
analysed for this report and the results show In all interventions, except for “C – Counting
key areas that have benefited from efforts made births, deaths and causes of death, there were
over time, and also show critical areas in need of low- income countries that attained sustainable
strengthening that require focused national and capacity. This situation indicates that sustainable
international efforts. health information systems can be achieved at
all income levels. Counting births and deaths
and causes of death was the single intervention
where a large majority of low-income countries
Forge sustainable were not able to demonstrate the existence of a
health data systems viable system. It is critical to know what people
for all countries are dying from. The current COVID-19 pandemic
has brought this situation into dramatic focus,
Countries at all income levels are conducting where countries face serious challenges in both
national population-based health surveys. While measuring the full burden of, as well as counting
some health topics, that require a survey as the the deaths due to the pandemic.
primary means of data collection, are still being
Measurement and analysis of inequality was
missed, countries are conducting standards-
assessed in the S, O and R interventions. The
based surveys world-wide. Large international
ability to know the distribution and burden
health survey programmes, such as the DHS,
of diseases across key population-groups
75
is necessary to achieve UHC, and for the frameworks, strategies that include specification
SDGs. Availability of disaggregated data as of health data architecture, data standards,
well as analysis of inequality in available data, data security, protection of data confidentiality,
continues to present challenges to countries. monitoring and evaluation functions, and
Moving forward, countries need to ensure institutional mechanisms for data use. Because
disaggregation is included in different data of the all-encompassing nature of health data
collections methods. governance, it is one challenging area to improve,
but also one critical area that has to be tackled
as the lack of it hampers all other areas of health
Ensure equitable information system.
investment across health

data systems SCORE – building
Focused attention on key programme areas foundations for the
such as immunization, HIV, TB, and malaria future
in the last two decades have improved data
availability in these areas but other priority areas This SCORE report highlights the status of
have struggled to attain similar gains. It will be country health information systems and lays
important, going forward, to maintain the gains building blocks for strengthening those systems
made in these programme areas but also to and enhancing country capacity to collect,
advance data availability and data use in other manage, and use data effectively. Countries,
health programmes by focusing on cross-cutting partners, and stakeholders must take up the
efforts that strengthen the overall health system. challenge – and build upon this foundation, to
create strong health information systems and
Data is only as good as its use. There will need meet the ever-evolving demand for quality data,
to be innovative efforts to increase institutional to inform policy and action that will lead to
capacity for analysis and use of data. In-country improved health for all.
public health and research institutions are key
in providing independent analysis and review of
country progress and performance. Strengthening
the capacities of national and regional institutions
will be critical to develop this SCORE pillar.
Strengthen good
data governance and
ownership
Governance of health data has traditionally
languished when special interest data collection
was pursued by different stakeholders. However,
given the drive to develop sustainable health
information systems, where countries will be
the drivers and managers of their own systems,
health data governance has taken a prominent
role. Governance of health data includes, but is not
limited to, access and sharing of health data, legal
76
CONCLUSION
77
Annexes
Annex 1.
SCORE Interventions, elements and indicators
Annex 2.
SCORE Assessment maturity models for
indicators included in scoring
78
Annex 1. SCORE Interventions,
elements and indicators
Key elements Indicators Key attributes
S1. S1.1. A system of regular • At least one survey conducted in the last five years that:
System of regular and comprehensive • Cover major health priorities
population-based population health surveys • Cover major dimensions of inequity
health surveys that meets international • Are aligned with international standards
standards • Are funded by government
S2. S2.1. Completeness and • Percentage of reporting sites that submitted

Surveillance of timeliness of weekly weekly report in last month: public sites
public health reporting of notifiable • Percentage of reporting sites that submitted
threats conditions (%)* weekly in last month: non-public sites
S2.2. Indicator and • If country has done SPAR, based on SPAR:

event-based surveillance • National IHR Focal Point functions under IHR
system(s) in place based • Early warning function: indicator-and event-based
on International Health surveillance mechanism for event management
Regulations standards (verification, risk assessment, analysis investigation).
• If country has not done a SPAR but done JEE,

based on JEE:
• Indicator- and event-based surveillance system
• Inter-operable, inter-connected, electronic real-time
reporting system
• Integration and analysis of surveillance data
• Syndromic surveillance systems
• System for efficient reporting
• Reporting network and protocols in country
• If country has not done SPAR or JEE, based on IHR:

• Self-assessment score for surveillance
• Self-assessment score for IHR coordination
S3. S3.1. Census conducted • Census conducted within last 10 years

Regular in last 10 years in line • Post enumeration survey conducted
population census with international • Population projections with all disaggregation
standards with
population projections for
subnational units
*The indicator or attribute is not included in the calculation of overall element score.
79
C1. C1.1. Completeness of • Completeness of birth registration (%)

Full birth and birth registration (%)
death registration
C1.2. Completeness of • Completeness of death registration (%)
death registration (%)
C1.3. Core attributes • Legal framework for CRVS

of a functional CRVS in • Easy access to registration offices
place to generate vital • Adequate training for registrars
statistics* • Formal CRVS Interagency collaboration
• All data are exchanged electronically
• Data quality assessment, adjustment, and analysis
using international standards
• System performance monitoring
• Vital statistics report published in last five years
C2. C2.1. Completeness • Completeness of deaths with cause

Certification of deaths with cause of death reported
and reporting of of death reported to
causes of death national authorities
and/or international
institutions (%)
C2.2. Quality of cause- • Quality of cause-of-death data, measured as

of-death data (% of cause percentage of records with ill-defined or unknown
of death with ill-defined causes of mortality
or unknown causes of
mortality)
C2.3. Core attributes of • Legislation for MCCD is line with international

a functional system to standards
generate causeof-death • ICD compliant MCCD are used
statistics* • Medical students trained in correct death
certification practices
• Statistical clerks trained in mortality coding
• Verbal autopsy (if applicable) is applied
• Data quality assurance and dissemination
• Cause of death statistics available
80
SCORE INTERVENTION, ELEMENTS, AND INDICATORS
O1. O1.1. Availability of • Annual statistics available for 11 key facility-based

Routine facility annual statistics for indicators, including key disaggregation
reporting system selected indicators • Data quality for primary care facilities
with patient derived from facility data • Data quality for hospitals
monitoring • Completeness of reporting by public, primary care facilities
• Completeness of reporting by public hospitals
• Completeness of reporting by private health facilities
O1.2. Functional facility/ • National unique patient identifier system

patient reporting • Cancer registries for all types of cancer
system in place based • Master facility list is up-to-date
on key criteria* • Institutional system of data quality assurance
• Standards of practice for health management information
systems describe all parts of process, are fully
implemented and revised periodically
• System of electronic data entry: aggregate at district level
• System of electronic capture - patient level primary
care facilities
• System of electronic capture - patient level in hospitals
• Standards based data exchange between systems
O2. O2.1. Well established • Regular independent assessments of the quality

Regular system to system to independently of care in hospitals and health facilities
monitor service monitor health services • System of accreditation of health facilities based on data
availability, • System of adverse event reporting following medical
quality and interventions*
effectiveness
O3. O3.1. Availability of • Data available within last five years on:
Health service latest data on national • Public health expenditure
resources: health health expenditure • Private health expenditure
financing and • Catastrophic spending
health workforce
O3.2. Availability of data • Information, including availability at subnational level and
on health workforce major levels of disaggregation for:
density and distribution • Medical doctors
updated annually • Nurses
• Midwives
• Dentists
• Pharmacists
O3.3. National human • Human resource for health information systems tracks
resources health • Number of entrants to the labour market
information system is in • Number of active stock on the labour market
place and functional* • Number of exits from the labour market
• Demographic distribution of health workers
• Subnational level data of active health workers
• Number of graduates from education and training
institutions
• Information on foreign-born and/ or foreign-trained
health workers
81
R1. R1.1. High quality • Analytic report published within last five years:
Regular analytical analytical reports • Uses all available data sources
reviews of on progress and • Assesses progress against targets
progress and performance of health • Pays attention to measures of inequity
performance, sector strategy/plan are • Links performance to health inputs
with equity produced annually • Provides comparative analysis
• Includes Subnational rankings
• Evaluates performance of hospitals and large facilities
• Summarizes main findings for use for policy
and planning
R2. R2.1. Institutional • Involvement of public health institutes/schools

Institutional capacity in data of public health
capacity for analysis at national and • Subnational capacity in ministry of health or institutions
analysis and subnational level to conduct health analysis*
learning • Capacity at national ministry of health to conduct
health analysis
• Capacity at NBS to: draw sample, implement
surveys and conduct analysis
82
SCORE INTERVENTION, ELEMENTS, AND INDICATORS
E1. E1.1. National health plan • National health plan/policies include review
Data and evidence and policies are based on of past performance (trends)
drive policy and data and evidence • National health plan/policies include burden
planning of disease analysis
• National health plan/policies include health system
strength analysis (response strength)
• Presence of a central unit or function in ministry of
health for data and evidence to policy translation
• Level of output of a central unit or function in ministry
of health for data and evidence to policy translation
• Coordination function between ministry of health
and partners
E2. E2.1. Health statistics are • Frequency of updating national database

Data access and publicly available • Contents of national database
sharing • Navigation ease of national database
• Statistical report publication frequency
• Statistical report includes disaggregation
• Bona fide users have Access to HMIS data
• Bona fide users have access to health survey data
• Open data policy
E3. E3.1. National monitoring • National M&E plan that:

Strong country-led and evaluation (M&E) is • Includes core indicator list with baselines and targets
governance based on standards • Includes specification on data collection methods and
of data digital architecture
• Includes data quality assurance mechanisms
• Includes analysis and review process specifications
• Specifies use of data for policy and planning
• Specifies dissemination of data
• Specifies resource requirements to implement
the strategic plan/policy
E3.2. National digital • National digital health/eHealth strategy that:

health/eHealth strategy is • Includes discussion of health data architecture
based on standards • Includes description of health data standards
and exchange
• Includes handling of data security issues
• Includes specifications for data confidentiality
and data storage
• Specifies access to data
• Specifies alignment/is integrated with national
HIS strategy
E3.3. Foundational • Legal framework or policies exist for health

elements to promote information systems
data use and access are • Legal framework or policies are enforced
present*
83
Annex 2. SCORE Assessment
maturity models for indicators
included in scoring
Nascent Limited Moderate Well- Sustainable

capacity capacity capacity developed capacity
capacity
1 2 3 4 5
S1. Overall score is Overall score is Overall score is Overall score is Overall score is
System <0.25 0.25-0.49 0.50–0.70 0.71-0.89 ≥0.90
of regular
population-
based health
surveys
S2. Average % Average % Average % Average % Average %

Surveillance of implementation implementation implementation implementation implementation
public health of surveillance of surveillance of surveillance of IHR of surveillance
threats indicators indicators indicators surveillance indicators
≤20% 21%-40% 41%-60% indicators 81%-100%
61%-80%
S3. 25% of criteria 26-49% of 50-70% of 71-90% of Greater than

Regular are met or less criteria are met criteria are met criteria are met 90% of criteria
population are met
census
C1.1. There is no <50% 50-74% 75-89% ≥90%

Full birth data on birth
registration completeness
- birth
C1.2. There is no <50% 50-74% 75-89% ≥90%

Full birth data on death
registration completeness
- death
C2.1. There is no Score <30% Score 30-69% Score 70-89% Score ≥90%
Certification standardised
and reporting system
of causes for medical
of death certification of
- reporting cause of death
C2.2. Not At least 30% 20-29% 10-19% Less than 10%

Certification applicable ill-defined or ill-defined or ill-defined or ill-defined or
and reporting in the absence unspecified unspecified unspecified unspecified
of causes of of data causes causes causes
death - quality
84
SCORE ASSESSMENT MATURITY MODELS FOR INDICATORS INCLUDED IN SCORING

capacity capacity capacity developed capacity
capacity
1 2 3 4 5
O1. Meets <25 % Meets 25-49% Meets 50-70% Meets 71-89% Meets ≥90%
Routine facility of criteria for of criteria for of criteria for of criteria for of criteria for
reporting availability availability availability availability availability
system with
patient
monitoring
O2. Survey-based Survey-based Survey-based Survey-based Survey-based

Regular system system for system for system for system for system for
to monitor monitoring monitoring of monitoring of monitoring of monitoring of
service of the quality the quality of the quality of the quality of the quality of
availability, of services services = 2 or services = 3 services = 4 services = 5 or
quality and = 1 and accreditation accreditation
effectiveness accreditation system = 2 system = 3
system = 1
O3.1. Key health Total weighted Total weighted Total weighted Total score of
Health service expenditure score of key score of key score of key key indicator
resources indicators are indicator items indicator items indicator items items is 3
- health not produced is less than 1 is between is between
financing 1 and 2 2 and 3
O3.2. Meets <20 % Meets 20-39% Meets 40-59% Meets 60-79% Meets ≥80%
Health service of criteria for of criteria for of criteria for of criteria for of criteria for
resources availability availability availability availability availability
- health
workforce
R1. No report Total weighted Total weighted Total weighted Total score of
Regular produced in score of key score of key score of key key indicator
analytical past 5 years indicator items indicator items indicator items items is 25 or
reviews of is less than 12 is 12 to less is 20 to less higher
progress and than 20 than 25
performance,
with equity
R2. Key indicator Key indicator Key indicator Key indicator Key indicator
Institutional items meet items meet items meet items meet items meet at
capacity for 25% or less of more than 50% to less 67% to less least 85% of
analysis and standards 25% but less than 67% of than 83% of standards
learning than 50% standards standards
standards
85

Capacity capacity capacity developed capacity
capacity
1 2 3 4 5
E1. Total score of Total score of Total score of Total score of Total score of
Data and key indicator key indicator key indicator key indicator key indicator
evidence drive items is 3 or items is 4-6 items is 7-8 items is 9-11 items is 12 or
policy and less higher
planning
E2. Total score of Total score of Total score of Total score of Total score of
Data access key indicator key indicator key indicator key indicator key indicator
and sharing items is 8 or items is 9-12 items is 13-16 items is 17-20 items is 21 or
less higher
E3.1. No M&E or HIS Total score of Total score of Total score of Total score of
Strong plan exists key indicator key indicator key indicator key indicator
country-led that is linked items is 9 or items is 10-14 items is 15-17 items is 18 or
governance of to the current less higher
data – M&E national health
sector strategic
plan
E3.2. An eHealth Total score of Total score of Total score of Total score of
Strong strategy is key indicator key indicator key indicator key indicator
country-led non-existent items is 8 or items is 9-12 items is items is 16 or
governance of or is no longer less between 13-15 higher
data – eHealth current
strategy
86
SCORE ASSESSMENT MATURITY MODELS
87
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Foreword by Dr Tedros Adhanom Ghebreyesus, WHO Director-General...................................................................iv

Survey populations and health risks..................................................................... 8

Count births, deaths and causes of death.......................................................24

Optimize health service data.................................................................................... 36

Review progress and performance...................................................................... 50

Enable data use for policy and action................................................................ 58

Data availability and global health priorities..................................................................... 72

HEADQUARTERS This document was edited by Prudence Smith.

AFR WHO African Region

AMR WHO Region of the Americas

ART Antiretroviral Therapy

CRVS Civil Registration and Vital Statistics

DFI Delivery for Impact

DHS Demographic and Health Survey

EMR WHO Eastern Mediterranean Region

EUR WHO European Region

HDC Health Data Collaborative

HHFA Harmonized Health Facility Assessments

HIS Health Information System

HMIS Health Management Information System

HRHIS Human Resource Health Information System

HRSDG Health-Related Sustainable Development Goals

ICD International Classification of Diseases

IHR International Health Regulations

LSMS Living Standards Measurement Study

M&E Monitoring and Evaluation

MICS Multiple Indicator Cluster Surveys

MoH Ministry of Health

NHA National Health Accounts

NHO National Health Observatories

NHSP National Health Sector Strategic Plan

OPD Outpatient Department

PES Post Enumeration Survey

SCORE Survey, Count, Optimize, Review, Enable

SDG Sustainable Development Goal

SEAR WHO South-East Asia Region

SHA System of Health Accounts

SPAR State Party Self-Assessment Annual Reporting

UHC Universal Health Coverage

UNDESA United Nations Department of Economic and Social Affairs

UNSD United Nations Statistical Division

WHO World Health Organization

WPR WHO Western Pacific Region

To meet the increasingly complex demands on country health information

35% Moderate 47 11%

27% 22% Sustainable 7 6%

Unprecedented demand for data

Monitoring progress: Monitoring progress

• support global monitoring; Underpinning SDG 3 - ”to ensure healthy lives

Meeting the HRSDGs requires health

Emergency protection means preparedness, In addition:

WHO’s SCORE for Health

SCORE Essential SCORE Tools SCORE Assessment SCORE Assessment

Survey Count Optimize Review Enable