Monitoring District Health System performance in South Africa: A proposed dashboard based on key pragmatic indicators

Effective monitoring and evaluation (M&E) systems are central to ensuring the performance and accountability of the district health system (DHS). Current systems in South Africa are suboptimal and poorly oriented to the decision-making needs of district managers. Drawing on a WHO measurement framework for the performance of primary healthcare, and as a follow-up to a first article describing the challenges of M&E systems in the DHS, this article proposes a DHS performance monitoring dashboard that is both practical and pragmatic. The dashboard was constructed in an iterative and consultative process, and consists of 20 indicators for quarterly monitoring. A set of general criteria underpinning the choice of indicators is spelled out (e.g. the data are readily available and reliable). Indicators that do not have much variability, or are better suited to annual evaluation (e.g. number of community health workers per 1 000 population) are not included. The dashboard includes the name or description of the indicator, the definition of the indicator, why it is useful, challenges and pitfalls to be considered when analysing the indicator and how it can be used for decision-making. We propose that these indicators be assessed, tracked and monitored on a quarterly basis by relevant managers at the facility subdistrict and district levels. We emphasise that the purpose of this dashboard is not external compliance, but rather to support district managerial decision-making and accountability.