This guide explains how to create effective SMART actions during the scorecard process. Using the SMART action framework helps you generate actions that will:

• directly address the root causes of the issue
• ensure the intervention is well coordinated
• help improve the performance of the scorecard indicators

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Introduction to the SMART framework

Using actions during the scorecard process

Scorecards are management tools. The main objective of scorecards is to use data to inform decision making and improve health outcomes.

There are 4 main stages in the scorecard process. This process happens on a regular basis (such as once every quarter). The 4 stages are:

1. Populate the scorecard tool with data from existing sources
2. Review and plan solutions to problems within existing management processes
3. Carry out the actions
4. Monitor progress on the actions

In stage 2, after a scorecard is reviewed, you might identify underperforming indicators that you want to improve. In this stage, you will need to identify actions to deal with the underperforming indicator. You can use the SMART framework to make sure your actions are easy to track and that you are implementing the right interventions to improve indicator performance.

SMART framework

The SMART acronym stands for:

• Specific
• Measurable
• Achievable
• Results-oriented
• Time-bound

Specific

Actions must include all the information required for the action owner to coordinate the action. You should be clear and specific about what is expected, when and at what level.

Measurable

Actions should quantify the target to define success. They should include numbers to clearly indicate how much will be achieved. For example, depending on the action, it could include:

• number of commodities to be ordered
• number of staff to be trained
• number of people to be sensitised in community education sessions

Achievable

Actions should be realistic and achievable by the identified action owner. The owner needs to have the ability to implement the action. If it’s a collaboration with a partner organisation, you should think about how the action will be coordinated and completed.

Results-oriented

Actions should address the root causes of the problems. This will increase the likelihood of the action improving an indicator’s performance. You should think about:

• the expected outcome of the action
• whether the action will improve the indicator’s performance in subsequent quarters on the scorecard
• what data you currently have available and whether it can help you clearly track results of the action

Time-bound

Actions should have a specific and clear deadline that tells the action owner when it should be completed. If there are several stages required for the action, we recommend you create a separate action and deadline for each stage.

For example, if you are organising 4 training sessions once a quarter, you could create 4 separate actions for each training session.

Example of a SMART action

In this example, we have reviewed and analysed the scorecard. Through this analysis, we have identified low performance of indicators in two regions.

Bottleneck

After consultation, we identified the bottleneck causing this low performance. The low performance was caused by a ‘stockout of artemisinin-based combination therapies (ACTs) in Districts X and Y leading to low ACT treatment rate for confirmed cases.’

SMART action example

Here is an example of a SMART action to resolve this bottleneck:

The regional medical store manager to submit an order to the Central Medical Store for 30,000 doses of ACTs and deliver 14,000 doses to District X and 16,000 to District Y by 23 November 2021

How this example is specific

This action is specific because it clearly explains:

• who is responsible for the action (regional medical store manager)
• what needs to be done (submit order to Central Medical Store of ACTs and deliver doses to District X and District Y)
• when it needs to be done by (23 November 2021)
• where it needs to be done (District X and District Y)

How this example is measurable

This action is measurable because it clearly describes the number of doses to be:

• ordered by the Central Medical Store (30,000 doses)
• sent to District X (14,000 doses)
• sent to District Y (16,000 doses)

How this example is achievable

This action is achievable by the identified owner because:

• the action owner is capable and has the authority for implementing the action (the regional medical store manager is able to and has the authority to order and coordinate the delivery of medicine)

How this example is results-oriented

The action is results-oriented because:

• ordering and distributing the artemisinin-based combination therapies ACTs will resolve the stockout issue and lead to an improved treatment rate

How the example is time-bound

The action is time-bound because it clearly explains:

• when the action needs to be completed (23 November 2021)

Characteristics of good SMART actions

Actions should be specific – who, what, where and when

All stakeholders involved must be able to read an action and understand what is being done where, who is responsible for it, and when it will be completed.

Actions should describe the ‘how’, rather than the objective

Focusing on the objective – rather than how to do it – in the action description is a common mistake, and makes it difficult for the action owner to know exactly what to do to achieve the end result.

Actions should clearly state who is responsible

We call this the action owner. Without an action owner, there’s no ownership and the action might not get completed. It’s also important that the action owner can implement the action – do they have the authority or the resources to complete the action?

Actions should be measurable so you can monitor progress

If an action is not measurable, you won’t be able to track the progress being made on the action, and you won’t know when the action has been completed and achieved.

Types of common actions used to improve health indicators

Most action items fall into one of these 9 categories:

Examples of countries using SMART actions to improve performance

Advocacy for high level policy and strategy change – Republic of Kenya

The malaria scorecard was used in Kenya to advocate for policy change. Insecticide resistance was identified as the main contributor to high malaria incidence, occasioned by delayed approval in using new insecticides.

A formal request was made to include a public health expert in the approval board to fast-track approvals for public health commodities.

In 2021, indoor residual spraying (IRS) will use a new insecticide.

Request support from partners – Republic of Zambia

In Zambia, during a district management meeting, the review of the scorecard showed that there was a drop in the proportion of pregnant women receiving long-lasting insecticidal nets (LLINs) through antenatal care (ANC).

The analysis showed that they had nets in storage at the district which had not been distributed to health facilities.

The district health officer used the scorecard to advocate for resources from local partners who then contributed to purchase fuel and hire staff for the delivery of nets to the health facilities.

Manage procurement and supply chain issues – United Republic of Tanzania

In a region of Tanzania, the scorecard review showed low performance for iron and folic acid supplementation (IFA).

The Regional Commissioner directed the regional pharmacists to have all facilities purchase IFA to deal with stock out issues, following which performance improved.

Build capacity – Republic of Kenya

In Siaya County in Kenya, the scorecard review showed skilled birth deliveries (SBA) were just over 50%.

One key action was the re-orientation of traditional birth attendants (TBAs) to become birth companions and referral agents for facility deliveries. Health workers from primary health care facilities were also provided with mentorships at the county referral hospital to learn more about how to handle pregnancy-related complications and when to refer.

Over 400 TBAs were retrained and supported more than 14,900 women to go to health facilities for skilled birth assistance.

Address funding – Republic of the Congo

In Congo, the NTD scorecard tool was used to advocate for more resources.

Using the scorecard to present gaps identified during its analysis, the NTD programme mobilised funds from the government and a new budget line for NTDs was created with a pledge of 100,000 million CFA francs (almost US$170,000) to support the four NTD programmes.

Improve quality and use of data – Republic of Kenya

In Kenya’s Siaya County, the health management information system (HMIS) reporting rates were low.

The county carried out data quality audits and trained new HMIS staff and performance improved.

Catalyse community engagement – Republic of Ghana

In Ghana, during a community scorecard discussion, it was noted that the local health facility lacked essential equipment.

Community members purchased 2 vaccine fridges. The Chief donated 2 hospital beds, bed sheets, blood pressure apparatus and other community-prioritised medical supplies.

Adopt behavioural change communications – Republic of Zambia

In Zambia, the review of the scorecard showed decreasing uptake of services during the beginning of the COVID-19 pandemic.

The Ministry of Health commissioned national television and radio advertising campaigns to sustain levels of service levels despite COVID-19.

Investigate the root cause of the problem – Republic of Mali

In Mali, a review of priority indicator performance at district level showed low uptake of postnatal care (PNC) services.

Root cause investigation was then carried out which revealed that the PNC unit was located at the back of the health facility and hard to access.

This led to the relocation of the family planning and postnatal services next to the immunisation clinic which improved uptake.