LAUSR

instrument for health systems has two primary purposes: improve performance and encourage accountability, besides allowing judicious health system decision making.3 While choosing a measure that eventually contributes to a composite index, a few crucial elements that need consideration are defining priority areas, avoiding positively correlated measures (as it may lead to “double counting),”3 and data that are robust and part of a routine process. Health outcome measures such as under-five mortality rate or suicide rate are dependent not only on the health service system but also on an extraneous complex of social, cultural, environmental, and political factors. For example, the suicide rate is also determined by employment and livelihood issues, religious beliefs, gender, socioeconomic status, rural– urban differences, etc.4 However, health systems, too, are part of the latter complex. In contrast, inputs and process indicators are contingent on the functioning of the health service systema and are sensitive to change.