Moving away from tick box syndrome

Institutions and mangers need to feel good.

Great job! You organised 60 training across the world and had over 2000 participants. Doesn’t it sound a great achievement? This is a typical year-end evaluation in many institutions. These are great programmatic achievements, but no one is sure about what exactly the achievements were. However, they tick those boxes. Training team feels elated; their boss feels what a team, but no one can demonstrate what was accomplished. E.g. 100 rapid response team members were trained. Does that mean all the detected events were responded and controlled on time?

Many of us are suffering from the tick box syndrome, as many institutions evaluate employees for getting “stuff” done. At the end of each year, during an annual performance evaluation, it shows a lot of stuff had been done, and eloquently their boss says, “Good Job and I am proud of my team”. Then collectively, a new list of tick boxes is created.

Some may argue, what’s wrong on these figures. Indisputably, there is nothing wrong with those figures, and they demonstrate the excellent execution of programs or projects in terms of inputs, process and outputs. The issue is that while everyone achieves a lot of stuff, it may not be positively affecting public health. It probably isn’t making any skill improvement, changing behaviours and most importantly, positive public health changes. In summary, demonstrating achievements in terms of inputs/process and sometimes output level information of the program or project is tick box syndrome. They are suitable for program or activity monitoring but don’t demonstrate tangible accomplishments.

Moving away from Tick Box Syndrome; does this help?

Tick box syndrome doesn’t measure the results and outcome and impacts of ticking those boxes. Best practices aren’t identified so naturally; they rarely get repeated. The tick box syndrome leads to ineffective programs that appear on the surface to be contributing to the success in the public health – but don’t really impact it all.

Reporting achievements based on inputs/process/outputs are not wrong, but it is our responsibility to report their outcomes and impact so that we all are aware of what we have achieved or achieving. With these program indicators, we can convince our bosses or some donors. Still, we need to demonstrate actual results and impact making policy and behaviour changes and convincing decision-makers. When I talk about moving away from the tick box syndrome, I often hear people saying it takes time to observe the results. Agree, my request is to demonstrate the results that they are working for the last 4-5 years depending on programs. If one cannot demonstrate the outcome of their inputs/process/outputs in 4 years, it is due to either they don’t know what to measure or pour water in the sand (tick box syndrome). E.g. a maternal and child health team should demonstrate its achievement of an increase of four antenatal care (ANC) visits with the reduction of burden due to maternal health. Merely using the logic model, anyone can demonstrate. An increased number of ANC visits is supposed to improve maternal health (reducing morbidity and mortality).

It is not only one factor or intervention that leads to the outcome, and there are many, and we can list them. For instance, vaccination and risk communication with health services provision lead to a decrease of vaccine-preventable disease (VPD) cases, and vaccination is one of the keys for this decrease.

Few examples of Tick Box Syndrome in public health

Tick box syndrome Moving away from the tick-box syndrome
60% of children with suspected pneumonia are taken to an appropriate health provider (good program indicator) 1. Demonstrate that this has led to the reduction of morbidity and mortality due to pneumonia

2, Demonstrate the proportion of suspected cases were actual pneumonia
77% of women of reproductive age who married have their need for family planning met (good program output level indicator) 1. Demonstrate the results of this (e.g. reduction of growth rate, increase on birth spacing, reduction of maternal mortality ratio (MMR), under-five-mortality, reduction in disability-adjusted life years lost (DALY) due to maternal condition etc.

2. Show a few examples like what happened to MMR, under-five mortality, reduction in DALYs etc. when it is not met.
200 mid-level health workers trained on the rapid response (good program indicator) 1. Demonstrate how many trained are part of the rapid response team (not all will be part of the team)

2. Demonstrate how many events detected were responded on time (24-48 hours)
A country has 80% surveillance capacity (what does this mean?) 1. Demonstrate the number of events detected and verified

2. Demonstrate how many signals received from early warning systems
Number of countries submitted their annual reports (tick boxes) 1. Demonstrate how this information is translated for the decision makings (plan updated, the policy changed, prioritization done, etc.)

Some example to demonstrate outcomes and impact:

Take a figure below (the data is used for one syndrome (but based on the real data) and look at reducing deaths. This reflects the outcome and impact of disease control initiative(s).


  1. Increased incidence – due to early case detection (in the past, cases were reported only when they developed complications). The case fatality rate was high too. (Impact)
  2. The decrease in mortality – due to improvement of early detection, sensitive case definitions and adequate case management, the mortality reduced, and case fatality rate decreased. (OUTCOME and IMPACT)
  3. If this is a diarrheal disease syndrome, this reflects the lack of adequate sanitation and safe drinking water and personal hygiene as the number of cases is increasing. (OUTCOME)

Simple example – Cooking

We can demonstrate the outcome and impact of cooking (or food preparation).  Check the matrix below.

Leading junk food chains meet their business outcomes (profits, employment, revenue for the government, etc.). Still, at the same time, their business has adverse outcomes and impact on public health. It is the responsibility of relevant authorities to demonstrate these outcomes and make policy decisions. With this information, we can tax these outlets (like a carbon tax), which can be used for public health and take a policy decision to control the impact of junk food.