Using Health Facility Assessment data to Improve Health Policy and Program at the National Level American Public Health Association – APHA 135 th Annual Meeting and Expo November 3-7, 2007 Washington, DC Alfredo Fort, Nancy Fronczak, Laurie Liskin, Gulnara Semenov, Rathavuth Hong, Paul Ametepi

2 Background Similar to DHS, the SPA (Service Provision Assessment) is a nationally representative sample survey of health facilities Started in 1998 Expanded instruments & methods from earlier initiatives – e.g. Population Council’s Situation Analysis, MEASURE Evaluation’s Quick Investigation of Quality, several program & project- wide evaluations of services (MCH/FP) Uses international standards (e.g., IMCI, Safe Motherhood, WHO guidelines, RBM)

3 Components Audit-inventory of basic infrastructure, sanitation, equipment, supplies and pharmaceuticals Management & QA practices Observation of actual provider-client interactions Client Exit Interviews Health Worker Interviews

4 Methodology Sample of around Regional representation (not district) Government-Non-government Types of facilities (e.g. Hospitals, Health Centers, Dispensaries) Adaptation of questionnaire, pre-test and training of interviewers Fieldwork ~ 2 months Teams of health workers & social scientists (~4) MCH and/or HIV/AIDS modules

5 Where have SPAs been conducted? Kenya 1999; 2004 HIV/AIDS & MCH SPA Bangladesh 2000 (modified) Rwanda 2001 Ghana 2002 Uganda 2002 (modified) Egypt 2002; 2004 Guyana HIV/AIDS 2004 Zambia HIV/AIDS 2004 Ongoing: Tanzania, Rwanda & Uganda

Illustrative Results

7 Supervision and Training of Child Health Providers Management

8 Availability of Infection Control Items Egypt 2004

9 Hazardous waste disposal

10 Capacity to provide VCT

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12 Assessment of sick child Egypt SPA 2002

13 Client Exit Interviews

14 Use of SPA for Policy – making I Kenya SPA 2004 Ample national and provincial level dissemination Results used for Second National Health Sector Strategic Plan ( ) and the National AIDS Coordinating Project’s annual strategic plan Results have also served to highlight the need for closer collaboration between public and private health sectors in the country. The National Coordinating Agency for Population and Development (NCAPD), convened a meeting of 23 administrators of public and private hospitals in Nairobi to discuss SPA results and their implications; the participants acknowledged the lack of collaboration and even any contact between managers of private health care facilities and high level policy makers in the Ministry of Health. They also recognized the need to foster this collaboration to improve health care delivery. As a result of this meeting, Dr. Gakuruh, the Head of Health Sector Reform in Kenya, highlighted the lack of collaboration between the public and private sectors at a health summit convened by the Ministry of Health in June Consequently, the Assistant Minister for Health, Dr. Machege, challenged both sectors to respond to the need. She asked the private hospitals to form a professional association. This association will then represent the needs of the private sector at the Ministry of Health. This action is the first ever formal effort to coordinate the work of both sectors in Kenya.

15 Use of SPA for Policy – making II Zambia 2005 SPA USAID has allocated funds for dissemination of the Zambia HIV SPA to high level stakeholders in the MOH and policymakers Egypt 2002 & 2004 SPA Wide dissemination of the results The Minister of Health keeps the SPA report on his desktop computer for easy reference. It’s being used at the highest levels of government.

16 Use of SPA - III A study on the effect of health care services on IUD use in Egypt has recently been published in the BMC Health Services Research, in June 2006 Presentation at Johns Hopkins University, Health Systems Program & Center for Refugee and Disaster Response Departments of International Health & Health Sciences Informatics (School of Medicine) – request for data sets for further analysis

17 Strengths of SPA Helps prioritize efforts, geographically, by content areas (e.g. immunization, delivery services) and type of facilities (e.g. weak dispensaries) Assesses weak areas needing investment (e.g. sanitation, privacy), improved provider performance (e.g. incentives, training), better management practices (e.g. quality circles, supervision, community participation), strengthen re-supply of medicines & other supplies Can measure progress (if trend analysis) Data comparable across countries, though more useful to each country (e.g. Egypt strong on facilities offering FP and availability of commodities but weak on infection control)

18 Limitations of SPA Sample-based. Should not be used to single out individuals, specific facilities or clients – confidentiality agreements Does not provide the full picture of health care – no info on small private or informal outlets (e.g. pharmacies, consultation offices) Results do not necessarily correlate with health outcomes/impact at population level (depends on a multitude of other factors, e.g. population access and equity, living standards, transportation, education)