Service Provision Assessment (SPA) and Service Delivery Indicators (SDI) Surveys Shouldn’t they be Merged? Presentation Prepared by Moses Busiga (USAID) and Waly Wane (World Bank) Tanzania DPG Health – November 14, 2012

What are SPA Surveys? Sample survey of formal sector health facilities Provide information about the overall service environment and functioning of components of the health system that may affect the quality of services Objective: to provide a “snap-shot” of the service environment, resources, and practices used to provide health services in formal sector health facilities

What questions can a SPA survey answer? What is the overall availability of different health services? e.g., what proportion of facilities offer child health services? family planning services? To what extent are facilities prepared to provide these services? What infrastructure, resources and support systems are available, e.g., regular electricity and water supply, trained staff, items for infection control, visual and auditory privacy, service guidelines, management practices, To what extent does the service delivery process follow generally accepted standards of care? Does the process followed in service delivery meet standards of acceptable quality and content? Are clients and service providers satisfied with the service delivery environment? Clients’ perception of service provided and providers’ satisfaction with the work environment

Demographic and Health Surveys (DHS) INSERT GRAPHIC TO ADD MAP MAP IS 6.17” TALL Figure 1. Relationships between Contextual and Individual Factors, the Health System and Health Outcomes Adapted from: J. Bertrand and Escudero, G., Compendium of Indicators for Evaluating Reproductive Health Programs, Volume One. MEASURE Evaluation Manual Series, No. 6, August 2002. HFS = Health Facility Surveys; PBS = Population-based Surveys DHS, THMIS SPA Nutrition Demographic and Health Surveys (DHS) Demographic and Health Surveys also include the Malaria Indicator Survey (MIS) and the AIDS Indicator Survey (AIS). Nationally representative survey on demographic and health indicators 228 completed surveys from 1985 to present 95 surveys with GPS location of surveyed clusters

What are the contents of SPA surveys? Systems Guidelines & protocols Referral systems Staff training and supervision Services Maternal & Child Health ANC, Delivery, Newborn care Vaccination services Curative care for children under 5 Growth monitoring for children Family planning (FP) services HIV / AIDS CT ART PMTCT Tuberculosis (TB) Malaria STI Non-Communicable Diseases Infrastructure Water Electricity Client latrine Items for infection control Infection control practices Privacy Resources Laboratory Diagnostics Equipment Pharmaceuticals

Standard SPA Questionnaires Inventory questionnaire General information: staffing levels, health care waste management, processing of equipment, methods of eliciting client opinion, Availability of services (child health services, FP, ANC, Delivery, HIV testing, STI, TB..) and frequency (i.e., # of day/week service is offered) Detailed information pertaining to the service, if offered: equipment, guidelines Laboratory diagnostics services: availability of different tests, systems for external testing, QC Medicine and supplies Health provider questionnaire Provider qualifications, services provided, training, continuous education Supervision Perception of the work environment Observation protocol Observation of consultations and examinations of sick children, ANC, and family planning sessions, STI, etc. Checklists cover basic elements of service delivery; special studies needed for more info Client exit interview questionnaire With clients who were observed receiving services to elicit their perception on consultation and service received

SDI Perspective Perspective adopted by SDI is that of citizens accessing services Can be viewed as a service delivery report card However, instead of using citizens’ perceptions, assemble objective and quantitative information from a survey of frontline service delivery units Uses modules from: Public Expenditure Tracking Survey (PETS), Quantitative Service Delivery Survey (QSDS), Staff Absence Survey (SAS) Observational studies.

Table 1: A health service delivery report card At the clinic: Inputs and infrastructure Infrastructure (electricity, water, sanitation) Medical equipment per clinic Medical personnel: Effort and knowledge Absence rate Time spent counseling patients per clinician Diagnostic accuracy in outpatient consultations Funding: Effort in the supply chain Health expenditures reaching primary clinics Delays in salaries 8

Pilot surveys in Senegal and Tanzania SDI piloted in Senegal and Tanzania in the spring/summer of 2010. Main objective: test the survey instruments and to verify that robust indicators of service delivery quality could be collected with single facility-level instrument Anglophone and Francophone country with different budget systems. 9 9

Sample size and design Designed to provide representative estimates for each of the key Indicators, broken down by urban and rural location. Stratified multi-stage random sampling design, with number of units proportional to population Given resources available, 180 facilities to be surveyed in each sector Sample frames: most recent list of all public primary schools and public health facilities, including information on size of population they serve. 10

Sample information 11

Survey implementation Survey used sector-specific questionnaire administered at facility level. Questionnaires built on international good practice for PETS, QSDS, SAS and observational surveys. Pre-test was done by SDI team, in collaboration with in-country research partners, in early 2010. The questionnaires were translated into French for Senegal and Swahili for Tanzania. 12

At the clinic: Inputs and infrastructure Infrastructure (electricity, water, sanitation) Medical equipment per clinic

Infrastructure 14

Medical equipment per clinic DEFINITION: Measured as = 1 if there is a thermometer, stethoscope and weighting scale available on the premises, and as = 0 otherwise. 15

Medical equipment per clinic 16

Medical personnel: Effort and knowledge Absence rate Time spent counseling patients per clinician Diagnostic accuracy in outpatient consultations

Absence Rate 18

Time spent counseling patients per clinician DEFINITION: Use data on time spent per patient (from the observational study) Multiply by total number of patients treated per day Divide by number of clinicians (on the roster)

Time spent counseling patients per clinician 20

Diagnostic accuracy in outpatient consultations DEFINITION: Share of clinicians who reached correct diagnosis based on patient case simulations (“vignettes”)

What do Patient Case Simulations measure? Knowledge/skills (performance frontier) PCS Performance with real patients

Diagnostic accuracy

Diagnostic accuracy

Diagnostic accuracy

More information: Process quality DEFINITION: A = Share of relevant history taking questions performed. B = Share of relevant physical examinations performed. Process quality is the average of A and B, averaged across 5 patient cases.

Process quality - number of relevant procedures

Case 1: Child with malaria and anaemia Per cent of clinicians who performed procedure HISTORY TAKING Sen Tan Duration of fever 82 99 Pattern (periodicity) of fever 37 66 Presence of chills, sweats 3 21 Presence of vomiting 47 58 Presence of cough 60 56 Presence of convulsions 6 31 Presence of ear problems 2 7 …and more… EXAMINATIONS Sen Tan Take temp with a thermometer 81 85 Check neck stffness 2 13 Look for palmor pallor (or other signs of anaemia) 6 27 Check ear/throat 7 General health condition (awake/lethargic) 62 Check for visible wasting 4 Look for oedema both feet 1 Check weight (against growth chart) 11 …and more….. 28

Funding: Effort in the supply chain Health expenditures reaching primary clinics Delays in salaries

Health expenditure reaching primary clinics per capita 30

TANZANIA HEALTH At the Clinic 18% Medical Personnel 78% Funding 21% Clinics with electricity, water, sanitation Clinics with basic equipment[3] Medical Personnel Health workers absent on a given day Time spent counseling patients per day Cases diagnosed accurately by clinicians[4] Funding Expenditure reaching primary clinics per capita Medical personnel experience a 2- month+ delay in salary 18% 78% 21% 29m 57% $7.01 2%

What’s Next for SPA & SDI in TZ? Already had a brainstorming session on how to merge SPA and SDI Merging SPA and SDI has many advantages SDI will participate in upcoming SPA stakeholder meeting in December Both SDI and SPA teams are open to alter their timelines to consider and work on the merge Tentatively the “merged” survey could start field operations before June 2013

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