Dissemination of Service Availability and Readiness Assessment (SARA) study A methodology for measuring health systems strengthening Conducted by IHI for MOH&SW in th Jan 2014, Julius Nyerere International Convention Centre,DSM

Outline What is SARA? Why measure SARA? What does SARA add? Design and methodology SARA findings General service availability and readiness Specific service availability and readiness Maternal, newborn Communicable diseases Non-communicable diseases Surgical, blood transfusion services Summary of key points

What is SARA? It measures general service availability (access to health services) Health infrastructure (density of facilities and inpatient beds) Core health personnel, inpatient/outpatient service utilization It measures general service readiness (capacity of health facilities to provide general health services) Presence of basic amenities, equipment, standard precautions for infections, diagnostic capacity and essential medicines It measures specific service availability and readiness Proportion of facilities providing specific key interventions and their capacity to provide them.

Why measure health services availability and readiness? More demand for accountability and to demonstrate results Need to track how health systems respond to increased inputs and improved outputs Need for strong country monitoring system of health facilities (public & private) and their readiness to deliver services : Need for core indicators of service availability and readiness and appropriate sustainable measurement strategies to generate required data over time

Why measure SARA in Tanzania? Commitment of the Government of Tanzania to equitable delivery of quality health services. Existence of a wide network of health facilities pre-dating Alma Ata declaration on Primary Health care Help address major challenges such as HRH, information systems and equipment and drugs for combating major diseases Global Fund Round 9 Health System Strengthening Proposal

What does SARA add? Independent data quality assessment of service delivery Establishes a baseline for monitoring progress in scale up of service delivery Strengthens the analysis for annual health sector and mid-term review 6

METHODOLOGY SERVICE AVAILABILITY AND READINESS ASSESSMENT, TANZANIA 2012

Service Availability and Readiness: Survey Tool Global core set of indicators and measurement methods to detect change and monitor progress in HSS Measurement tool for Service Availability and Readiness to address critical data gaps in service availability and readiness – Availability : Physical presence of services – Readiness : Capacity to deliver services Builds on experiences of SAM, SPA working with USAID and partners to scale up SARA in countries

SARA Questionnaire Standard questionnaire built on prior facility survey instruments Primary level Additional questions for hospitals and large facilities Uses commonly accepted guidelines & recommendations Sick child: IMCI Family Planning: USAID; UNFPA; WHO Maternal Health: Safe Motherhood Initiatives STIs and TB: WHO/others HIV/AIDS: variety of initiatives Adapted to country needs Technical meeting with MOH Pretested and adjusted

Main domains assessed Service availability Facility density, health worker density, service utilization General service readiness Basic amenities, equipment & supplies, diagnostics, essential medicines & commodities Specific service readiness areas: Family planning, antenatal care Obstetric care Neonatal care and child health (curative, immunization) HIV, PMTCT, TB, Malaria Chronic Diseases

Where was SARA data collected? Sentinel Panel of Districts (District Observatory)

How was SARA data collected? Conducted a 5 day training including field practice Data collection was done in three phases in May, June and December 2012 Facility Based Information System coordinators in collaboration with CHMT members Data was collected on paper forms and entered electronically into a central database developed in google forms Respondents: facility in-charge, plus most knowledgeable person present day of survey for particular service.

Sample and sample weights A total of 1,297 health facilities in 27 districts were visited This a national representative sample of district selected by National Bureau of Statistics Two-stage, population-weighted probability sample Sampling weights at first stage were calculated as a reciprocal of the probability of a district to be included in SPD sample. No weights in the second stage since all facilities were included in the district

Quality Control Field supervision (by a joint team from MOHSW&IHI) Spot checks (based on information received during data entry) Validation through sample of facilities to be re-surveyed by supervisors Regular conference calls using IHI closed user group for rapid problem solving and information sharing 14

RESULTS

General Service Availability Health Infrastructure Heath workforce

Number of health facilities by type CharacteristicHospitals Health Centers Dispensary MCH Clinics PercentTotal Managing authority Government/Public %923 Mission/Faith based %132 NGO/Not-for-profit %9 Private-for-profit %233 Ownership Government/Public %923 Private %374 Residence Rural %844 Urban %453 Percent by level 4%11%85%1% Total ,1008 1,297

Distribution of facilities by level and residence Percent of facilities by residence Source: SARA Tanzania 2012

Health workforce density Skilled health personnel per 10,000 population Source: SARA Tanzania 2012

General Service Readiness Basic amenities Basic equipment Standard precautions Laboratory diagnostics Medicines is a composite score summarizing information from five domains of health service delivery It refers to the capacity of health facilities to provide general health services

Basic amenities Percent of basic amenities Source: SARA Tanzania 2012

Basic equipment Percent with basic equipment Source: SARA Tanzania 2012

Standard precautions for infection prevention

Diagnostic capacity

Diagnostic capacity by facility level

Essential medicines Percent of essential tracer medicines Source: SARA Tanzania 2012

General Service Readiness (GSR) Index Source: SARA Tanzania 2012 Mean availability of components of service provision and GSR index

General Services Readiness: Comparison with other countries

Key Message: General Service Availability and Readiness Basic equipment availability scored the highest Fewer facilities had basic amenities such as power, computers with /internet, private consultation room and sanitation facilities Diagnostic capacity was surprisingly low even in health centers and hospitals Medicines score was also low. 30%-40% was out of stock of 4 basic medicine General service readiness index was 42%.

Maternal, Newborn, Child and Adolescent Health Family Planning Antenatal Delivery Routine immunization Preventive and Curative Adolescent Health Source: SARA Tanzania 2012

Availability of Family Planning services Percent of family planning services

Readiness to provide FP services Source: SARA Tanzania 2012

Availability of ANC services Source: SARA Tanzania 2012

Readiness to provide ANC services Source: SARA Tanzania 2012

Availability of emergency obstetric and new born care Source: SARA Tanzania 2012

Readiness to provide BEmOC services Source: SARA Tanzania 2012 BEmOC Basic Emergency Obstetric Care

Availability of child Immunization services Source: SARA Tanzania 2012

Readiness to provide immunization services Source: SARA Tanzania 2012

Availability of preventive and curative services Source: SARA Tanzania 2012

Readiness to provide curative and preventive services Source: SARA Tanzania 2012

Availability of adolescent health services by ownership and residence 75% of public facilities offered adolescent health services Source: SARA Tanzania 2012

Readiness to provide adolescent heath services No facility had guidelines for adolescent health services Source: SARA Tanzania 2012

Key Messages: Maternal, Newborn, Child and Adolescent Health Availability of maternal, newborn, child and adolescent health was generally good. Although ANC services were available in 85% of the facilities, readiness was found to be 58% More than three quarters of the facilities had the capacity to deliver immunization services Adolescent services were mostly present in public facilities and in rural compared to urban facilities though no facility had guidelines Availability and readiness for preventive and curative services for under fives was 82% and 65% respectively

Communicable Diseases Source: SARA Tanzania 2012  Malaria  Tuberculosis  HIV counseling and testing  HIV care and support  ARV prescription and client management  PMTCT  Sexually Transmitted Infections

Availability of malaria services Source: SARA Tanzania % of health facilities offer malaria diagnosis and treatment services

Readiness to provide malaria services Source: SARA Tanzania 2012

Availability of TB services Source: SARA Tanzania 2012 Less than 40% of facilities offered TB services

Readiness to provide TB services Source: SARA Tanzania 2012

Availability of HIV counseling and testing services Counseling and testing services were more likely to be offered in public facilities Source: SARA Tanzania 2012

Readiness to provide HIV counseling and testing Source: SARA Tanzania 2012

Availability of HIV care and support services Source: SARA Tanzania 2012

Readiness to provide HIV care and support services Source: SARA Tanzania 2012

ARV prescription and client management Source: SARA Tanzania 2012

Readiness to provide ARV prescription and client management services One out of five facilities were ready to provide ARV prescription Source: SARA Tanzania 2012

Availability of PMTCT services Source: SARA Tanzania 2012

Readiness to provide PMTCT services Source: SARA Tanzania 2012

Availability of STIs services Source: SARA Tanzania 2012

Readiness to provide STI services Source: SARA Tanzania 2012 Two thirds of facilities were ready to provide STI service

Key Messages: Communicable Diseases Malaria, PMTCT, HIV counseling and testing services were available in more than 70% of facilities Diagnostic capacity for communicable diseases was high except for TB Availability of staff trained to deliver communicable services was better for malaria and PMTCT services Medicines for malaria and TB were more available compared to those for HIV Source: SARA Tanzania 2012

Non-Communicable Diseases Source: SARA Tanzania 2012  Diabetes  Cardiovascular Disease (CVD)  Chronic Respirator Disease (CRD)

Availability of diagnosis and/or management of NCDs Percent of facilities providing diagnosis and /or management of NCDs Source: SARA Tanzania 2012

Readiness to provide treatment or management of Diabetes, CVD and Chronic Respiratory Disease Source: SARA Tanzania 2012 n=291 n=248 n=316

Key message for NCDs Overall, availability of treatment and /or diagnosis of NCDs was low 91% of facilities had equipment available for CVD (blood pressure apparatus, stethoscope and adults scale) Staff trained in the last two years and guidelines were less common. Approximately 3 out of 10 facilities Readiness scores for Diabetes and CVD were better off compared for CRD Source: SARA Tanzania 2012

Basic surgical and blood transfusion services

Availability of basic surgical services 26% of facilities provided basic surgical services Source: SARA Tanzania 2012

Readiness to provide basic surgical services Approximately one third of facilities were ready to provide basic surgical services Source: SARA Tanzania 2012 IMEESC Integrated Management for Emergency & Essential Surgical Care

Availability of blood transfusion services Percent availability of blood transfusion services by level and ownership Source: SARA Tanzania 2012

Readiness for provision of blood transfusion services Source: SARA Tanzania 2012 Readiness for blood transfusion services

Key messages surgical and blood transfusion services One quarter of the facilities offered basic surgical services Readiness score for surgical services was 31% Blood transfusion was available in only 8% of facilities. Private facilities were twice more likely to have blood transfusion service compared to public Readiness score was 23 out of 100 Source: SARA Tanzania 2012

SARA take home messages This is the first SARA in Tanzania and provides a good baseline for future assessments General Service Readiness highlighted low scores in basic amenities and low diagnostic capacity to perform basic diagnostic tests Specific Service Availability was at two thirds or more for services such as malaria, child health, PMTCT and immunization but lower for TB and HIV care and support. Specific Service Readiness varied across with high scores for immunization and family planning scoring but lower for ARV prescription and client management and basic surgery

Acknowledgements Ministry of Health & Social Welfare Global Fund World Health Organization HMIS focal persons in SPD districts IHI members