Health Facility Surveys and Quantified Supervisory Checklists Health System Innovations Workshop Abuja, Jan , 2010

Health Facility Surveys – What are they? Assessments of different types of health facilities using a standardized questionnaire Usually done through a simple random sample of all health facilities Surveyors are usually trained health workers (often doctors) Usually look at many different aspects of service delivery including technical quality of care 2

Health Facility Surveys Advantages Can assess quality of care Can be independent of service providers Can be done more frequently than HHS Disadvantages Complex to design Lots of data, can overwhelm Cannot provide information on coverage, equity 3

An example from Afghanistan: 600+ facilities surveyed every year 2004 to 2008 by a team led by JHU Contents developed through consultative process Very careful quality assurance Each facility rated on a score of 0-100, can be aggregated at county, state, national level Present results through “balanced scorecard ” 4

What the BSC Looks At: Presence of staff Knowledge of staff Quality of patient-provider interaction Availability of drugs and supplies (also quality on sample basis) Patient satisfaction (different from HH results) Waste management Use of facilities, use by women, and the poor etc. 5

Can Look at Provincial Progress – Color Coded 6

32% Improvement in Total Scores in Contracted Facilities (from health facility survey)

Looking at Provincial Progress on Total Score 8

Can Look At Areas Needing Attention 9

Health Facility Assessment in Nigeria under Malaria + Program covering 327 facilities

Illnesses: Fever/Malaria; Pneumonia; Dysentery and Diarrhea

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Poor awareness of PMVs regarding new Malaria treatment policy

What are the challenges with Health Facility Surveys? Deceptively difficult to do Requires talented technical staff experienced in survey design Need to do it every year or so to look at changes Costs about $300,000 per year (more during development) 17

What are the challenges with Health Facility Surveys? Generates a lot of data (400+ questions on each facility) Tough to explain to managers – need means, like BSC, to summarize data Quality assurance is a real challenge Easy to do badly – consumers won’t know 18

Quantitative Supervisory Checklist – What is it? A reduced version of a health facility assessment Objectively assesses a variety of indicators to come up with total score. Takes about 2-3 hours to complete A copy of results left in the health facility, easy to track progress QSC is both a management intervention and tool for M&E 19

Example of a Quantitative Supervisory Checklist Date of Visit 5/127/198/1110/21 Availability of Drugs (0-10)3546 Presence of staff (0-5)2122 HMIS implementation (0-10)3355 TB Case Detection Rate (0-5)0112 DPT3 coverage rate (0-10)2334 Consultations per capita (0-10)2425 Deliveries in facility (0-10)0113 TOTAL SCORE (out of 60) Supervisor’s signature HF in-charge signature 20

Development of QSC in the Philippines New HMIS forms developed which were supposed to facilitate supervision “Checklist Safari” in 7 provinces found: – 25 different checklists – 95 items, average 4.5 pages long – Rarely used, never found in health facilities – Designed in such a way to make follow up difficult Supervision was sporadic, not systematic, mostly dreaded by health workers 21

Development of QSC in the Philippines Discussions with key program managers led to definition of 20 indicators. Indicators scored from 0-3 with specific definitions and means of calculation Copy of QSC could be left in HF so future supervisors & staff could track progress Copy with supervisor so s/he could track which indicators were lagging Before & after assessments in 4 experimental provinces and 6 control provinces 22

Example of a Quantitative Supervisory Checklist Date of Visit 5/127/198/1110/21 Availability of Drugs (0-10)3546 Presence of staff (0-5)2122 HMIS implementation (0-10)3355 TB Case Detection Rate (0-5)0112 DPT3 coverage rate (0-10)2334 Consultations per capita (0-10)2425 Deliveries in facility (0-10)0113 TOTAL SCORE (out of 60) Supervisor’s signature HF in-charge signature 23

Evidence for the Effectiveness of QSC 24 % Change in Scores from Baseline

Other Findings from QSC Health workers liked it because it made it clear what was expected. Supervisors not angry Supervisors liked it because made interaction with HWs more focused on key results HWs tracked performance and became adept at tracking their own performance Was launched nation-wide but fell into dis-use after devolution 25

Quantified Supervisory Checklists Advantages Can assess QOC. Can be independent of service providers Can be done often Inexpensive Clarifies what is expected of HWs Can be adapted to conditions as they change Disadvantages Challenging to design Cannot provide information on coverage, equity Ensuring continued use is difficult 26