1. Key The BSC scores indicate that quantity of services provided by public sector health-facilities improved in 2011 compared to 2009 level but quality became worse than before. Though the time-gap between the surveys was only two years, BSC scores could identify short-term changes in performance. 10 out of 30 indicators showed improvements, 14 remained unchanged and 6 indicators declined. Policy Implications- Health-sector policy-makers in developing countries should consider wider use of BSC for independent external monitoring of health-facility performance. BSC should be also used as a guide to make amendments in five year plans, commonly made in developing countries, to achieve mission, vision, and goals of the plans. Discussion Using Balanced Score Card indicators to monitor changes in Health Facility performance: Case study based on Nationally Representative Health Facility Surveys in Bangladesh Naveed Sadiq, MPH & Mahmud Khan, PhD Background Over the past two decades, Government of Bangladesh has invested significant amount of resources to improve quality and quantity of services provided through public-sector facilities. Demography 1 Administratively, Bangladesh is divided into 7 divisions, 64 districts, and 545 Upazilas, each having a hospital at every level and sub-level. The current population of Bangladesh is over 150 million, majority of which resides in rural areas. Bangladesh has incorporated a Sector-Wide Approach (SWA) in its five year plan to provide essential and quality health care services to meet the needs of the population including but not limited to family planning, maternal and child care, workforce, systems support (management information system), and coordinated services. There had been a progressive decline in fertility rate, teenage marriages, and subsequently teenage pregnancies from 1991 to 2011. The prevalence of uptake of family planning services for any and modern methods increased over two decades. The receipt of antenatal and postnatal services from medically trained provider, and skilled assistance at delivery also increased in the past two decades. That resulted in a subsequent decrease in neonatal and under 5 child mortality. The percentage of children receiving immunizations increased significantly in two decades. Being largely rural and poor, the delivery of healthcare services had not been efficient. Accessibility 1 Bangladesh has an extensive health network throughout the country that provide a number of services free of cost to the people but the services are not client focused, needs based, of high quality and within the reach of the poorest 2. Being largely rural country, only 8% of the rural population could avail the services while only 2% of the mothers could seek care for their children 3. Quality Improvement Having an extensive network of healthcare facilities but with poor planning and bad health policies, further improvements in utilization will require improved quality of services. In order to monitor the goals set up in the five year plan, Balanced Score Card (BSC) can be used to see the change in the quality of services. Balanced Score Card “The Balanced Scorecard is an approach to performance measurement that combines traditional financial measures with non-financial measures to provide managers with richer and more relevant information about the outcomes they are targeting and the activities they are managing, increasing the likelihood of organizational objectives being achieved.” 4 Case Study of Bangladesh Nationally representative health-facility surveys were conducted in 2009 and 2011 in Bangladesh. The purpose of this study was to use BSC, incorporated in health-facility assessment questionnaire, as a guide for observing changes in performance of health-facilities to monitor improvements in quantity and quality of health-care services provided through public-sector facilities over a period of two years. 5 Improvements i.Health worker satisfaction index improved from 55 in 2009 to 65 in 2011. ii.Availability of functional basic clinical equipment improved from 67% in 2009 to 85% in 2011. However, the overall availability decreased from 69% to 65% in 2011. iii.Essential drug availability (37 drugs) improved significantly. iv.Staffing index for physicians, auxiliary staff, and other healthcare personnel also improved significantly over 2009 to 2011. v.The use of HMIS index and clinical guidelines index improved much in 2011 as compared to in 2009. vi.Patient history and physical exam index improved significantly over the period of two years. Deterioration i.The overall outpatient satisfaction score remained the same (84 out of 100) over these two years while the patient perception of quality of care declined from 86 to 80. ii.Availability of immunization equipment and family planning supplies declined. iii.Provider knowledge score on child & maternal health, and STI decreased significantly over the period of two years in 2011. iv.Facilities having TB register significantly decreased in 2011 to 36% from 100% (in 2009). Laboratory Equipment availability and functionality index remained more or less unchanged. On average, outpatient visit per-month per-facility increased by about 22%. References Background, Demographics, & Quality Table: Comparison of Balanced Score Card Indicators for 2009 and 2011 Case Study Results Balanced Scorecard Indicators2009 2011 Including CCs 2011 Excluding CCs A. Patients & Community Overall Patient Satisfaction, outpatient848584 Patient Perception of Quality Index868180 Overall Patient Satisfaction, inpatientNA**76 B. Staff Health Worker Satisfaction Index556465 Salary payments current100 C. Capacity for Service Provision Equipment Availability Index693765 Equipment Functionality Index673385 Index of regular use of equipmentNA3155 Essential Drug Availability Index (37 drugs)356963 Union Drug Kit Availability Index808279 EPI equipment and supply index783640 EPI index excluding refrigerator + thermometer-6057 Family Planning Availability Index909978 Laboratory Equipment Availability Index58**57 Laboratory Functionality Index92**93 Regular use index of Lab equipmentNA**53 Staffing Index647576 Provider Knowledge Score : child health595254 Provider Knowledge Score : Maternal health766567 Provider Knowledge Score : STI834951 Staff received training in last year424443 HMIS Use Index293240 Clinical Guidelines Index273039 Infrastructure Index674263 Facilities having TB register1002636 D. Service Provision Patient History and Physical Exam Index: under 54259 Patient Counseling Index605859 Proper sharps disposal694161 Average outpatient visit per month per facility13028231587 Facilities providing antenatal care905587 Facilities providing delivery care753663 E. Financial Systems Facilities with user fee guidelines3.13.23.0 Facilities with exemptions for poor patients1.73.12.9 F. Overall Vision Females as % of new outpatients516265 1.Bangladesh Health & Demographic Survey, 2011. 2.http://www.napsipag.org/pdf/Issues_of_inequality.pdf, accessed Nov. 14, 2014http://www.napsipag.org/pdf/Issues_of_inequality.pdf 3.BHFS Report 2011 4.Chowdhury, Rabi. 2004. Bangladesh's Crusade for Millennium Development Goal One: Impotent without Basic Healthcare for the Poor. American International School: Dhaka 5.http://2gc.eu/resource_centre/balanced-scorecard accessed Nov. 14 th, 2014http://2gc.eu/resource_centre/balanced-scorecard