1. Health Facility Surveys: An Introduction by Magnus Lindelow and Adam Wagstaff December 12, 2001 Revised April 25, 2006 Based on Policy Research Working Paper # 2953 January 2003

2. Examples of health facility surveys… up to 2001 Measure –Evaluation –DHS+ (service provision assessments) WHO –Integrated Management of Childhood Illness (IMCI) World Bank: –Living Standards Measurement Surveys (LSMS) –Public Expenditure Tracking Surveys (PETS) –Quantitative Service Delivery Surveys (QSDS) RAND –Family Life Surveys (FLS)

3. Dimensions along which health facility surveys vary Motivation—why the data were collected What data were collected, and how What the data were used for

4. Household behaviour Public providers Motivation #1—understanding provider-household links Interest in impact of availability, quality, etc. on care-seeking behavior and health outcomes This was the reason why World Fertility Survey added facility survey to its household surveys back in 1970s. And a factor motivating LSMS’s and DHS’s decisions to do so in 1980s Private providers

5. Public providers Motivation #2—measuring & understanding provider performance Measurement of costs, quality & efficiency (various studies) Measurement of health worker perceptions & attitudes (e.g. Ethiopia)

6. Private providers Public providers Motivation #3—government- provider linkages Accounting for flows of govt. funds to facilities (e.g. PETS) Influence of govt. on performance through promotion of competition (e.g. UK), increased autonomy (e.g. Paraguay MEASURE Evaluation) Government expenditure policy regulation

7. What data were collected, and how—i Inputs –A check on administrative data –Capital inputs; Drugs and vaccines; Personnel –Interview vs. direct observation vs. record review Costs –Top-down vs. bottom-up approaches –Joint costs—accounting methods? Outputs, activities and throughputs –“Readiness-to-serve” capability or rendered services? –Adjusting for service mix and casemix variation –Facility-level records vs. administrative data from higher level?

8. Can we trust administrative records? Not in Uganda

9. What data were collected, and how—ii Quality –Inputs Geared towards ‘structural’ aspect of quality; commonest approach to date (up to 2001 anyway) –Consultation observation, clinical vignettes Geared towards ‘process’ aspect of quality Observation more costly; may be subject to observation bias; but reflects better real incentives Examples up to 2000: Jamaica LSMS, Indonesia FLS, DHS SPAs, … –Beneficiary perceptions Geared towards patient satisfaction Exit polls bundled into facility survey design; cf. dedicated (non-facility) surveys (e.g. report cards)

10. What data were collected, and how—iii Staff perceptions and behavior –Informal activities (e.g. overcharging, theft of drugs); Uganda –Subjective data health worker performance & motivation (use of psychometric scales); Georgia Institutional & organizational environment (to link to performance) –How facilities are managed—characteristics of managers, system used to manage inputs, etc.; Sri Lanka –Financing, support & supply systems, supervision arrangements; Uganda

11. How have facility data been used? Planning and budgeting –Resource adequacy and estimation of resource needs Monitoring, evaluation, & accountability –Monitoring Health outcomes and welfare monitoring (DHS, MICS, LSMS) Health care quality/facility performance (SPA, SA) –Evaluation—e.g. IMCI, social investment funds, etc. –Accountability—e.g. PETS Uganda Research –Quality & health outcomes, –Quality and health-seeking behavior –Econometric estimation of cost functions –…

12. Some issues… identified in 2001 Some common core variables of interest—e.g. inputs, costs, outputs, quality –But is there an emerging consensus on measurement & data-collection instruments? HFSs have done better at documenting performance than at –shedding light on causes of differences, and on –impacts of policies on performance HFSs have many potential uses. But could they have had a bigger impact? –Engaging policymakers early on –Tension between making appropriate to context and achieving (international) comparability