Health Facility Surveys: An Introduction

by Magnus Lindelow and Adam Wagstaff

December 12, 2001Revised April 25, 2006

Based on Policy Research Working Paper # 2953 January 2003

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)

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

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

Private providers

Public providers

Motivation #2—measuring & understanding provider performance

Measurement of costs, quality & efficiency (various studies)

Measurement of health worker perceptions & attitudes (e.g. Ethiopia)

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

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?

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Can we trust administrative records?Not in Uganda

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)

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

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– …

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