Health Facility Surveys and Quantified Supervisory

Checklists

Health System Innovations Workshop Abuja, Jan. 25-29, 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

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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

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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”

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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

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

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45

50

55

60

65

70

75

80

2004 2005 2006 2007

MOPH Alone

PPA Median

Looking at Provincial Progress on Total Score

Balanced Score Card Results from 2007 Compared to Previous Years

Province 2004 2005 2006 2007 Change from 2004

to 2007

Badghis 48.7 59.3 49.8 80.2 31.5

Balkh 55 71 71.6 78.6 23.6

PPA Median 53.4 60 62.8 75.8 22.4

National Median 53.2 59 65.4 70.2 17

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Can Look At Areas Needing Attention

Index 2004 2005 2006 2007 Change 2007-2004

Patient Counseling 29.6 35.1 36.6 48.7 19.1 Equipment Functionality 65.7 67 78.7 83.8 18.1 Family Planning Availability 61.4 70 82.9 93.7 32.3 Patient History & Exam 70.6 73.5 82.2 83.1 12.5 Proper sharps disposal 62.2 52 77.5 84.4 22.2 Obstetrical care 25.4 22.3 42.3 59.5 34.1 BHC's with >750 patients 22.2 32.3 55 57.4 35.2 HMIS Implementation 67.7 65.8 74.9 91.5 23.8 Provider Knowledge 53.5 69 68.7 68.7 15.2 Drug Availability 71.1 83.7 85.7 81 9.9

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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)

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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

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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&E19

Example of a Quantitative Supervisory Checklist

Date of Visit 5/12 7/19 8/11 10/21

Availability of Drugs (0-10) 3 5 4 6Presence of staff (0-5) 2 1 2 2HMIS implementation (0-10) 3 3 5 5TB Case Detection Rate (0-5) 0 1 1 2DPT3 coverage rate (0-10) 2 3 3 4Consultations per capita (0-10) 2 4 2 5Deliveries in facility (0-10) 0 1 1 3TOTAL SCORE (out of 60) 12 18 18 27Supervisor’s signatureHF 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

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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

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Example of a Quantitative Supervisory Checklist

Date of Visit 5/12 7/19 8/11 10/21

Availability of Drugs (0-10) 3 5 4 6Presence of staff (0-5) 2 1 2 2HMIS implementation (0-10) 3 3 5 5TB Case Detection Rate (0-5) 0 1 1 2DPT3 coverage rate (0-10) 2 3 3 4Consultations per capita (0-10) 2 4 2 5Deliveries in facility (0-10) 0 1 1 3TOTAL SCORE (out of 60) 12 18 18 27Supervisor’s signatureHF in-charge signature 23

Evidence for the Effectiveness of QSC

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% 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

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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

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