quality of health services at the sub-district and

Quality of Health Services at the Sub-District and Community Levels Midline Study Report August 2017

Disclaimer: The contents of this report are the sole responsibility of the contractors and do not necessarily reflect the views of USAID or the United States Government. This midline study was implemented by Management Systems International (MSI) under the USAID/Ghana Evaluate for Health Project (Evaluate), with technical support from Mathematica Policy Research (Mathematica). It was conducted in collaboration with the Ghana Health Service (GHS) and USAID/Ghana Health, Population, and Nutrition Office (HPNO). The authors of this report are: Principal Investigator Kristen Velyvis and Contributing Investigators Jorge Ugaz, Evan Borkum, Anca Dumitrescu and Nikita Ramchamdani from Mathematica, and Frank Nyonator, Emmanuel Mahama, Deborah Orsini and Gwynne Zodrow from MSI. This report is made possible by the support of the American people through the United States Agency for International Development (USAID). Electronic copies of this report can be found on USAID’s online Development Experience Clearinghouse: http://pdf.usaid.gov/pdf_docs Cover image: USAID/Ghana Evaluate for Health

AUGUST 2017

http://pdf.usaid.gov/pdf_docs

QUALITY OF HEALTH SERVICES MIDLINE STUDY REPORT 2017 i

CONTENTS

ACKNOWLEDGMENTS ................................................................................................. v

ACRONYMS .................................................................................................................... vi

Executive Summary ......................................................................................................... 1 Introduction ......................................................................................................................................... 1 A. Research Questions ...................................................................................................................... 1 B. Evaluation Design ........................................................................................................................... 2 C. Data Collection.............................................................................................................................. 2 D. Key Findings.................................................................................................................................... 2

1. Quality of Care and Services.............................................................................................................. 2 2. Culture of Quality Assurance and Quality Improvement ........................................................... 6 3. Community and Governmental Support for CHPS ...................................................................... 6 4. Health Insurance ................................................................................................................................... 7

E. Future Evaluation Plans ................................................................................................................. 7

1. Introduction .................................................................................................................. 8 A. Overview of USAID’s Health Portfolio .................................................................................... 9 B. Ghana Health Service .................................................................................................................. 11 C. Research Questions .................................................................................................................... 12 D. Evaluation Design ........................................................................................................................ 13 E. Road Map of the Report ............................................................................................................. 14

II. Data Sources and analysis approach ........................................................................ 14 A. Structure and Functions of Ghanaian District Health System .......................................... 14 B. Quantitative Data Collected Through Facility Surveys ....................................................... 15 C. Qualitative Data Collection ...................................................................................................... 17 D. Analysis Approach ...................................................................................................................... 20

III. Quality of Care and Services ................................................................................... 21 A. Service Provision at Health Facilities ...................................................................................... 21

1. CHPS Zones ........................................................................................................................................ 21 2. Health Centers .................................................................................................................................... 22

B. Integration of Care: Referrals and Follow-Up Care ............................................................ 22 C. Availability of Services ................................................................................................................ 26

1. Malaria .................................................................................................................................................. 26 2. Family Planning and Contraception .............................................................................................. 27 3. Maternal Health ................................................................................................................................. 28 4. Nutrition................................................................................................................................................ 30 5. Community-Based Services .............................................................................................................. 32

D. Staff Training ................................................................................................................................. 37 1. Training for Caregiving ..................................................................................................................... 37 2. Training for Data Tracking, Management and Logistics ........................................................ 41 3. Training Challenges ........................................................................................................................... 43

E. Treatment Protocols and Sanitation and Infection Prevention ......................................... 44 1. Availability of Treatment Protocols ................................................................................................ 44 2. Sanitation and Infection Prevention Measures .......................................................................... 45

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F. Access to Supplies and Equipment ............................................................................................ 46 1. Supply Chain Management.............................................................................................................. 47 2. Availability of Supplies and Equipment ......................................................................................... 51 3. Availability of Communication Technology ................................................................................... 60

G. Client Satisfaction ........................................................................................................................ 61 1. Perceptions of Quality at CHPS Zones ......................................................................................... 61 2. Perceptions of Quality at Health Care Centers .......................................................................... 62 3. Infrastructure and Transportation .................................................................................................. 63

H. Health Promotion ........................................................................................................................ 63 1. Awareness of the GoodLife, Live It Well campaign ................................................................... 64 2. Changes in Behavior Associated with Campaign ....................................................................... 64

IV. Culture of Quality Assurance (QA) and Quality Improvement (QI) .................. 65 A. QA and QI Activities at Facilities ............................................................................................ 65 B. Collecting High-Quality Data .................................................................................................... 67 C. Use of Data ................................................................................................................................... 68

V. Community and Governmental Support for CHPS .............................................. 71 A. Community to Health Sector Linkages ................................................................................... 71

1. Existence and Function of CHCs .................................................................................................... 71 2. Community Engagement with CHPS Zones ................................................................................ 74 3. Awareness of Patients’ Rights .......................................................................................................... 75

B. District-Level Support ................................................................................................................. 75 1. Support from District Assemblies ................................................................................................... 75 2. Collaboration Between District-Level Officials and USAID ...................................................... 76

VI. Health Insurance ...................................................................................................... 77 A. Health Insurance in Ghana ........................................................................................................ 77 B. Membership in Health Insurance and Claims Submission by Facilities ............................ 77 C. Health Insurance and the Location and Quality of Care ................................................... 79

VII. Summary and Conclusions ..................................................................................... 79 A. Quality of Care and Services .................................................................................................... 79 B. Culture of QA and QI ................................................................................................................ 80 C. Community and Governmental Support for CHPS ............................................................ 81 D. Health Insurance ......................................................................................................................... 81 E. Evaluation Time Line ................................................................................................................... 81

References ....................................................................................................................... 82

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LIST OF TABLES: Table 1. Midline survey sections Table 2. Sample size for qualitative data collection Table 3. Qualitative data topics by type of respondent Table 4. Scale of service provision at facilities Table 5. Referrals out of and into a facility Tale 6. Availability of Malaria Service – Midline only Table 7. Availability of family planning services – Midline only Table 8. Availability of delivery and antenatal care services Table 9. Availability of nutrition services Table 10a. Availability of community based services among CHPS Table 10b. Availability of community based services among health centers Table 11. Staff training for malaria caregiving Table 12. Staff training for nutrition and other key caregiving services Table 13. Staff training for data tracking and management Table 14. Availability of treatment protocols at facilities Table 15. Sanitation and infection prevention Table 16. Availability and use of tools and mechanisms for supply chain management Table 17. Management of essential supplies Table 18. Stock-outs for specific commodities in previous two months, among facilities with relevant

control cards Table 19. Availability of essential supplies among facilities Table 20a. Availability of essential equipment among CHPS zones Table 20b. Availability of essential equipment among health centers Table 21. Health promotion using campaign material Table 22. Existence of QA/QI teams and plans among facilities Table 23. Data validation among facilities Table 24. Display of data and information among facilities Table 25. Community support Table 26. Health insurance among facilities LIST OF FIGURES: Figure 1. Focal and Non-focal regions for USAID’s Health Investments in Ghana Figure 2. USAID projects and initiatives, by type of intervention Figure 3. Primary Health care organization in Ghana Figure 4a. Characteristics of respondents of CHPS survey Figure 4b. Characteristics of respondents of health centers survey Figure 5a. Common reasons for referrals out of the CHPS in the previous two months (all regions) Figure 5b. Common reasons for referrals out of the health centers in the previous two months (all

regions) Figure 5c. Referrals out of CHPS zones who return with feedback Figure 7. Availability of family planning services among CHPS and Health centers (focal regions) Figure 8. Availability of delivery and antenatal care services among CHPS and health centers (focal

regions) Figure 9. Availability of registers in CHPS and health centers (all regions) Figure 10. Key topics of discussion during last community health meeting among CHP zones Figure 11. Malaria training support at CHPS and health centers (focal regions) Figure 12a. Percentage of CHPS zones in which staff have received supportive supervision in MNCH

and nutrition in previous 12 months (focal regions) Figure 12b. Percentage of health centers in which staff have received supportive supervision in

MNCH and nutrition in previous 12 months (focal regions) Figure 14. Availability of treatment protocols in CHPS and health centers (all regions) Figure 15. CHPS and health centers with key sterilization measures in place for prevention and

control of infections (all regions)

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Figure 16. Frequency of CHPS zones experiencing stock-out (all regions) Figure 18a. facility experienced stock out of any 4 nutrition commodities (Albendazole, iron and folic

acid tablets, ORS and zinc tablets, vitamin A) (Focal regions) Figure 18a. Stock-outs for specific malaria commodities in previous two months (focal regions) Figure 18c. Stock-outs for specific family planning commodities (focal regions) Figure 19. Facilities with all key immunizations available (asles, Polio, Pnuemo, Rotarix, Pentavalent,

Tetanus toxiod, yellow fever, Bacillus Calmette-Guerin) (All Regions) Figure 20a. Availability of essential equipment in focal regions (midline only) Figure 20b. Availability of essential equipment (focal regions) Figure 20c. Availability of storage equipment (focal regions) Figure 21. Availability of communication technology (focal regions) Figure 22. QA/QI activities in health centers Figure 23.1. Percent of facilities which used generate data for monthly reports for the following

purposes in last 12 months (focal regions) Figure 25. Community support for CHPS zones Figure 26. Percentage of facilities that submitted at least one NHIS claim in last two months (focal

regions) APPENDICES: Appendix A: Conceptual Framework for USAID Health Projects in Ghana………………………. A1 Appendix B. Sampling, Data Collection, and Analysis Approach……………………………………A2 Appendix C: Additional Tables……………………………………………………………………. A11 Appendix D: Comprehensive Midline Tables……………………………………………………... A13 Appendix E: Quantitative Instrument……………………………………………………………... A72 Appendix F: Qualitative Interview Guides……………………………………………………….. A144

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ACKNOWLEDGMENTS

The investigators would like to thank the USAID/Ghana Health, Population, and Nutrition Office and its implementing partners for their insights and feedback on the design and findings of this report. We thank in particular Rubama Ahmed, our Contracting Officer's Representative, for her input throughout the midline study.

We thank our colleagues at the Ghana Health Service (GHS) who provided input on the design of the study and data collection instruments, and facilitated our data collection throughout the country. We are also grateful to the Director of the Policy, Planning, Monitoring and Evaluation Division, and the GHS directors at the national, regional and district levels for allowing us into their facilities, and to the health officers and clients interviewed.

DevtPlan was responsible for collecting the survey and qualitative data. We thank them for their organization of the field data collection and the timely submission of the survey quantitative and qualitative data.

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ACRONYMS

C4H Communicate for Health CDCS Country Development Cooperation Strategy CHAP Community Health Action Plan CHC Community Health Committee CHN Community Health Nurse CHO Community Health Officer CHPS Community-Based Health and Planning Services CHV Community Health Volunteers CMAM Community Management of Acute Malnutrition DA District Assembly DDHS District Director of Health Services DHIMS2 District Health Information Management System (Second Edition) DHMT District Health Management Team DHS Demographic and Health Survey E4H USAID/Ghana Evaluate for Health Project FP Family Planning GHS Ghana Health Service GoG Government of Ghana IP Implementing Partner IPC Infection Prevention and Control LEAP Livelihood Empowerment Against Poverty MCSP Maternal and Child Survival Program M&E Monitoring and Evaluation MNCH Maternal, Newborn and Child Health MOH Ministry of Health MSI Management Systems International NHIS National Health Insurance Scheme OPD Outpatient Department OTSS Outreach Training and Supportive Supervision QA Quality Assurance QI Quality Improvement RDT Rapid Diagnostic Test RING Resiliency in Northern Ghana RRIRV Report Requisition Issue and Receipt Voucher SC Supply Chain SDHO Sub-district Health Officer (Members of SDHT) SDHT Sub-district Health Team SPRING Strengthening Partnerships, Results and Innovations in Nutrition Globally T3 Test, Treat and Track Initiative USAID United States Agency for International Development WASH Water, Sanitation and Hygiene WHO World Health Organization

QUALITY OF HEALTH SERVICES MIDLINE STUDY REPORT 2017 1

EXECUTIVE SUMMARY

Introduction

In its effort to attain universal health coverage for all its citizens, Ghana has invested substantially in public health service delivery and has achieved important advances in health outcomes in recent years. However, the country continues to confront the need for expanded access to quality health services and strengthened national and community-based health systems. To respond to these challenges, USAID/Ghana is investing in health sector projects whose goal is to achieve equitable improvements in health status in Ghana. These investments primarily seek to increase access to integrated health services, expand the availability of community-based resources, strengthen and increase the responsiveness of the health system and improve health sector governance and accountability.

This report presents midline findings from a longitudinal study of health services at the sub-district and community levels in Ghana, conducted as part of USAID’s Evaluate for Health (Evaluate) project. The Evaluate project, launched in September 2014 and implemented by Management Systems International (MSI), is designed to provide overall monitoring and evaluation support for USAID’s health portfolio in Ghana. This midline study, conducted from February to March 2017, follows a baseline study conducted from February to April 2015. The midline study’s two main objectives were to: (1) provide information on the current levels of key indicators related to health services to guide USAID program implementation and improvement and (2) assess changes in these key indicators over the two years from baseline to midline for an overall evaluation of USAID’s health sector investments.

This Executive Summary lists the key research questions that drove the midline study design, describes the study’s data collection process, provides a synthesis of the key findings related to each research question and outlines the study’s future evaluation plans.

A. Research Questions

MSI and its subcontractor, Mathematica Policy Research, identified the study research questions through discussions with USAID/Ghana’s Health, Population and Nutrition Office (HPNO) and its primary implementing partners (IPs) before the baseline in 2015. The final list of research questions reflects those determined to be most relevant to USAID’s investments and that could not be answered by existing data.

The final research questions are organized into four thematic areas:

1. Quality of health care and services

• What is the state of the quality of care across Ghana in CHPS zones and health centers? • Is there a continuum of care throughout the health hierarchy from community to CHPS zone to

health center to district hospital? • What is the state of the quality of services? • Do facilities have access to needed medical supplies? • Do facilities have access to essential equipment? • How satisfied are clients with the quality of care and services provided?

2. Culture of QA and QI

• Are data used for making decisions related to health care and services? • Does the use of data for decision making lead to care or service improvements?

3. Community and governmental support for CHPS

• How engaged are communities in CHPS? Do they exhibit ownership and empowerment? • How do district assemblies support CHPS?


4. Health insurance

• Is the rate of National Health Insurance coverage increasing? • Does National Health Insurance coverage change how and where people receive care?

B. Evaluation Design

This evaluation of the performance of USAID’s health sector investments uses a pre-post design to identify changes in key indicators over time. The midline findings in this report provide interim values for these indicators, which are compared with pre-intervention values to measure changes over the two-year period of implementation, 2015 to 2017. An endline evaluation is planned for 2019.

C. Data Collection

The midline study relied on both quantitative and qualitative data collected by DevtPlan Consult, a Ghanaian data collection firm. Quantitative data collection occurred through a survey of community- and sub-district-level health facilities (CHPS zones and health centers) in all 10 regions of Ghana. The midline survey covered the same facilities that were sampled at baseline. This sample was representative of all CHPS zones and health centers in Ghana to provide national-level estimates. However, the study oversampled in five focal regions in which USAID invests most heavily — Central, Greater Accra, Northern, Volta and Western Regions — to provide precise estimates for this group. Like the baseline survey, the midline survey collected basic descriptive data about the sampled facilities, together with data on key indicators relevant to the research questions. All the sampled facilities responded to the facility survey, yielding a final sample size of 609 facilities (464 CHPS zones and 145 health centers), of which about two-thirds were in the USAID/Ghana focal regions.

To complement the facility survey, the study collected qualitative data in the five USAID focal regions through key informant interviews and focus group discussions on three levels: district (district directors of health services [DDHSs] and District Assembly [DA] members); sub-district (sub-district health team [SDHT] leaders and members); and community (CHPS zone clients, community leaders and community health committee [CHC] members). In total, the study team completed 169 qualitative interviews (151 key informant interviews and 18 focus groups) across the five focal regions. The report includes the data collection instruments and full data tables in the appendices.

D. Key Findings

The study triangulated information from the quantitative facility survey and qualitative interviews and focus groups to identify aspects of the health system that were working well at midline, key changes between baseline and midline and important remaining gaps in each of the study’s four thematic areas. The key midline findings, organized by thematic area, follow.

1. Quality of Care and Services

There were important improvements between the baseline and midline in the provision of several key services by facilities, although certain gaps remain.

At midline, CHPS zones and health centers improved service provision in key areas, including:

1. Comprehensive family planning services: Almost all facilities offered both contraceptives and family planning counseling services; almost all facilities with relevant control cards reported being able to provide long-acting methods of contraception on the day of the midline survey; two-thirds of CHPS zones and three-quarters of health centers reported being able to provide at least four modern methods of contraception.


2. CHPS zones deliveries: The proportion of CHPS zones conducting deliveries almost doubled to 49 percent in focal regions and 42 percent nationwide; per qualitative interviews, client demand for CHPS delivery services is very high.

3. CHV services: The range of services provided by CHVs increased broadly from baseline.

4. CHO routine home visits: the number of home visits carried out by CHOs more than doubled in focal regions and increased by 60 percent nationwide.

Some important gaps in service provision remained at midline, including:

1. Malaria treatment: Less than half of CHPS and health centers were adhering to the GHS malaria protocol that requires facilities to test all clients with a provisional diagnosis of malaria, record results, and provide and record treatment to all clients testing positive for malaria, likely constrained by the limited availability of rapid diagnostic tests (RDTs) and labs for malaria testing.

2. Identification of stunted and underweight children: While the large majority of facilities had a child nutrition register, the percentage of facilities maintaining child anthropometric information on height and weight-for-age decreased substantially at midline.

3. Poor physical infrastructure: Qualitative data suggest a need for more rooms to serve different types of clients, toilet facilities, staff accommodations, as well as compounds in the 28 percent of CHPS zones that lacked a compound.

4. Lack of transportation: This shortfall affected outreach, supplies and transport of clients to facilities.

At midline, CHPS showed improvements in their referral systems through increases in the number of clients returning with feedback notes after being referred out, and use of innovative technology to communicate referral information across facilities.

At midline, the percentage of clients referred to other facilities remained approximately the same as at baseline (4.8 percent at CHPS and 12.5 percent in health centers). Similarly, as at baseline, the most common reasons for referrals were malaria, pregnancy-related complications, anemia, hypertension, and injuries.

Similar to the baseline, the midline found that 43 percent of CHPS zones in focal regions and 48 percent nationwide did not maintain referral records on site. However, there were large improvements in the percentage of clients referred out who returned with feedback notes in both focal and all regions. For CHPS in focal regions there was a 20.6 percent increase from 21 to 41.5 percent of clients. For all regions, percent of clients increased from 25.8 to 44.3 percent. Qualitative interviews found evidence of innovations in referral processes, notably the use of mobile technology, such as short message service (SMS) and the WhatsApp platform, to communicate referral information across facilities.

Changes in staff capacity building between baseline and midline were mixed: high-quality capacity building (defined as training plus supportive supervision) on malaria topics decreased, while high-quality capacity building on some nutrition topics increased.

The proportion of facilities with staff recently trained in all three key malaria topics (malaria case management, RDTs and malaria in pregnancy) increased between baseline and midline for both types of facilities. At midline, about 60 percent of CHPS zones and 62 percent of health centers in focal regions met this standard. However, 30 percent of CHPS zones and 41 percent of health centers in focal regions (31 and 58 percent in all regions, respectively) had staff receiving high quality capacity building in the year prior to the study, defined as training on all the key malaria topics complemented by supportive supervision. When looking at the change from baseline to midline, the change in facilities that had at least one staff member trained in any aspect of malaria care (malaria-related topics in general) and who received supportive supervision in the previous 12 months decreased by 13 percentage points among CHPS zones nationwide, and 16 percentage points among health centers. However, the limited one-year timeframe referenced in the


midline study question might have underestimated the training and supportive supervision provided since baseline.

For nutrition, increases from baseline occurred in both types of facilities in terms of staff recently trained on both community management of acute malnutrition and management of acute malnutrition. However, the overall proportion of facilities with trained staff is far from universal; for example, only about a third of CHPS zones in focal regions had staff who received high quality capacity building (i.e. training plus supportive supervision) on these two topics. When all three key nutrition topics (community management of acute malnutrition, management of acute malnutrition, and infant and young child feeding) were assessed, only 19 percent of CHPS zones and 26 percent of health centers in focal regions had staff having received high quality capacity building. Nonetheless, for some individual nutrition topics, high-quality capacity building did increase between baseline and midline.

Although the availability of written treatment protocols continued to be limited at midline, facilities substantially increased compliance with standard guidelines for sanitation and infection control.

At midline, more than two-thirds of CHPS zones reported not having written MNCH protocols, and more than half reported not having written acute undernutrition protocols.

Facilities surveyed at midline substantially increased compliance with standard guidelines related to sanitation, sterilization, waste disposal, and exposure to contagious clients: these practices were in place in more than half of CHPS zones and about 90 percent of health centers at midline, a significant increase over the baseline. However, CHPS zones continue to face challenges in water and sanitation infrastructure. Only about a third of CHPS zones in focal regions and nationwide reported having access to piped or borehole water at midline, and only about half reported having a functional latrine or toilet.

Supply chain management significantly improved in both CHPS zones and health centers at midline; however, maintaining adequate stocks of medicines, supplies and equipment remains a significant obstacle to quality health care service provision.

The midline indicates that supply chain management significantly improved in facilities, most notably through increased availability and use of control cards. The average increase in the percentage of CHPS zones with control cards across all commodities examined at midline was 15 percentage points in the focal regions and 11 percentage points in all regions. At midline, control cards for all immunization commodities were available in about half of CHPS zones; control cards for most nutrition, malaria and family planning commodities were available in an even higher share of CHPS zones. The availability of control cards in CHPS zones that had been updated in the 30 days before the survey represented a substantial increase since baseline. Health centers also showed a broad increase in the availability of control cards and updated control cards at midline, exceeding 80 percent for most commodities.

Despite the increase in use of control cards, the midline did not find an accompanying systematic decrease in stock-outs. In general, stock-outs were occurring more frequently at midline in facilities that had experienced the lowest level of stock-outs at baseline. This might be related to the fact that although more than three-quarters of CHPS zones in focal regions had a dedicated person to order supplies, almost half had not used an official report requisition issue and receipt voucher (RRIRV) in the previous two months to reorder commodities based on consumption, and more than half did not have a standard operating procedures manual. However, district- and sub-district-level interviewees overwhelmingly suggested that the critical problem in the supply chain is not the monitoring system, but shortages of supplies at the district and regional levels. Per qualitative data, the situation appears complicated by the lack of timely NHIS reimbursements of claims, which hampers facilities’ ability to procure and obtain drugs and supplies in a timely fashion.

While key medical commodities were available on average in more than 80 percent of CHPS zones and almost 90 percent of health centers, data also indicated that more than 90 percent of CHPS zones and


health centers with control cards for key commodities (e.g. vitamin A, pentavalent, uterotonic drugs, malaria RDTs, artesunate and amodiaquine and injectable contraceptives) had commodities in stock that had expired.

In terms of equipment, only a few types of equipment increased in availability at midline, and increases were typically modest. Some evidence indicated a systematic increase in the availability of essential equipment for delivery in health centers, especially in the focal regions.

Despite improvements since baseline, availability of information communication technology was still limited at midline. For example, only about 19 percent of CHPS zones in focal regions had a computer at midline, and only about 8 percent had a computer with internet access.

Clients and community leaders continued to have a positive opinion of CHPS zones and health centers, although they recognized challenges in terms of supplies, equipment, infrastructure and staff.

As at the baseline, most clients interviewed had a very positive opinion of CHPS zones, and mentioned especially care of pregnant women and children. Most clients reported that waiting times were reasonable and that CHPS staff took time to interact with them and answer their questions. Overwhelmingly, clients felt satisfied with the treatment they received. Many district-level respondents in the Northern and Western regions also noted an increase in the number of CHPS compounds in the past two years, which expanded access to health services. Clients also reported satisfaction with the quality of care at health centers, and district and subdistrict-level respondents noted improvements since baseline in terms of more midwives, which they reported had led to more women giving birth in health centers instead of with traditional birth attendants.

However, respondents in all regions noted that care could still be improved. Areas identified for improvement included ensuring consistent treatment standards across facilities, maintaining a regular supply of medications, infrastructure additions and renovations (including facilities for clients, lab facilities, toilet facilities and accommodation for health workers) and increased staffing (e.g., having a doctor at health centers, as well as additional nurses and midwives). Respondents also mentioned transportation issues, noting a lack of available transportation, high costs of transport and poor roads affecting the ability to obtain supplies, conduct outreach and ensure clients’ access to facilities.

Awareness of the “GoodLife, Live It Well” campaign was very high, and clients’ recall of messages and reports of behavior change suggest receptivity to the messages.

GHS relaunched a national health promotion campaign, “GoodLife, Live It Well” in July 2016, using television, radio, social media and print materials to promote positive health behaviors in family planning, MNCH, malaria prevention and treatment and water, sanitation and hygiene. At midline, about three-quarters of CHPS zones and health centers reported using GoodLife, Live It Well campaign materials during health promotion activities. Almost all clients interviewed who were exposed to campaign messages reported changing behaviors since the campaign was introduced. The most often-cited changes were increased handwashing and sleeping under insecticide-treated bed nets. Although this cannot be considered definitive evidence of impact given the relatively small sample of clients and the possibility that clients reported desirable responses or are referring to other health promotion campaign materials, it does suggest that the campaign affected knowledge and attitudes to some degree.


2. Culture of Quality Assurance and Quality Improvement

Modest improvements occurred in formal quality assurance/quality improvement (QA/QI) activities between baseline and midline; however, facilities continue to conduct a range of QA/QI activities even without formal plans.

Health centers are expected to have a team focused on QA/QI activities that meets on a regular basis to discuss quality improvement efforts (CHPS zones are typically too small to support a team, and are normally part of the sub-district QA/QI team; however, they still have QA/QI plans). The midline suggests a modest increase in the percentage of health centers that reported having a QA/QI team, but only 36 percent of health centers in focal regions and 45 percent nationwide had active QA/QI plans at midline. Active is defined as having both a QA/QI plan in place and a QA/QI team that met at least once in the three months before the survey.

Midline data from qualitative interviews suggested that many facilities, both CHPS and health centers, continue to conduct a range of QA and QI activities despite the lack of a formal QA/QI plan. These activities included improvements in infrastructure, supplies, staff, client satisfaction, data quality and community outreach.

District- and sub-district-level stakeholders perceive that the quality of District Health Information Management System (DHIMS2) data has improved over the past two years.

District- and sub-district-level stakeholders reported that DHIMS2 data quality was good and has improved over the past two years, largely because facilities used the GHS guidelines for data reporting and validated data before submission. At midline, almost 90 percent of CHPS and 95 percent of health centers nationwide reported that they validated data against source documents before submission. Interviewees noted that the lack of access to computers and reliable internet connections continues to hamper accurate and timely data collection, storage, compilation and transfer.

Data are used for planning and decision-making at district, sub-district and facility levels.

The overwhelming majority of DA members interviewed noted that they use data to inform their health sector decision-making, though the frequency and formality of the process varied across districts. More specifically, many DA members mentioned use of data for development planning, responding to emergencies such as disease outbreaks and developing their health budget. All DDHSs interviewed reported using DHIMS2 data to track the performance of facilities and to inform decisions related to human resource allocation and training at health facilities. At the sub-district level, SDHOs reported actively using data for monitoring, QA/QI and decision-making, including adjusting services conducted at their facilities or outreach activities to respond to gaps in coverage or disease outbreaks. At midline facilities confirmed data use to plan community outreach, improve supply chain logistics, allocate resources and develop action plans. However, these proportions are similar to the baseline, suggesting that data use has not changed significantly in these facilities over the past two years.

3. Community and Governmental Support for CHPS

The proportion of CHPS zones with a CHC has seen a large increase since baseline, but qualitative data indicate that many CHCs do not function per official guidelines.

CHCs, composed of volunteers selected from the communities within each CHPS zone, are designed to serve as the link between health facilities and communities, with a focus on overseeing the health system at the community level and supporting CHVs. Between baseline and midline, the proportion of CHPS zones with a CHC increased from 54 to 91 percent in focal regions and from 63 to 94 percent nationwide. However, qualitative data indicated that many CHCs do not function per official guidelines, with notable


concerns including the frequency of meetings and their role in developing community health action plans (CHAPs). CHCs also continue to face several challenges that hamper their effectiveness, e.g., political disputes among communities served by a single CHPS zone, lack of financial incentives for CHC members to perform their required tasks and limited strategic planning engagement by CHCs with community members.

District level support for CHPS zones remains strong, despite funding challenges. Many districts also have strong relationships with USAID-funded projects.

DA members are informed about and interested in supporting CHPS zones and health centers in their districts. They support CHPS zones, primarily through providing funding for construction of CHPS compounds and provision of certain equipment. However, securing adequate funding for the required support remains an important challenge. Nearly all DDHSs and DA members interviewed have working relationships with USAID and are familiar with USAID-funded projects, which they report having had positive effects on their communities, especially RING, SPRING and Systems for Health.

4. Health Insurance

Membership in the NHIS at midline appears to be widespread, but slow payment of claims to facilities continues to be a challenge.

Qualitative interviews with clients and community leaders revealed that enrollment in an NHIS scheme is widespread throughout the focal regions. Most clients interviewed were insured and reported planning to renew their insurance when it expires. Nationwide, about two-thirds of CHPS zones and about 90 percent of health centers reported submitting NHIS claims in the two months before the midline, representing a small decrease since baseline. However, according to DDHS respondents, there are challenges with facilities receiving timely payments from NHIS to reimburse claims which causes problems in facilities’ ability to access drugs and supplies.

Insured clients at times must unexpectedly pay for medications or be referred to other facilities for treatment.

As at baseline, most clients reported in interviews that they received prompt, quality treatment at CHPS zones and health centers. However, at midline, some challenges related to NHIS coverage caught clients unaware. For example, because NHIS regulations restrict reimbursement of medications and treatment at different types of facilities, clients may be asked to pay for some medications and treatments or be referred to another facility where these are covered. In addition, some clients found that when stock-outs occurred, they had to pay for covered medicines because the facility had purchased them in the market, or clients would be sent to buy the medicine themselves.

E. Future Evaluation Plans

The midline findings in this report examine changes in key indicators relevant to USAID/Ghana’s health portfolio two years after the 2015 baseline. Although these findings cannot fully be attributed to the impact of USAID interventions, they do inform the understanding of changes in the Ghanaian health system coinciding with the projects. The midline findings also highlight several important remaining gaps in the coverage and quality of health care in CHPS zones and health centers. The endline survey, planned for early 2019, will similarly enable assessment of changes in key indicators four years after baseline. By then, some interventions will have ended and other ongoing interventions will have been implemented for a longer period. The endline should capture changes coinciding with more complete implementation of the latter interventions. The endline could also provide insights for the design of future interventions by GHS, USAID/Ghana and the development partner community to address remaining gaps in sub-district and community facility-based health care in Ghana.


1. INTRODUCTION

Ghana has invested substantially in public health and achieved advances in health outcomes in recent years, notably in terms of reductions to early childhood mortality and malnutrition rates and improvements in maternal health from 2004 to 2014 (Demographic Health Survey 2015). However, Ghana continues to confront the need for both expanded access to quality services and strengthened national and community-based health systems (National Community-Based Health Planning and Services Forum 2016).

To assist the country in meeting these challenges, the U.S. Agency for International Development in Ghana (USAID/Ghana) has sought to achieve the following improvements in the Ghanaian health system through its 2013–2017 Country Development and Cooperation Strategy (CDCS): (1) increased access to integrated health services; (2) expanded availability of community-based resources; (3) strengthened and responsive health systems; and (4) improved health sector governance and accountability. These improvements are intended to contribute to the CDCS development objective to achieve equitable improvements in health status in Ghana.

This report presents midline findings from a longitudinal study conducted as part of USAID’s Evaluate for Health (Evaluate) project. The Evaluate project, launched in September 2014 and implemented by Management Systems International (MSI), is designed to provide overall monitoring and evaluation support for USAID’s health portfolio in Ghana. The Evaluate midline study, which was conducted from February to March 2017, follows up its baseline study,1 which was conducted from February to April 2015. The midline study’s two main objectives were: (1) provide USAID and its primary client, the Ghana Health Service (GHS), with information on the current levels of key health indicators of relevance to USAID’s investments to guide current program implementation and improvement; and (2) assess changes in key health indicators over the two years from baseline to midline for an overall evaluation of USAID’s investments. (Final data collection and analysis will occur in 2019.)

MSI and its subcontractor, Mathematica Policy Research, designed and conducted the midline evaluation, which relied on primary quantitative and qualitative data. The study collected quantitative data through a survey of the same health facilities sampled in the baseline — community-based health and planning services (CHPS) zones at the community level and health centers at the sub-district level — across all 10 regions of Ghana. USAID’s interest focused on measuring changes in quantitative indicators in five focal regions in which it invests most heavily — the Central, Greater Accra, Northern, Volta and Western regions (see Figure 1and Appendix C – Table B for full list of IPs per region). However, the midline evaluation also measured changes in all 10 regions together, because some of USAID’s investments (particularly those related to malaria, maternal and child health, nutrition and supply chain) are not restricted to the focal regions and because GHS wanted to measure changes over time at the national level. The study collected qualitative data for the midline evaluation from community-level stakeholders and clients, sub-district health team leaders and district-level decision-makers in the five focal regions. Most stakeholders interviewed for the midline had not been part of baseline data collection.

Sections I.A, I.B and I.C of this introductory chapter describe USAID’s health portfolio in Ghana and the work of the GHS and list the key research questions that identified indicators for the evaluation. Section I.D briefly describes the performance evaluation design used to analyze changes over time in these indicators. This chapter concludes with a road map for understanding the content of the rest of the report.

1 http://pdf.usaid.gov/pdf_docs/PA00KW1F.pdf

http://pdf.usaid.gov/pdf_docs/PA00KW1F.pdf


FIGURE 1. FOCAL AND NON-FOCAL REGIONS FOR USAID’S HEALTH INVESTMENTS IN GHANA

A. Overview of USAID’s Health Portfolio

USAID’s health portfolio in Ghana aims to improve various aspects of the Ghanaian health system through investments in 21 projects or initiatives. (Figure 2 lists these projects or initiatives and indicates the health areas that each addresses). For this midline evaluation, the study team consulted with the implementing partners of the major USAID-funded health projects, which have been implementing their projects for varying periods of time, and reviewed their project monitoring and evaluation needs to guide updates and additions to the evaluation’s indicators. The section below briefly describes these eight five-year USAID-funded projects. Five of them contributed substantively to the baseline and the midline design: (1) Systems for Health (Systems); (2) Strengthening Partnerships, Results and Innovations in Nutrition Globally (SPRING); (3) the Maternal and Child Survival Program (MCSP); (4) Resiliency in Northern Ghana (RING); and (5) MalariaCare, with three new projects that launched in 2015 or 2016 consulted for the midline: (6) Communicate for Health (C4H); (7) WASH for Health; and (8) Global Health Supply Chain and Procurement Services Management (GHSC-PSM).


FIGURE 2. USAID PROJECTS AND INITIATIVES, BY TYPE OF INTERVENTION

Source: Implementing Partners Annual Reports FY2016. Intervention acronyms: CHPS, Community-Based Health and Planning Services; FP, Family Planning; HIS, Health Information Services; IPC, Infection Prevention and Control; MNCH, Maternal, Newborn and Child Health; M&E, Monitoring and Evaluation; QI, Quality Improvement; SC, Supply Chain; WASH, Water, Sanitation and Hygiene.

USAID’s flagship project, Systems for Health (Systems), is being implemented by University Research Corporation LLC from 2014 to 2019. It aims to increase the sustainability of the six fundamental building blocks of successful health systems: leadership and governance, health information systems, health workforce, medical products and technologies, health financing and service delivery. It includes activities that help balance supply and demand for health services and increase gender equity. Systems works in the areas of maternal, newborn and child health; family planning and reproductive health; malaria; nutrition; and infection prevention and control, using a quality improvement approach. It works at the national level on policy and governance and supports community-level health services through programmatic and infrastructure support for Ghana’s CHPS program, concentrating on USAID’s five focal regions.

John Snow Inc. implemented Strengthening Partnerships, Results and Innovations in Nutrition Globally (SPRING) from 2013 to 2017. The project aimed to reduce stunting by 20 percent in the two regions most affected by stunting and severe anemia—Northern and Upper East. SPRING’s activities addressed anemia reduction; infant and young child nutrition; water, sanitation and hygiene; aflatoxin reduction; and support to the Livelihood Empowerment Against Poverty (LEAP) Program, which provides cash transfers and health insurance. SPRING sought to improve nutrition services at facilities through supportive supervision, training and coaching and used a “1,000 Day Household” approach, which targeted households with pregnant women and children 2 years of age and younger.

Maternal Child Support Project (MCSP), implemented by Jhpiego from 2014 to 2019, is organized around three strategic objectives to improve reproductive, maternal, newborn and child health: supporting increased coverage and use of evidence-based, high quality interventions; closing innovation gaps to improve health outcomes among high-burden and vulnerable populations; and fostering effective policymaking, program learning and accountability. The project focuses on standardizing strategies, guidelines, training materials, tools and monitoring systems and on strengthening preservice education to midwives and nurses in training facilities across Ghana.

Resiliency in Northern Ghana (RING), implemented by Global Communities from 2013 to 2018, is a partnership effort under USAID’s Feed the Future (FTF) initiative. RING aims to contribute to efforts of the

CHPS FPHIV/ AIDS

HIS IPC Malaria MNCH M&E NutritionPre

Service Ed

QI SC WASH

1 RING (Global Communities)2 Systems for Health (URC)3 SPRING (JSI)4 MalariaCare (PATH)5 MCSP (JHPIEGO)6 WASH for Health (Global Communities)7 Communicate for Health (FHI360)8 GHSC- PSM (CHEMONICS) 9 Africa Indoor Residual Spraying (IRS) (Abt)

10Ghana Information for Improves Health

Performance (GIIHP) – Boston University 11 Ghana Social Marketing Program (PSI)12 HealthKeepers Network13 Health Finance and Governance (Abt) 14 People for Health (SEND)15 PreMaND (NHRC- Navrongo)16 RISK (WAPCAS)17 Saving Maternity Homes (Banyan Global)

18Sustaining Health Outcomes through

Private Sector (SHOPS) (Abt)19 United States Pharmacopeia (USP)20 Strengthening the Care Continuum (JSI)21 Vector Works/PMI (JHU)

Key

Mid

line

Stud

y IP

s O

ther

IPs

Implementing Partners


Government of Ghana (GoG) to sustainably reduce poverty and improve the livelihoods and nutritional status of vulnerable populations in districts across the Northern Region. The project includes several activities designed to support three complementary project components: increasing the consumption of diverse quality foods, especially among women and children; improving behaviors related to nutrition and hygiene among women and young children; and strengthening local support networks to address the ongoing needs of vulnerable households. It also works closely with district governments to bolster their capacity to carry out needs assessments and develop work plans, budgets and monitoring systems.

MalariaCare, implemented by Path from 2013 to 2017, works in seven regions in Ghana to improve malaria case management across the continuum of care—from communities to health facilities—in both the public and private sectors. The project collaborates with the National Malaria Control Program (NMCP) and other partners to build case management capacity at all levels of the health system. The main activities include strengthening quality assurance (QA) and quality improvement (QI) systems and supporting routine systems for malaria diagnostic services, monitoring and evaluation, with a focus on CHPS.

For the midline evaluation, the following IPs, whose projects launched in 2015, were also consulted.

Communicate for Health (C4H), implemented by FHI 360 over the period 2014 to 2019, focuses on support to the GHS to increase demand and use of key health services and commodities and to foster healthy behaviors. The project’s large-scale behavior change communications initiative, implemented in partnership with the GHS Health Promotion Division, is intended to expand the promotion of the “GoodLife, Live It Well” brand through national media campaigns and community-level messaging in USAID’s focus regions. The project addresses family planning; maternal, newborn and child health; nutrition; water, sanitation and hygiene; malaria; and HIV/AIDS.

WASH for Health (WASH), implemented by Global Communities over the period 2015 to 2020, in the five USAID focal regions plus the Eastern Region, and is designed to improve equitable and sustainable access to safe water and improved sanitation facilities and to strengthen community infrastructure and ownership. Its activities include expanding existing water facilities and repairing damaged boreholes, increasing the number of household or family latrines, and promoting improved sanitation behaviors and point-of-use household water treatments.

Global Health Supply Chain Program—Procurement and Supply Management (GHSC-PSM), is implemented in several countries worldwide by Chemonics and will operate in Ghana from 2016 to 2021. The program works to reduce costs and increase efficiencies in global and national health supply chains and to strengthen national supply chain systems and collaboration among supply chain stakeholders. The GHSC-PSM operates across all 10 regions of Ghana.

B. Ghana Health Service

To implement its health projects, USAID works closely with Ghana’s Ministry of Health (MOH) and its service provision agency, the Ghana Health Service (GHS). The MOH formulates policy, monitors and evaluates performance, and mobilizes resources to develop the health sector. GHS is responsible for maintaining high levels of performance in the provision of preventive and clinical care services as well as health promotion at the community, sub-district, district and regional levels.

Ghana’s national health policy, “Creating Wealth through Health” (MOH 2007), is executed through a series of medium-term development plans (MTDPs), the most recent of which covers the period 2014 to 2017 and identifies poor access to health services and the low quality of services as the most severe problems in the sector. To address these critical issues, GHS, in cooperation with the development partners, is implementing a strategy that emphasizes community involvement and the creation of CHPS zones to provide local-level health services and health promotion, including reproductive, maternal and child health services; treatment of diarrhea, malaria, acute respiratory infection and childhood illness; comprehensive family planning; childhood immunizations and health outreach. CHPS zones are staffed with community health officers (CHOs), who are usually trained community health nurses (CHNs) assigned to the zone. Community health volunteers (CHVs) support CHOs and are involved in educating the community on basic health issues and assisting with referral services and community social mobilization. CHPS services are delivered mainly


through home visits, although treatment is provided for clients who come to the CHPS compound, if there is one. The strategy relies on communities, government and private stakeholders to provide financial or in-kind resources for CHPS infrastructure and to provide oversight for service delivery and welfare of the CHOs. Currently, there are more than 3,000 CHPS zones across the 10 regions of Ghana.

During the time frame between the baseline and midline rounds, GHS adopted two key documents related to CHPS service delivery: a revised national CHPS policy, followed by the CHPS National Implementation Guidelines. The national CHPS policy document was proposed and discussed extensively beginning in November 2014 when the GoG declared CHPS a national priority. The MOH officially adopted the policy and guidelines in August 2016, accompanied by renewed investment by GoG and development partners in making CHPS zones functional through investments in infrastructure (e.g., construction of CHPS compounds), equipment (including transportation) and capacity building among health workers at CHPS and in the sub-districts. The guidelines also resulted in the development of specific protocols (e.g., antenatal care and acute malnutrition) to use at the national, regional, district, sub-district and community levels. Challenges remain, however, in ensuring the widespread availability and application of the revised guidelines and protocols, especially at the CHPS level.

Although the guidelines were not formally adopted until six months before the midline fieldwork, given the national attention accorded to the revised guidelines as of 2014, it is possible that several of the new guidelines influenced operations at CHPS zones in the period between the baseline and midline evaluations. The new CHPS guidelines cover the following areas:

• Basic required package of services (39 total, including maternal, neonatal and child health; reproductive health; treatment of minor ailments; health education and counseling; and follow-up)

• Health financing—role of local government, National Health Insurance Scheme reimbursement, and development partner contributions

• Leadership and governance—role of the District Director of Health Services and District Assembly (DA)

• Visits and meetings guidelines • Guidelines for referrals to and from facilities • Community engagement and community health action plan • Facility and resource management • Supportive supervision • Performance measurement and evaluation

C. Research Questions

The research questions that the evaluation sought to inform were identified through discussions with project stakeholders (USAID’s Health, Nutrition and Population Office and its primary implementing partners- see above) before the baseline in 2015. These discussions drew on a conceptual framework developed by USAID that illustrates the key pathways through which USAID’s investments are expected to result in changes in health outcomes (see Appendix A). Two main criteria determined the final list of research questions: first, which questions were the most relevant to USAID’s investments and of greatest interest to GHS, either for planning or evaluation purposes; and second, which questions could not be answered using existing data sources, such as the Ghana Demographic and Health Survey (DHS). Because of the wealth of data available on population-level questions, the final list of evaluation research questions focuses on questions that require answers on the facility level, using a quantitative survey, and from key community and district stakeholders, using qualitative interviews.

The study organizes the final research questions into four thematic areas:

1. Quality of care and services

• What is the state of the quality of care across Ghana in CHPS zones and health centers?


• Is there a continuum of care throughout the health hierarchy from community to CHPS zone to health center to district hospital?

• What is the state of the quality of services? - Are appropriate and complete suites of services offered? - Do staff have access to implementation guidelines? - Are staff trained?

• Do facilities have access to needed supplies? - Is access to supplies timely, or are there stock-outs? - Is the access to supplies through the supply chain sustainable?

• Do facilities have access to essential equipment? • How satisfied are clients with the quality of care and services provided?

2. Culture of QA and QI

• Are data used for making decisions? - What types of data are collected? - Are the collected data of good quality? - Are data disaggregated at usable levels (geographic and gender)?

• Does the use of data for decision-making lead to service improvements?

3. Community and governmental support for CHPS

• How engaged are communities? Do they exhibit ownership and empowerment? - Is there a community-to-care linkage? - Is there a community health committee (CHC)? - Are users educated about their health rights and empowered to press for them?

• How do district assemblies support CHPS?

4. Health insurance

• Is the rate of insurance coverage increasing? • Does insurance coverage change how and where people receive care?

D. Evaluation Design

The evaluation of the performance of USAID’s health sector uses a pre-post design to assess changes in indicators over time. The midline findings in this report provide interim values of selected key indicators, which are compared with pre-intervention (baseline) values to measure changes over the two years of implementation. An endline evaluation is planned for 2019 in the post-intervention period to measure changes over the entire four-year period, 2015-2019. The pre-post design reflects USAID’s desire to focus resources on an evaluation that can inform a diversity of projects nationwide, with more rigorous evaluation designs (such as random assignment) reserved for more targeted interventions. At each data collection time point, the study will describe quantitative outcomes at the national level (all regions) and for the five focal regions as a group. Reporting the levels of the outcomes for the focal regions as a group will enable measurement of changes for the focal regions over time and illuminate how those translate into changes in national indicators. For certain USAID interventions—notably those related to the MalariaCare and MCSP projects—national-level changes are more relevant because these projects are not restricted to the focal regions.

An important caveat of the pre-post evaluation design is the inability to attribute any documented changes specifically to the USAID interventions given the number of confounding factors and variables at play in the regions, such as trends over time or interventions by the GoG or other agencies. Nonetheless, it will be valuable to document trends in outcomes of importance to the health sector and in which USAID has invested, and use qualitative information to assess the extent to which the USAID interventions might have contributed to the observed changes. Additionally, these documented trends in outcomes may assist in generating new hypotheses for various additional health-related assessments or studies.


E. Road Map of the Report

Chapter II covers the data sources used in this midline evaluation, including the quantitative and qualitative components, and the basic characteristics of the public health facilities in the midline sample. Chapters III through VI present findings related to the four thematic areas addressed by the research questions: (1) the quality of care and services, (2) the culture of QA and QI, (3) community and governmental support for CHPS and (4) health insurance. Finally, Chapter VII summarizes the findings, discusses implications and outlines the timeline for the endline evaluation.

II. DATA SOURCES AND ANALYSIS APPROACH

This chapter describes the data collected for the midline evaluation and briefly summarizes the characteristics of the health facilities that were the focus of data collection. As mentioned in Chapter I, the study collected longitudinal quantitative data from a sample of health facilities in all 10 regions of Ghana and qualitative data from health sector stakeholders in the 5 focal regions. DevtPlan Consult, a local data collection firm, conducted all data collection activities from February to March 2017, following interviewer training by MSI and Mathematica in January 2017. This chapter starts with a brief description of the structure of the health system in Ghana, then describes the samples and types of information gathered as part of the quantitative and qualitative data collection efforts (for further details on the sampling, data collection and analysis approach, see Appendix B). The chapter ends with a brief summary of the characteristics of the health facilities.

A. Structure and Functions of Ghanaian District Health System

The structure of the GHS was used to identify the appropriate health facilities for the quantitative survey. At midline, the overall structure of the GHS and its service provision, in line with government legislation (1996 GHS and Teaching Hospitals ACT 525), had not changed from the baseline. Administratively, the public health system continues to operate at national, regional and district levels with service provision organized along these levels. The district level remains the lowest administrative unit of the local government structure and shares the same boundaries as the health service delivery system—the Office of the District Chief Executive and the District Assembly (DA) exercising administrative oversight.

The district-level health delivery system is further organized into three tiers of service delivery systems, in which static and outreach systems provide most services to the general population. These include district hospitals (mostly at the district capital), health centers in the sub-districts and CHPS Zones in communities. Both the midline and baseline studies focused on service provision elements at the sub-district and community levels.

As illustrated in Figure 3, within each district, health service delivery and the local government structures and services are defined by the same borders and are organized in a three-tier hierarchy that includes the community level (with CHPS), the sub-district level (with health centers) and the district level (with district hospitals).2

• At the community level, households are linked to a specific CHPS zone, a geographical area that covers about 750 households (a population of about 5,000). CHPS zones deliver basic preventive and curative primary health care services to households. They provide treatment for minor ailments such as vomiting and diarrhea, first aid and maternal services. CHPS zones have developed at different rates throughout the country. Some already offer nutritional rehabilitation, adolescent health and development, prevention of mother-to-child transmission of HIV and early-infant diagnosis. A CHPS zone can include a structure or compound in which CHOs provide services, but not all CHPS zones have compounds. When that is the case, services are provided at other venues, including outdoors. CHPS zones typically include a CHO—a trained CHN who might be assigned to

2 The health system also includes polyclinics, which serve urban populations much as health centers serve rural populations. However, there are only a few of these facilities and, as we note later, our facility survey sample did not include them.


a community within the zone—and trained community health volunteers (CHVs), nonsalaried community members who assist the CHOs. CHPS zones are typically managed by community health committees (CHCs) composed of community leaders drawn from the CHPS zone who volunteer to provide community-level guidance to their CHPS, mobilize the planning and delivery of health activities and oversee the welfare of the CHOs in their communities.

• At the sub-district level, health centers provide preventive, curative and outreach services to the communities in their catchment areas. They also provide reproductive health, delivery and minor surgical services such as suturing. They are the first point of referral for CHPS zones. In general, a medical or physician assistant leads the health centers and they are staffed with program heads in the areas of midwifery, laboratory services, public health, environment and nutrition. Each health center serves a population of 20,000 to 30,000. Depending on the size of a sub-district, there could be up to five health centers, or none at all.

• At the district level, district hospitals serve a large population of 100,000 to 200,000 and provide more advanced care, surgical services and public health services. Health centers can refer severe or complicated cases to the relevant district hospital.

FIGURE 3. PRIMARY HEALTH CARE ORGANIZATION IN GHANA

Source: CHPS National Implementation Guidelines (2016).

B. Quantitative Data Collected Through Facility Surveys

Discussions during the baseline study design with USAID, GHS and other stakeholders allowed identification of community- and sub-district-level health facilities (CHPS zones and health centers) as the appropriate sites for the facility survey, given that these lower-level health facilities are the primary locations at which Ghanaians receive basic health services. These services are the most relevant to address the study’s research questions. The midline survey included the same facilities that were sampled at baseline.

USAID’s interest in examining levels of and changes in key outcomes for the five focal regions and at the national level influenced the study’s sampling approach. To describe key outcomes associated with USAID’s investments in Ghana’s health care system, the quantitative survey required a representative sample of CHPS zones and health centers in all 10 regions. In addition, the sample had to provide sufficient statistical power to detect meaningful changes in outcomes, especially for the five focal regions, while supporting a practical and feasible data collection strategy. The study used a two-stage sampling scheme to select the facility sample by first randomly selecting districts in each region, then randomly selecting sub-districts in each sampled


district, and including in the survey all health centers and CHPS zones within each sampled sub-district at baseline. The study used proportional sampling within each type of region, and oversampling from the five focal regions, guaranteeing a sufficient sample for the focal regions alone and, with reweighting, a sample representative of all 10 regions.3 (Appendix B describes the sampling approach in more detail.)

USAID and IPs would have liked data with more disaggregation, including the regional and district levels. However, the sample size required to produce reliable estimates at these levels would have been very large and resource-intensive. Due to budget constraints and other design decisions, the samples for the quantitative survey were not large enough to provide statistically precise estimates at the regional or district levels. Rather, the evaluation sought to provide precise estimates at the national level or for the five focal regions as a group.

Mathematica designed the baseline and the midline survey instruments with substantial input from MSI and its local Evaluate staff, USAID, IPs and GHS. Both surveys collected basic descriptive data about the sampled facilities and a range of indicators relevant to the research questions, focusing on the quality of health care and services, the culture of QA and QI, community support for CHPS and health insurance. Table 1 summarizes the sections and key topics covered by the midline facility survey; Appendix E provides a text version of the survey as it was programmed into the computer-assisted personal interviewing tablets used for data collection.4

TABLE 1. MIDLINE SURVEY SECTIONS

Section Key topics covered

Identifying information

Name of facility, region, district, sub-district, global positioning coordinates and location description, Type of facility, Respondent’s name, job title, and length of tenure

Facility descriptive information

Number of CHVs, community health meetings (durbars)—number, topic, organization; number of clients; presence of working computer, cell phone and camera; access to texting, multimedia sharing and Internet

Quality of health care and services

Referrals to and from facility—number and reason; availability of written care protocols; sanitation, sterilization, disposal and contagion control measures; water source type and presence of functioning toilet or latrine; malaria testing and treatment protocols; training—topic, training type, provider, and type and number of staff trained; supportive supervision; access to essential medications, equipment and supplies; stock-outs; childbirth delivery (regular and emergency), antenatal care, family planning counseling and contraceptives, and malaria in pregnancy; home visits—number and type, health promotion—GoodLife, Live It Well Campaign

Culture of QA and QI

Data collection—type and frequency; referral records; childbirth delivery registers, antenatal services registers, neonatal and maternal mortality records, and nutrition registers or record books; data entered into registers; extent to which data are current; malaria tracking and data capture, and reporting; training in these areas; QA and QI team, activities, action plans, progress — reported, tracked or monitored, displayed and up to date; data validation; uses of data; inventory control tracking, planning, and ordering

Community support for CHPS

CHCs—existence, type of work and quality of work; recruitment of CHVs, services they provide and support they receive; community health action plans

Health Insurance

National Health Insurance Scheme (NHIS)—Health facilities submitting claims, number of clients who are members, knowledge about coverage under the NHIS.

3 The survey sample consisted of an average of 8.4 districts per region in the focal regions (39 percent of districts in each focal region) and 5.0 districts per region in the nonfocal regions (25 percent of districts in each nonfocal region). Districts contain about 4.0 sub-districts on average. A random sample of three sub-districts was selected from each selected district. The facility sample represented about 23 percent of all such facilities in Ghana. 4 USAID and the IPs are interested in tracking a wide range of indicators. This report focuses on key indicators, with the full set presented in Appendix D.


The response rate to the facility midline survey was 100 percent among targeted facilities. The final sample size included 609 facilities, including 464 CHPS and 145 health centers, of which about two-thirds were in the focal regions.5

In all instances, interviewers interviewed either the person overseeing the operation of the health facility at the time of the midline survey or a trained staff member. For CHPS zones, the most common type of respondent was a CHN or enrolled nurse (55 percent) or a CHO (34 percent); for health centers it was a midwife (35 percent) or the medical or physician assistant in charge of the facility (26 percent) (Figure 4A & 4B). Most (81 percent) of the respondents had worked in their role at the CHPS for at least one year, and thus should have good knowledge of what was taking place in the facility. At sampled health centers, 79 percent of respondents had worked in their role at the health center for at least one year (Appendix C, Table A).

After receiving consent for the interview, interviewers asked respondents to collect up to 22 types of records, registers and reports for reference during the interview (Appendix E includes the full list on page 7 of the survey). Health centers typically had most of the requested documents. Most CHPS also had good documentation regarding the basic services they render, such as immunizations, community visits and weighing children. For CHPS zones without a compound (28 percent of CHPS zones), records were more

limited, because storage was a challenge. Interviewers were instructed to request documents to verify data for questions whenever possible; when documents did not exist, facility staff gave their best estimates. Interviewers generally did not record whether responses to specific questions were based on documents or were self-reported, except for a small number of indicators. For these indicators, interviewers recorded whether they verified the data. The tables in Appendix D disaggregate the data accordingly when possible. Data presented in the body of this report combine numbers reported by respondents and observed in record books. In general, there could be some over-reporting of desirable responses, however when feasible, the study team triangulated responses from different perspectives (community, sub-district and district level; and/or qualitative and quantitative) to obtain a more complete picture.

C. Qualitative Data Collection

To complement the facility surveys, the study team collected qualitative data in the five focal regions, focusing on one district in each region. The study team purposively selected these five districts during the baseline with input from USAID and its IPs. The same districts were used for midline data collection. Selection criteria included districts in which IPs had begun work early in their projects’ implementation

5 The response rate for the baseline was 98 percent, with a final sample size of 597 facilities. The 12 facilities interviewed at midline but not at baseline were dropped from the analyses in this report to avoid changes in the sample size driving the estimated changes over time.

CHO, 34%

CHN or enrolled

nurse, 55%

Midwife or public health nurse

midwife, 12%

FIGURE 4A. CHARACTERISTICS OF RESPONDENTS OF CHPS SURVEY

CHO, 3%CHN or enrolled nurse, 15%

Midwife or public

health nurse

midwife, 35%

Medical or

physician assistant

in charge , 26%

FIGURE 4B. CHARACTERISTICS OF RESPONDENTS OF HEALTH

CENTERS SURVEY


periods or districts that were somewhat representative of the region as a whole. Within each of the five selected districts, the Evaluate team selected two sub-districts sampled for the survey in which to collect qualitative data. Criteria for selecting the sub-districts were similar to those used for selecting districts, but ease of access was an additional criterion. Within each selected sub-district, the team selected two communities, using the same criteria as were used for sub-districts. Once again, interviewers for the midline data collection returned to the same communities selected for the baseline.

The main modes of qualitative data collection were key informant interviews and focus groups with six types of participants (see summary in Table 2):

• District level. Two types of decision-makers were interviewed in each selected district. One was the district director of health services (DDHS), who is the head of the district health management team (DHMT) and the official responsible for tracking health issues for GHS in each district. The DDHS provided important perspectives on the process of making and implementing district-level decisions about health care delivery and changes in the past two years. The second type of decision-makers interviewed was District Assembly (DA) members, who are elected and play an integral role in the socioeconomic development of their communities. Interviewers attempted to interview the district coordinating director and the chair of Social Services Subcommittee, as these DA members are expected to have knowledge about and provide support to the health services in their districts.

• Sub-district level. In each of the selected sub-districts, interviews were conducted with the sub-district health team leader (SDHT leader). SDHT leaders coordinate the management of the sub-district health team and are expected to know about the health services in their sub-district. They also collect health data from CHPS zones and incorporate the information into the District Health Information Management System (DHIMS 2) national database.6 The SDHT leader could be a health center in-charge and is often a public health nurse or disease control officer. A second interview in each sub-district was conducted with another sub-district health officer (SDHO) such as the health information officer. These interviews sought to improve our understanding of community engagement in health care, QI in the CHPS zones and health centers and data in CHPS zones and health centers, particularly with regard to record keeping, reporting and evidence-based decision-making.

• Community level. To gain the community-level perspective on the quality and delivery of health services, interviews and focus groups were conducted with three types of local-level participants in each selected community: (1) CHPS zone clients to obtain their perspectives on health care delivery and quality (about one-third had also been clients of health centers); (2) community leaders including chiefs, an assembly member, school leaders, religious leaders and others who play important roles in their villages or towns, for insights on facility care and community support; and (3) members of a CHC for their views on CHC support for community-based health activities in CHPS zones.

Participation in the interviews and focus groups was very high, with more than 96 percent of the targeted interviews completed. In total, 169 qualitative interviews (151 key informant and 18 focus groups) were completed across the five focal regions (Table 2). Two focus groups with CHCs were not possible as no CHCs existed in the communities chosen at the time of the midline, and four interviews with sub-district health management team leaders could not be conducted in four sub-districts that did not have health information or disease control officers. These issues were concentrated in the Western and Volta regions.

6 DHIMS2 is a comprehensive health information management system, now in its second edition, that collects data across all facilities and aggregates performance information to monitor health outcomes and improve service delivery. GHS instituted the electronic database for reporting and analyzing routine health service data at every level of the GHS. CHPS zones send their data to the sub-district or the district level to have them entered into this nationwide database.


TABLE 2. SAMPLE SIZES FOR QUALITATIVE DATA COLLECTION

Data source Geographic area Mode

Number of interviews or

FG per geographic

area

Number of geographic

areas

Total interviews or FG targeted

Total interviews

or FG completed

District

DA members District Interview 2 5 10 10

District director of health services District Interview 1 5 5 5

Sub-district

Sub-district health officers Sub-district Interview 2 10 20 16

Community

Health care clients Community Interview 4 20 80 80

Community leaders Community Interview 2 20 40 40

CHC members Community FG 1 20 20 18

Total key informant interviews 155 151

Total focus group interviews 20 18

Total interviews 175 169

Table 3 summarizes the data collected from each participant type to inform outcomes regarding quality of care and services, the culture of QA and QI, community and governmental support for CHPS and health insurance (Appendix F contains the qualitative data collection protocols).

All qualitative interviewers spoke both English and Twi, a dialect of the Akan language understood by a majority of Ghanaians, which ensured linguistic coverage for most interviewees. Given time constraints, it was agreed that a formal written transcription of the full set of community-level protocols was not practical. However, an audio recording of key words was prepared by a native Twi speaker, which was reviewed and used for reference by the interviewers. The interviewers did encounter language barriers for certain client interviews in the Northern Region when community respondents spoke neither English nor Twi. In such cases, translators who spoke Dagbani, the most common Northern dialect, were used. This limitation will be addressed in the endline evaluation by adding Dagbani to the mix of languages for qualitative interviews.

To benefit from cultural, lingual and budgetary advantages related to local data collectors, the study team selected a skilled team of local qualitative interviewers, most of whom had participated in the baseline study and all of whom had health sector experience or knowledge. To ensure that the interviewers had a clear understanding of the focus of the qualitative protocols they underwent an intensive interactive training on the protocols, including mock interviews in the classroom and pretest interviews in the field. The study team also participated in direct field observations of the interviewers at the start of fieldwork. To ensure continuous learning in the field, the qualitative team debriefed each evening, and their team leader remained in close contact with the study team throughout the fieldwork to discuss updates and answer any questions she might have. The qualitative team also took reflective as well as descriptive notes daily throughout the data collection period. Interviewers also reviewed and edited their interview transcripts and notes at the end of the field period and submitted a report of their summary observations and findings. This process will be maintained for the endline.

This process generated a rich qualitative data source that provides important insights into the health care services provided in the focal regions. The large number of respondents that included a variety of stakeholders ensured that the study captured a range of perspectives that were triangulated within and across stakeholders. When responses were inconsistent, similar and disparate responses were compared to understand the full scope of possible perceptions and experiences. However, the findings from the qualitative analyses might not be generalizable beyond the study sample.


TABLE 3. QUALITATIVE DATA TOPICS BY TYPE OF RESPONDENT

Participant type Key topics covered

District Directors of Health Services

Quality of district health care and services and access to supplies Availability and use of treatment guidelines and protocols at local and sub-district facilities Use of DHIMS 2 data in decision-making Collaborating with the District Assembly and USAID on health initiatives Community-level engagement and support for CHPS zones in their districts

District Assembly members

Perceptions of the quality of care and community engagement in their district Ways in which District Assemblies support the health system How decisions are made regarding health service delivery and the extent to which data inform decisions Whether and how they collaborate with USAID and suggestions to make collaborations more fruitful

Sub-district health officers

Quality of sub-district health care and services Integration of care through the referral system Disease outbreak and control Availability and use of treatment guidelines and protocols at CHPS and HCs Quality of data and data collection and tracking Use of data by facilities to inform health-related and other decisions, Access to supplies and use of tools and mechanisms for supply chain management Community engagement

CHPS zone clients

Health clients’ rights Use and satisfaction with CHPS zone services Use and satisfaction with health center services Health Promotion through GoodLife, Live it Well How their community engages with the CHPS zone Health insurance

Community leaders

Health clients’ rights Perceptions of the quality of CHPS zone care and services Linkages between communities and health care, such as through community support for CHPS zones, the work of their CHCs, community action plans and other community engagement Health insurance

CHC members

The use of Community Health Action Plans (CHAPs) Client referral system CHC roles, responsibilities and operation - How CHCs support CHPS zones including CHVs Community engagement, support and linkages with CHPS CHC linkages with the DA Health insurance

D. Analysis Approach

Quantitative data. The quantitative data analysis accounted for the sampling design. The reported means have been weighted to account for different sampling probabilities, largely driven by different proportions of districts sampled in the focal and nonfocal regions.7 These weights ensure that the results are representative of all CHPS zones or health centers in the focal and nonfocal regions, as well as for all regions combined. The baseline and midline data were analyzed in Stata version 14 (StataCorp) using the appropriate “svy” set of commands to obtain the correct standard errors for the estimated differences, taking the sampling approach into account. Using the survey data, the analysis for this report seeks to describe the baseline and midline characteristics of the sample across key indicators for the group of five focal regions and the country as a whole, to estimate the changes for these indicators between baseline and midline and to assess whether those differences are statistically significant (at the 1, 5, or 10 percent level of significance) (See Appendix B).

Qualitative data. For the qualitative data, the study team used NVivo to code the qualitative transcripts by question number, which were matched to analytic categories. The study team analyzed the coded data for each relevant concept by triangulating information from multiple sources and identifying major themes that emerged from the data related to the research questions. This analysis enabled the team to develop a key set of qualitative findings that took into account similarities and differences in perspectives across different participant types, providing a comprehensive picture of concepts of interest. (See Appendix B).

7 Some variation also occurred in the number of sub-districts in each district, and some rounding approximations.


III. QUALITY OF CARE AND SERVICES

Quality of health care services in rural settings is a major determinant of health outcomes and can influence the extent to which community members use or seek health care services. This chapter describes the scale of service provision at CHPS and Health Centers, the various dimensions of the quality of care and of services provided by facilities in the focal regions and all regions and how these have changed from baseline to midline. In terms of quality of care and services, this chapter first examines the integration of care by assessing the existence, functionality and dynamics of a referral system between health facilities. Then it describes the availability of key health services; assesses the quality of health care staff, measured by their receipt of training in key areas; and examines standards of care, measured by the availability and use of treatment protocols and sanitation measures in the facilities. Lastly, this chapter looks at the availability of supplies and equipment and explores clients’ satisfaction with care received at these facilities.

KEY FINDINGS FROM THIS CHAPTER

• Both CHPS zones and health centers improved in several key areas of service provision between the baseline and midline, notably in the provision of comprehensive family planning services and in the number of facilities that conduct deliveries. However, some important gaps in service provision remain unchanged, such as appropriate malaria testing and treatment, and others decreased, such as maintenance of key child health and nutrition data.

• At midline, more than half of CHPS zones still did not keep referral records; however, there were substantial increases since baseline in the percentage of clients referred from CHPS zones who return with completed referral feedback notes. Showing positive trends in terms of clients referred to another facility and in use of mobile technology to communicate referral information across facilities.

• Changes in staff capacity building between baseline and midline were mixed: high-quality capacity building (defined as training plus supportive supervision) on malaria topics decreased, while high-quality capacity building on some nutrition topics increased.

• Although the availability of written treatment protocols continued to be limited at midline, facilities substantially increased compliance with standard guidelines for sanitation and infection control.

• Supply chain management significantly improved in both CHPS zones and health centers at midline, however, maintaining adequate stocks of medicines, supplies and equipment remains a significant obstacle. Key challenges include financial constraints and stock-outs at the regional level.

• Clients and community leaders overall continued to have a positive opinion of CHPS zones and health centers, although they recognized challenges in terms of supplies, equipment, facilities and staff.

• Awareness of the “GoodLife, Live It Well” campaign was very high and clients’ recall of messages and reports of behavior change suggest receptivity to the messages.

A. Service Provision at Health Facilities

This section summarizes data from the facility survey and qualitative interviews on the scale and scope of health service provision at CHPS zones and health centers, to set the stage for the discussion of quality of care and services below.

1. CHPS Zones

The facility survey collected data on the number of clients who received services at each CHPS zone in the two months before the survey. Table 4 shows that the nationwide average number of clients for a CHPS zone was highest for services for children, with a mean of 272; however, the number varied substantially across CHPS. Qualitative interviews with clients showed that the most common examples of CHPS child care services were weighing and immunizing children during child welfare clinics (CWCs), either on scheduled days within the community or at the CHPS compound. Clients also indicated they took their


children to the CHPS zone when the children became sick. Survey data show that outpatient departments were the next most highly used services, with a nationwide average of 159 clients in the two months before the survey. CHPS zones in the five focal regions, on average, served more clients than those in the nonfocal regions for every service or department listed.

2. Health Centers

Nationally, health centers on average served most clients in their outpatient departments, with a mean of 1,110 clients in the two-month period before the survey. However, similar to CHPS zones, facilities varied significantly in the number of clients served. The second most common reason to visit a health center nationally was seeking services for children, with a mean of 749 clients in the two months before the survey.

TABLE 4. SCALE OF SERVICE PROVISION AT FACILITIES

Type of Service CHPS Zones Health Centers

Focal regions All regions Focal regions All regions Average (mean) number of clients facility has seen in previous two months:

At outpatient department 181 159 1,000 1,110 By the midwife 171 87 298 237 For family planning 68 52 184 188 Who were children 311 272 819 749 At prevention of mother-to-child transmission of HIV and early infant diagnosis unit 13 10 82 61

At adolescent health and development center 14 14 90 66 At nutritional rehabilitation center 82 46 461 247

Median number of clients facility has seen in previous two months: At outpatient department 144 91 696 886 By the midwife 12 5 150 128 For family planning 42 32 115 95 Who were children 225 207 583 553 At prevention of mother-to-child transmission of HIV and early infant diagnosis unit 0 0 33 33

At adolescent health and development center 0 0 0 5 At nutritional rehabilitation center 0 0 0 0

Source: Health, Population and Nutrition Office Health Systems baseline and midline survey data.

B. Integration of Care: Referrals and Follow-Up Care

An effective referral system ensures close relationships among various levels of the health system, ensuring people can receive the best possible care close to home, while making effective use of hospitals and primary health care services. CHPS zones and health centers are expected to follow standardized procedures for providing referrals and follow-up care to clients. In particular, these facilities are supposed to refer clients to other health facilities depending on the condition of the client, proximity to the referral destination and type of care the client requires.

Facilities mainly use paper referral forms to send clients’ information to the referral facility; however, qualitative interviews with DDHSs and SDHTs showed that facilities also use phone calls to communicate among themselves regarding referrals. In addition, qualitative interviews revealed that at midline some facilities used text messages or WhatsApp platforms to proactively notify a referral facility about a particular client’s referral. Interviews in the focal regions indicated that the formalized use of this new technology in the referral system varied by location. For example, in the Western region, a DDHS reported that facilities use SMS to communicate referral information when they cannot do so by phone. In Greater Accra, the system is more formalized. A DDHS and a SDHO both noted that the district information officer (DIO) distributed to all SDHO mobile phones that contained the phone numbers of CHNs. Moreover, they set up a district WhatsApp group to inform facilities of referrals and provide clients’ information needed for follow-up with CHPS zones. Interviewees in other districts and sub-districts also mentioned efforts to improve the


referral process, such as using a coordinator to relay information between facilities and holding quarterly meetings to review all referred cases. Those using these new technologies confirm that they facilitate more effective communications and follow-up services for referrals.

The referral system between the CHPS and the health center works … because they know each other. When they are referring anybody from the CHPS to the health center they are able to communicate through phone or a WhatsApp platform. We have a district WhatsApp platform where they share information, so if they are referring any case to the health center, they are able to call their colleagues or the one they are referring the case to that, ‘Oh, this one is coming’ or the other way round. The health center also refers some cases to the community health nurses at the CHPS level to follow up, as in mothers who have delivered at the health center, or family planning clients. They are able to call them—the community health nurses at the CHPS level—to follow up on those clients at the community level.—DDHS, Greater Accra

The facility survey captured the number of clients referred in the sampled CHPS zones and health centers.8 The findings suggest that the overall share of clients referred out of CHPS zones and health centers at midline was very small. Only 5 percent of clients in CHPS zones in the focal regions and nationwide were referred out, while 13 percent of health center clients in the focal regions and 19 percent nationwide were referred out (Table 5).9 Less than 1 percent of clients were referred into health centers in focal regions and nationwide.10 These numbers were very similar at baseline.

TABLE 5. REFERRALS OUT OF AND INTO A FACILITY (% OF FACILITIES, UNLESS OTHERWISE INDICATED)

Percentage of CHPS Zones Focal regions All regions Baseline Midline Difference Baseline Midline Difference

No referral records 39.4 42.8 3.4 40.7 48.4 7.7**

No record for most recent referral 46.6 44.3 -2.3 47.5 49.3 1.8

Referrals in previous two months: Average percentage of all clients seen who were referred out of the facility 4.0 4.8 0.8 4.3 5.4 1.1**

Average percentage of clients who were referred out who returned with feedback notes, among facilities that referred clients out

21.0 41.5 20.6*** 25.8 44.3 18.4***

Percentage of Health Centers Focal regions All regions Baseline Midline Difference Baseline Midline Difference

No referral records 12.0 12.1 0.1 8.9 6.2 -2.7

No record for most recent referral 13.2 13.2 0.1 9.5 6.8 -2.7

Referrals in previous two months: Average percentage of all clients seen who were referred out of the facility 11.9 12.5 0.6 15.4 18.9 3.5

Average percentage of all clients seen who were referred into the facility n.a. 0.1 n.a. n.a. 0.1 n.a.

Source: Health, Population and Nutrition Office Portfolio Health Systems baseline and midline survey data n.a. = not applicable (question not asked at baseline, or not comparable).

The study team also examined whether facilities maintained records of referrals, which better ensure the referring facility can follow up with clients, and found that recordkeeping at midline was still more prevalent at health centers than CHPS zones and that the lack of availability of referral records is still a challenge.11

8 The number of clients referred was measured by asking respondents to the facility survey to use referral records when they were available and or to self-report when they were not (we did not distinguish between responses based on records and self-reports). As discussed later in this chapter, referral records were available in about half of the CHPS zones and the vast majority of health centers; therefore, there might be more measurement error in the numbers for CHPS zones, which are more likely to be based on self-reports. 9 For this table and all subsequent tables, the following definitions should be used for stars indicating statistical significance FOR THE DIFFERENCE OF THE ESTIMATES FOR BASELINE AND MIDLINE: *** statistically significant at the 1 percent level; ** statistically significant at the 5 percent level; * statistically significant at the 10 percent level. 10 The percentage of clients who were referred into health centers (1 percent) is not directly comparable to the percentage who were referred out of CHPS zones (5 percent), because these percentages depend on the number of clients seen at each facility, which is generally much higher in health centers. 11 We asked respondents to the facility survey whether they had referral records. We did not ask about specific types of referral records, such as referral booklets.


According to the facilities survey, at midline, about 43 percent of CHPS zones in focal regions and 48 percent in all regions had no referral records (Table 6). Although there was no statistically significant change in this percentage between baseline and midline in focal regions, there was an increase of about 8 percentage points in all regions in CHPS zones without referral records, indicating a deterioration in referral record-keeping. The percentages of CHPS zones without records for the most recent referral at midline were very similar.12 About 44 percent of CHPS zones in focal regions and 49 percent in all regions had no referral record for the most recent referral, and there was no statistically significant change between baseline and midline. The similarity in the proportion of CHPS zones with no referral records and with no record for the most recent referral suggests that most CHPS zones that keep records do so consistently. There is no evidence of a change in the proportion of health centers without referral records in general, or without referrals records for their most recent referral, across both groups of regions. However, these percentages were much lower than for CHPS zones—for example, only about 12 percent of health centers in focal regions and 6 percent in all regions had no referral records at midline. Again, evidence suggests that most health centers that keep records do so consistently, as both focal regions and all regions were only one percentage point higher in having no records for the most recent referral.

CHPS zones and health centers that refer clients to other facilities report referrals related to a variety of health issues. In facilities nationwide that provided any referrals in the two months before the midline, the most commonly specified health issues for referrals were malaria or severe malaria, pregnancy-related complications, anemia, hypertension and accidents and injuries (Figure 5A).13 The frequency with which most health issues were mentioned as reasons for referrals from CHPS zones did not change between the baseline and midline, with a few exceptions. For example, among CHPS zones, there is some evidence that more clients were referred out at the midline than baseline for hypertension in both

12 This was measured by asking respondents to the facility survey whether the most recent referral was recorded. In many cases, this could be verified by checking the name of the client against the referral records. However, there could still be some measurement error in this indicator if respondents do not accurately recall the most recent referral. 13 Due to the seasonality of some illnesses, the timing of this survey could affect the responses received. However, the baseline and midline surveys were conducted at the same time of year, so this information is comparable across the two rounds.

55.80%

44.10%

31.40%

24.80%

15.30%

47%

47.70%

28%

16.60%

16.20%

0% 10% 20% 30% 40% 50% 60%

Malaria or severe malaria

Pregnancy-related complications

Anemia

Hypertension

Accidents and injuries (e.g. snakebites, burns, and cuts)

FIGURE 5A. COMMON REASONS FOR REFERRALS OUT OF THE CHPS IN THE

PREVIOUS TWO MONTHS (ALL REGIONS)

Baseline (CHPS) Midline (CHPS)

59.4%

59.9%

48.8%

33.2%

32.0%

53.5%

53.2%

48.0%

30.0%

31.3%

0% 20% 40% 60%

Malaria or severe malaria

Pregnancy-related complications

Anemia

Hypertension

Accidents and injuries (e.g. snakebites, burns, and cuts)

FIGURE 5B. COMMON REASONS FOR REFERRALS OUT OF THE HCS IN THE

PREVIOUS TWO MONTHS (ALL REGIONS)

Baseline (HC) Midline (HC)


focal regions and all regions. Among health centers in the focal regions, the largest change came from more clients being referred out due to pregnancy-related complications (see Figure 5A & B, Appendix D). However, these changes were smaller and none were statistically significant when looking at all regions. Consistent with reports regarding reasons CHPS zones referred clients out, health centers reported receiving referrals from CHPS zones most commonly for malaria, accidents and injuries, pregnancy-related complications and anemia (Figure 5B). During qualitative interviews with community leaders and clients, referrals from CHPS zones for deliveries were often mentioned, consistent with the survey results. These referrals happened frequently and this was largely due to infrastructure and human resource capacity constraints. In addition to the complexity of the health care needs of the client, reasons for referrals included the lack of supplies needed to treat a client through stock-outs, National Health Insurance Scheme (NHIS) regulations determining coverage for medications at different facilities and regulations regarding medications that can be dispensed at different types of facilities.

Not being able to prescribe or administer certain drugs is another [challenge], as there are issues that the CHPS could manage but due to policy, are forced to refer to the next level.—DDHS, Northern

Sometimes when you come here with a problem they’ll tell you that this one we don’t have the medicine to treat you with. So that’s why they have to refer you. And looking at where they’ll refer you to the distance is very far. So we expect them to have the adequate medicines and materials so that when we come here we’ll not be referred to anywhere, but they’ll treat us.—Client, Western

For referrals to be effective, clients must follow through and seek care at the facility to which they are referred. The majority of CHC members and SDHOs reported that most clients follow through on their referrals and that those who do not face financial and transportation constraints. Financial concerns for cost of treatment were especially severe for those without health insurance. Although some facilities have ambulances and tricycle motor kings (Picture 1), many do not, leaving the burden of transportation on the client.

The person may not have money. If you go to Buntanga or Tamale and you don’t have health insurance, the money that you’ll spend is so much so they fear to go.—CHC, Northern

[The reason they do not follow through on referrals is] poverty. Some people don’t have the money to transport themselves, so if not for an emergency that will require an ambulance, they will decide not to go. — CHC Northern

CHPS zones try to follow up with clients after they have been referred, to verify that they received care and to ensure continuity of care. To facilitate follow-ups, the referral note from the CHPS zone includes a portion that the health facility referred to fill out and which the client should return to the CHO when they report back on their treatment and condition. The quantitative data from CHPS zones suggest that, at midline, 42 percent of clients in focal regions and 44 percent in all regions who were referred to another health facility returned to the original CHPS zones with completed referral feedback notes (Figure 5C).

21%

41.5%

25.8%

44.3%

0%

10%

20%

30%

40%

50%

Baseline Midline Baseline Midline

Focal regions All regions

FIGURE 5C. REFERRALS OUT OF CHPS ZONES WHO RETURN WITH

FEEDBACK

Picture 1: Motorking used as a community ambulance in Northern Region.


These midline levels reflect large improvements between the baseline and midline of 21 percentage points in focal regions and 18 percentage points nationwide. This significant improvement could be related to Systems for Health’s integrated coaching visits to hundreds of CHPS in all of the focal regions in the last two years, emphasizing that referrals should be made and documented for cases beyond CHPSs’ expertise. Several other USAID-funded health projects also stressed this protocol.

However, despite these improvements, more than half of all clients referred out did not return with completed referral feedback notes at midline. We cannot tell from the available data the extent to which this was due to referral forms not being available or filled out correctly; alternatively, it might have been because clients did not follow through on referrals or return the completed forms. Some SDHOs and DDHSs complained about inadequate feedback to the CHPS. However, CHCs, SDHOs and DDHSs noted that if clients do not return to the CHPS zones after they have been referred, it is the responsibility of the CHO or CHC to call or visit the clients, or for the hospital to call the CHPS. Client interviews revealed that many clients did receive home visits or calls and, in at least one region, an initiative was devised that involved the CHO collecting referred clients’ contact information and tracing any client who does not come back to the CHPS.

C. Availability of Services

This chapter describes the changes between baseline and midline in the availability of key services in CHPS zones and health centers in five areas most relevant to USAID interventions: (1) malaria, (2) family planning and contraception, (3) maternal health, (4) nutrition and (5) community-based services.

1. Malaria

In accordance with World Health Organization (WHO) guidelines, GHS promotes the Test, Treat and Track (T3) initiative for malaria care (PMI FY 2015 Ghana Malaria Operational Plan). The T3 initiative states that every case with a provisional diagnosis of malaria should be tested, every confirmed case should be treated and the treatment recorded and malaria should be regularly tracked through a reliable surveillance system. At midline, only about half of CHPS zones and fewer than half of health centers in focal regions reported that they tested and recorded the test results for all cases with a provisional diagnosis of malaria (Table 8)14,15. Among the facilities that did not test and record test results for all clients with a provisional diagnosis of malaria, the most common reasons for not testing and recording results both focal regions and across all regions were (1) insufficient supply of rapid diagnostic tests (RDTs) (cited by almost 90 percent of CHPS zones and health centers) and (2) lack of availability of a RDT or lab at all times of the day or night (reported by almost 30 percent of both types of facilities) (Table 6).16

TABLE 6. AVAILABILITY OF MALARIA SERVICES – MIDLINE ONLY (% OF FACILITIES)

Percentage of CHPS Zones Focal Regions Midline

All Regions Midline

Malaria testing Facility reported that all suspected cases of malaria were tested using RDT and/or microscopy and the results were recorded in the register.

52.7 51.6

Facility provided these reasons for not testing for malaria for every client with a provisional diagnosis of malaria, among facilities that did not test and record results for all clients with a provisional diagnosis:a

Insufficient supply of RDT 87.5 88.6 RDT/lab is not available at all times of the day and night. 29.6 28.0 Other reasons 2.4 6.8

Malaria treatment Facility has at least one staff member providing treatment for malaria. 85.3 79.1 Facility adhered to GHS protocol for malaria treatment in two previous months.b 46.0 47.7

14 Based on these data, we cannot disaggregate the number of clients with a provisional diagnosis of malaria who were not tested and the number who were tested but did not have their results recorded. 15 Because these and several other malaria-related indicators were not measured at baseline or were not measured in the same way, we cannot estimate changes. 16 These findings are also consistent with 2017 PMI Malaria Operational Plan (MOP) findings on shortages of shortage Malaria RDT supplies to lower level facilities in rural Ghana.


Percentage of Health Centers Focal Regions Midline

All Regions Midline

Malaria testing Facility reported that all suspected cases of malaria were tested using RDT and/or microscopy and the results were recorded in the register. 44.5 42.1

Facility provided these reasons for not testing for malaria for every client with a provisional diagnosis of malaria, among facilities that did not test and record results for all clients with a provisional diagnosis:a

Insufficient supply of RDT 89.3 89.3 RDT/lab is not available at all times of the day and night. 28.7 24.7 Other reasons 10.6 12.9

Malaria treatment Facility has at least one staff member providing treatment for malaria. 100.0 99.2 Facility adhered to GHS protocol for malaria treatment in two previous months.b 42.2 38.1

Source: Health, Population and Nutrition Office Portfolio Health Systems baseline and midline survey data. a Because multiple responses were possible, percentages may sum to more than 100. b Defined as testing all cases with provisional diagnosis of malaria and recording the treatment for all positive cases. n.a. = not applicable (question not asked at baseline, or not comparable).

At midline, as at baseline, about 80 percent of CHPS zones and all health centers in focal regions and across all regions reported they had at least one staff member providing treatment for malaria. However, fewer than half of both types of facilities were adhering to the GHS protocol that requires the facility to test all cases with a provisional diagnosis of malaria, record results and provide and record treatment to all clients with a positive result17.

2. Family Planning and Contraception

Providing family planning counseling and contraceptives is another essential health service. At baseline, about 80 percent of CHPS zones and 90 percent of health centers in focal regions were providing family planning counseling services and contraceptives to their clients (Figure 7 and Table 7). At midline, these percentages had improved even further, to 94 percent of CHPS zones and nearly all health centers. The survey data indicate that these changes were driven mainly by the addition of contraceptive provision at facilities that offered only family planning counseling at baseline.

In the midline (but not the baseline) survey, the study team also examined the availability of specific methods of contraception among facilities with control cards for these methods. Among CHPS zones and health centers with control cards for long-acting methods of contraception, 100 percent reported being able to provide such methods on the day of the midline survey. About two-thirds of CHPS zones and three-quarters of health centers with control cards for various contraceptive methods reported being able to provide at least four methods of contraception on the day of the interview. 17 In contrast to the midline findings, GHS DHIMS2 national data at the end of 2016 reported that 73 percent of all health facilities nationwide were adhering to the GHS malaria protocol. Differenes in measurement approaches might contribute to the variation in findings.

15.0%2.6%

79.3%

3.1%1.6% 0.3%

94.2%

3.8%8.3%0.0%

90.6%

1.1%0.0% 0.0%

98.9%

1.1%0%

20%

40%

60%

80%

100%

Family planning counselingonly

Contraceptives only Both Neither

FIGURE 7. AVAILABILITY OF FAMILY PLANNING SERVICES AMONG CHPS AND HC (FOCAL REGIONS)

Baseline (CHPS) Midline (CHPS) Baseline (HC) Midline (HC)


TABLE 7. AVAILABILITY OF FAMILY PLANNING SERVICES – MIDLINE ONLY (% OF FACILITIES UNLESS OTHERWISE INDICATED)

Percentage of CHPS Zones Focal Regions Midline

All Regions Midline

Facility can provide long-acting methods of contraception on day of interview, among those with control cards for those methods.

100.0 100.0

Facility can provide at least four modern methods of family planning on day of interview, among facilities with control cards for those methods.

69.3 65.9

Number of clients receiving contraceptives for the first time from facility in previous two months (mean)

19.4 14.9

Percentage of Health Centers Focal Regions Midline

All Regions Midline

Facility can provide long-acting methods of contraception on day of interview, among those with control cards for those methods. 98.9 99.5

Facility can provide at least four modern methods of family planning on day of interview, among facilities with control cards for those methods. 72.3 73.6

Number of clients receiving contraceptives for the first time from facility in previous two months (mean) 46.8 51.4

Source: Health, Population and Nutrition Office Portfolio Health Systems baseline and midline survey data. n.a. = not applicable (question not asked at baseline, or not comparable).

3. Maternal Health

Health centers are expected to provide basic delivery services (Ghana Health Service, Regional and District Administration 2015), but CHPS zones that do not have qualified personnel to conduct deliveries (e.g., midwives) are instructed to refer all deliveries to higher-level health facilities. However, when a qualified midwife is posted to a CHPS zone, deliveries can be undertaken under the midwife’s care. Health workers in CHPS zones can also conduct emergency deliveries if a woman is unable to reach a higher-level health facility in time for her delivery (usually when presenting with the baby’s head already in the birth canal) (CHPS National Implementation Guidelines 2016). The facility survey provided evidence of a large increase in the proportion of CHPS zones conducting deliveries between baseline and midline: about 22 percentage points in focal regions and about 18 percentage points in all regions (Table 8). There were also smaller increases for health centers. A possible factor behind the increase in CHPS zones conducting deliveries could be recent policy changes that allow some trained CHOs to conduct deliveries at these lower-level facilities. This study also examined specific features of deliveries in those facilities that reported performing deliveries both at baseline and midline.18 In these facilities, the average number of deliveries per facility in the two months before the survey increased only among CHPS zones in focal regions (by 1.7 deliveries, or 27 percent of baseline). However, there was no significant change for CHPS zones in all regions, or for health centers. In delivery care, there was no change in the proportion of deliveries in which a mother received at least two doses of sulfadoxine-pyrimethamine in the CHPS zones in focal regions, but an increase of 6 percentage points in all regions19, reaching about 92 percent. Health centers across both groups of regions exhibited increases in this indicator, reaching about 85 percent. Nearly all CHPS zones and health centers reported registering deliveries that occurred at the facility and about half reported registering home deliveries.

18 This approach avoids having changes driven by changes in the samples from baseline to midline. For example, if facilities that started to offer deliveries between the baseline and midline had fewer deliveries because clients were not yet aware that they offered these services, adding these facilities to the midline sample would artificially decrease the average number of deliveries. 19 Finding was weakly statistically significant at 10 percent level.


Between baseline and midline, there were some small increases in the percentage of CHPS zones and health centers offering antenatal care (ANC)20. In general, fewer CHPS zones (about two-thirds) than health centers (nearly all) offered ANC at midline. As was the case at baseline, the availability of ANC registers, in which CHOs should record all ANC services, was nearly universal across all facilities providing ANC at midline. CHPS clients, community leaders and district-level respondents noted in qualitative interviews that they would welcome more delivery services at CHPS zones, to avoid referrals to larger facilities for delivery.

I think now [of] the services the clinic is supposed to provide for us, the most important one is that we do not have a midwife.… The other time, their boss even said that the clinic here, if a woman wants to give birth, and he delivers her and something happens, his license can be taken from him because that work is not his field, and I stood there myself and told him that we know that, but the community and the nation have agreed that the way in which he would help someone [is to] deliver. So, if something happens, we will not have a problem … if something will happen, it is meant to be. ---Community Leader, Western

Clients and community leaders reported they thought limited delivery services were largely caused by infrastructure and human resource constraints (e.g., not having enough rooms, a maternity ward, or a midwife in their CHPS compound). Some also noted that, because their CHPS does not have accommodations for staff, it is hard to attract midwives who could conduct deliveries to their CHPS zone.

They don’t have rooms. They don’t have beds to deliver the women. So they have to be referred more. --- Community Leader, Central

TABLE 8. AVAILABILITY OF DELIVERY AND ANTENATAL CARE SERVICES (% OF FACILITIES, UNLESS OTHERWISE INDICATED)


Delivery care Facility conducts deliveries. 26.3 48.5 22.2*** 24.3 42.1 17.8*** Delivery care in the previous two months, among facilities conducting deliveries:

Average (mean) number of deliveries in the facility 6.2 7.9 1.7** 6.7 7.0 0.3

Average percentage of deliveries in which mother received at least two doses of sulfadoxine-pyrimethamine

86.6 89.8 3.2 86.3 92.2 5.9*

Percentage of attended births that were registered at the facility n.a. 98.3 n.a. n.a. 98.4 n.a.

Facility registered any home births. n.a. 49.3 n.a. n.a. 41.9 n.a. Average percentage of births in the facility that were emergency deliveries 2.6 5.0 2.4* 2.2 2.9 0.8

Antenatal care Facility provides ANC 66.2 71.0 4.7* 61.5 66.0 4.5** Availability of ANC registers, among facilities providing ANC:

Register exists and seen 94.6 98.3 3.8** 94.9 97.0 2.2 Register exists, but not seen 4.4 0.0 -4.4** 3.0 0.0 -3.0*** No register 1.0 1.7 0.7 2.2 3.0 0.8

20 These increases were fewer than 5 percentage points, and the level of statistical significance varied across the type of facility and groups of regions.

26.3%

66.2%

48.5%

71.0%

85.8%92.7%91.4%

96.4%

0%

50%

100%

Facility conducts deliveries Facility provides ANC

FIGURE 8. AVAILABILITY OF DELIVERY AND ANTENATAL CARE SERVICES,

AMONG CHPS AND HC (FOCAL REGION)




Delivery care Facility conducts deliveries. 85.8 91.4 5.6*** 88.7 92.4 3.7* Delivery care in the previous two months, among facilities conducting deliveries:

Average (mean) number of deliveries in the facility 28.3 28.6 0.3 26.5 25.9 -0.6

Average percentage of deliveries in which mother received at least two doses of sulfadoxine-pyrimethamine

79.3 85.7 6.4* 79.9 87.4 7.4***

Percentage of attended births that were registered at the facility n.a. 100.0 n.a. n.a. 99.8 n.a.

Facility registered any home births. n.a. 45.9 n.a. n.a. 47.5 n.a. Average percentage of births in the facility that were emergency deliveries 2.3 4.3 2.0 3.5 3.4 -0.2

Antenatal care Facility provides ANC 92.7 96.4 3.6** 93.6 95.5 1.9 Availability of ANC registers, among facilities providing ANC:

Register exists and seen 90.2 100.0 9.8*** 93.9 100.0 6.1*** Register exists, but not seen 9.8 0.0 -9.8*** 6.1 0.0 -6.1*** No register 0.0 0.0 0.0 0.0 0.0 0.0

Source: Health, Population and Nutrition Office Health Systems baseline and midline survey data. n.a. = not applicable (question not asked at baseline, or not comparable).

4. Nutrition

Facilities are expected to offer nutrition counseling and services for young children and to monitor children’s growth using nutrition registers or record books. Some evidence exists of modest changes in adherence to expected levels of care between baseline and midline in the focal regions, although the direction of these changes is inconsistent (Figure/Table 9). Overall, the availability and updating of nutrition registers continued to be high at midline: nearly 90 percent of CHPS zones in focal regions had a register; of those, nearly 86 percent had been recently updated; these proportions were even higher for health centers.

All facilities are expected to register key anthropometric information from the children to whom they provide services. Among facilities with nutrition registers at baseline and midline, recording of child weight and age continued to be almost universal, as it was at baseline. However, there were decreases of up to 21 percentage points in the proportion of CHPS zones and health centers that recorded height and weight-for-age, in the focal regions and all regions (Table 9). The decreases in the recording of child height are problematic because it is required to identify stunted children, defined as children with low height-for-age. At the same time, the recording of weight-for-age also decreased, although children’s weight and age continued to be measured and recorded almost universally. This suggests that staff were not taking the next step required to identify underweight children. Recording of infant and young child feeding (IYCF) counseling data, measured at midline only, occurred in fewer than half of the CHPS zones, and less than two-thirds health centers. In general, reporting on some of these nutrition indicators is still a challenge—particularly in CHPS zones.

In the Northern, Upper East and Upper West regions, facilities have been receiving additional guidance and training on providing nutrition-related counseling materials through USAID investments. USAID/SPRING and RING projects, for example, have supported nutrition training, including IYCF and anemia prevention and

89.60%97.90%

85.50%

97%93.10%100%

93.40%100%

0%

20%

40%

60%

80%

100%

Nutrition Register Antenatal Register

FIGURE 9. AVAILABILITY OF REGISTERS IN CHPS AND HCS (ALL REGIONS)



control training to health workers in their respective zones of influence. In those regions, there were large decreases between baseline and midline in the proportion of CHPS zones with no nutritional counseling materials. These decreases were 15 and 18 percentage points in the Northern region (the only focal region among the three) and all three regions. At midline, these materials were almost universally available at CHPS zones in these three regions. In health centers in these three regions, these materials were already almost universally available at baseline and this continued to be true at midline (Table 9).

TABLE 9. AVAILABILITY OF NUTRITION SERVICES (% OF FACILITIES)


Availability of nutrition register: Register exists and seen 85.5 82.9 -2.5 85.9 82.1 -3.8 Register exists, but not seen 5.3 6.9 1.7 3.7 3.4 -0.3 No register 9.3 10.1 0.9 10.5 14.5 4.0

Data entered in the past two months among facilities with a nutrition register available: Data exist and seen 67.3 79.9 12.6*** 70.2 78.0 7.8** Data exist, but not seen 10.9 6.5 -4.5** 11.3 3.1 -8.2*** No data entered 21.7 13.6 -8.1*** 18.5 18.9 0.4

Specific types of data entered in the register, among facilities with data observed: Child’s weight data 98.6 97.3 -1.3 99.4 98.8 -0.6 Child’s age data 98.5 96.3 -2.2 99.3 97.5 -1.9** Child’s height data 19.4 12.1 -7.3** 22.1 11.4 -10.7*** Underweight, or weight-for-age data 77.6 60.2 -17.4*** 83.0 61.7 -21.3*** Infant and Young Child Feeding (IYCF) counseling data n.a. 43.3 n.a. n.a. 49.1 n.a.

Facility has nutrition register with entry in previous 30 days, among facilities that showed their nutrition register data.

74.6 85.9 11.2** 76.2 79.5 3.2

Availability of nutritional counseling materials:a Materials exist and seen 58.9 80.0 21.1** 64.9 84.4 19.5*** Materials exist but not seen 22.2 16.2 -5.9 12.2 11.0 -1.3 No materials 18.9 3.8 -15.1* 22.8 4.7 -18.2***


Availability of nutrition register: Register exists and seen 91.3 90.5 -0.8 87.3 92.2 4.9 Register exists, but not seen 7.6 1.1 -6.5** 5.8 1.2 -4.7** No register 1.1 8.4 7.3*** 6.9 6.7 -0.2

Data entered in the past two months among facilities with a nutrition register available: Data exist and seen 70.4 88.7 18.3*** 75.0 90.0 15.0*** Data exist, but not seen 23.1 1.1 -21.9*** 14.9 1.2 -13.8*** No data entered 6.5 10.2 3.7 10.0 8.9 -1.2

Specific types of data entered in the register, among facilities with data observed: Child’s weight data 98.0 99.0 1.0 99.0 99.5 0.5 Child’s age data 99.0 97.7 -1.3 99.5 97.7 -1.8 Child’s height data 35.6 14.8 -20.8*** 33.4 16.5 -16.8*** Underweight, or weight-for-age data 82.2 62.3 -19.9*** 85.0 65.4 -19.6*** Infant and Young Child Feeding (IYCF) counseling data n.a. 64.1 n.a. n.a. 59.1 n.a.

Facility has nutrition register with entry in previous 30 days, among facilities that showed their nutrition register data.

67.9 94.0 26.0*** 74.1 92.2 18.1***

Availability of nutritional counseling materials:a Materials exist and seen 75.0 90.6 15.6* 85.6 93.5 7.9 Materials exist but not seen 18.8 9.4 -9.4 12.2 6.5 -5.7 No materials 6.3 0.0 -6.3 2.2 0.0 -2.2

Source: Health, Population and Nutrition Office Health Systems baseline and midline survey data. a Asked only for facilities in the Northern, Upper East and Upper West regions. n.a. = not applicable


5. Community-Based Services

Both CHPS and health centers provide care and services in compounds or buildings, but also during home visits in the communities in their zones. This section looks at changes since the baseline in home visits and in services provided in communities, as well as at some services provided by CHVs.

Home visits

Facility staff, especially CHOs, conduct home visits. At midline, as at baseline, all CHPS zones had conducted at least one home visit in the two months before the survey (this includes routine home visits, follow-up visits and special care visits) (Table 10A). The same pattern exists for health centers, where slight increases between baseline and midline resulted in 100 percent of health centers reporting that they conducted at least one home visit in the previous two months.

Of particular note is the large increase from baseline to midline in the number of routine home visits carried out by CHPS staff in the previous two months: the mean number of routine visits more than doubled in focal regions and increased by 60 percent across all regions. This could be due to increased application of the National CHPS Implementation Guidelines related to systematic scheduling of home visits.

TABLE 10A. AVAILABILITY OF COMMUNITY-BASED SERVICES AMONG CHPS (% OF CHPS, UNLESS OTHERWISE INDICATED)

Type of Service Focal regions All regions Baseline Midline Difference Baseline Midline Difference

Home Visits Facility staff (including CHOs) conducted at least one visit in the previous two months. 97.3 100.0 2.7*** 97.9 100.0 2.1***

Facility staff (including CHOs) conducted at least one follow-up home visit in the previous two months.

79.9 76.6 -3.3 78.3 79.8 1.5

Facility staff (including CHOs) or other paid staff conducted at least 10 follow-up home visits in the previous two months.

32.4 37.0 4.5 32.1 35.0 3.0

Facility staff (including CHOs) or other paid staff conducted at least 24 follow-up home visits in the previous two months.

11.3 9.7 -1.6 11.4 8.1 -3.3*

Average (mean) number of home and school visits by facility staff (including CHOs) in the previous two months: Routine home visits conducted 26.1 58.4 32.3*** 26.9 43.3 16.3*** Follow-up home visits 10.7 10.9 0.2 10.2 10.1 -0.1 Clients needing special visits 4.9 8.7 3.8*** 4.6 7.1 2.6*** Postnatal home visits conducted 6.8 6.6 -0.3 5.3 5.5 0.3 School visits conducted 5.7 2.7 -3.0 4.1 2.7 -1.5

Community Health Volunteers (CHVs) Facility has at least one CHV. 90.4 92.7 2.3 94.6 96.1 1.5 Services offered by CHVs in the past 12 months:b

Home visits — assess, advise and educate on health 49.4 54.4 5.0 50.2 61.0 10.9**

Disease surveillance, identify cases, or report 39.6 51.8 12.2*** 48.4 67.3 19.0***

Mobilize and sensitize community for health management action 32.1 38.6 6.5 45.2 46.2 1.1

Provide first aid and treatment of minor ailments 31.5 32.8 1.3 41.1 39.2 -1.8

Disseminate health promotion materials or information 28.0 35.6 7.5* 37.3 42.0 4.6

Communicate between CHO and community on health status of community 23.7 35.1 11.4*** 37.3 42.8 5.5

Assist CHO with home visits, outreach, or work at the CHPS 29.9 46.3 16.4*** 32.0 54.0 22.0***

Support the organization of community health meetings (durbars) 19.3 46.5 27.2*** 31.5 51.1 19.6***

Home visits — follow up on defaulters 22.3 40.5 18.2*** 30.2 50.1 19.9***



Refer clients to CHO for disease treatment, family planning, or nutrition 26.4 34.9 8.6** 27.5 44.9 17.4***

Support antenatal, postnatal, or infant care 20.5 21.5 1.1 25.0 30.3 5.3 Collaborate with CHO or support CHPS service delivery 15.9 22.8 6.9** 19.8 27.7 7.9***

Help compile and update community register or profile 6.9 12.3 5.4** 12.3 18.6 6.3

Provide condoms or family planning information 9.2 23.3 14.0*** 10.9 21.2 10.2***

Number of CHVs working with facility: Number of CHVs (mean) 7.0 5.9 -1.0** 5.7 5.1 -0.6***

Community Health Meetings At least one community health meeting (durbar) was held in last complete quarter. n.a. 88.1 n.a. n.a. 84.8 n.a.

Number of community health meetings (durbars) held in the last complete quarter (mean)

n.a. 1.7 n.a. n.a. 1.9 n.a.

Key persons planning and organizing the last community health meeting, among facilities holding a community health meeting in the previous quarter:b

Community health officer (CHO) 55.3 70.2 15.0*** 60.9 60.7 -0.3 Community health volunteers (CHVs) 23.8 13.7 -10.2** 17.4 11.5 -5.8 Community leaders not part of community health committee (CHC) 28.1 18.6 -9.5 15.9 18.2 2.3

CHC 20.2 34.3 14.1*** 13.1 45.7 32.6*** Someone else 42.2 24.2 -18.0*** 45.9 26.7 -19.2***

Key topics of discussion during last community health meeting, among facilities holding a community health meeting in the previous two months:b

Family planning 20.5 23.2 2.7 26.6 39.1 12.5* Malaria (any topic) 25.3 33.9 8.6 22.9 43.5 20.5*** Cholera 22.7 19.8 -2.9 23.1 21.8 -1.3 Maternal and child health 14.0 30.3 16.2** 19.7 36.7 17.0** Antenatal care attendance 21.9 15.7 -6.2 18.7 32.1 13.4*** Newborn health 9.3 19.1 9.8** 11.1 19.0 7.9** WASH (water and sanitation hygiene) 18.0 21.6 3.5 14.3 20.7 6.4* Expanded Programme on Immunizations 10.0 15.8 5.8 9.9 23.4 13.5*** Postnatal care attendance 6.9 8.0 1.1 11.1 15.8 4.7 Administration of the health facility 9.5 21.5 11.9** 12.1 20.2 8.1 Health insurance 7.7 15.4 7.7 7.2 18.4 11.2** Injuries such as snake bites and burns 3.7 4.5 0.8 5.9 7.8 1.9 Nutrition n.a. 15.4 n.a. n.a. 18.5 n.a. Goodlife, Live it Well Campaign n.a. 5.5 n.a. n.a. 10.2 n.a. HIV/AIDS 0.8 12.9 12.2*** 1.7 17.4 15.7***

Source: Health, Population and Nutrition Office Health Systems baseline and midline survey data. B Because multiple responses were possible, percentages sum to more than 100. n.a. = not applicable (not measured at baseline, or not comparable).

TABLE 10B. AVAILABILITY OF COMMUNITY-BASED SERVICES AMONG HCS (PERCENTAGE OF HCS, UNLESS OTHERWISE INDICATED)


Home visits Facility staff (including CHOs) conducted at least one visit in the previous two months. 97.3 100.0 2.7* 96.4 100.0 3.6**

Facility staff (including CHOs) conducted at least one follow-up home visit in the previous two months.

84.0 72.9 -11.1* 80.3 76.8 -3.6

Facility staff (including CHOs) conducted at least one follow-up home visit in the previous two months that was recorded in the register.

43.6 56.7 13.1 56.3 60.7 4.4



Home visits Facility staff (including CHOs) or other paid staff conducted at least 10 follow-up home visits in the previous two months.

50.7 37.4 -13.3 47.6 35.3 -12.3**

Facility staff (including CHO) or other paid staff conducted at least 24 follow-up home visits in the previous two months.

15.9 14.2 -1.7 16.6 17.4 0.8

Average (mean) number of home and school visits by facility staff (including CHOs) in the previous two months: Routine home visits conducted 67.1 113.8 46.7* 51.9 78.9 27.0* Follow-up home visits 12.9 17.7 4.9 13.2 19.9 6.7* Postnatal home visits conducted 17.1 16.9 -0.2 14.6 12.6 -1.9 School visits conducted 9.5 4.6 -4.8 20.9 4.9 -16.0

Community health volunteers (CHVs) Facility has at least one CHV. 87.4 82.2 -5.2 91.6 89.0 -2.7 Services offered by Community Health Volunteers (CHVs) in the past 12 months:a

Home visits — assess, advise and educate on health 43.4 47.6 4.2 54.7 60.0 5.3

Disease surveillance, identify cases, or report 57.4 64.3 6.8 66.1 73.0 7.0

Mobilize and sensitize community for health management action 42.8 38.1 -4.7 47.2 47.2 0.0

Provide first aid and treatment of minor ailments 44.8 35.8 -9.0 54.8 46.2 -8.6

Disseminate health promotion materials or information 38.6 46.5 7.9 51.4 48.5 -2.9

Communicate between CHO and community on health status of community 29.1 39.3 10.2 45.2 40.4 -4.8

Assist CHO with home visits, outreach, or work at the CHPS 35.9 52.5 16.7* 41.7 55.4 13.7**

Support the organization of community health meetings (durbars) 28.1 44.4 16.3** 45.1 50.2 5.1

Home visits — follow up on defaulters 30.9 40.5 9.6 33.9 46.8 12.9* Refer clients to CHO for disease treatment, family planning, or nutrition 23.0 42.6 19.5*** 34.6 51.8 17.2**

Support antenatal, postnatal, or infant care 30.9 19.9 -11.0 36.5 40.2 3.7 Collaborate with CHO or support CHPS service delivery 24.1 20.3 -3.8 29.2 24.4 -4.7

Help compile and update community register or profile 15.5 17.4 1.9 27.2 16.4 -10.8**

Provide condoms or family planning information 13.1 28.1 14.9** 14.1 26.7 12.5***

Number of CHVs working with facility: Number of CHVs (mean) 12.7 10.3 -2.4* 13.0 10.6 -2.4**

Source: Health, Population and Nutrition Office Health Systems baseline and midline survey data. a Because multiple responses were possible, percentages sum to more than 100.

The study also examined follow-up home visits, which are not routine and thus a measure of the responsiveness of health workers. There is no evidence of a change between baseline and midline in the proportion of CHPS zones reporting they conducted at least one follow-up home visit (about three-quarters of CHPS zones), that had recorded at least one such visit in the registers (about half of CHPS zones), or that had conducted at least 10 such visits (about a third of CHPS zones), in the two months before the survey. In general, there were larger changes in these indicators between baseline and midline among health centers. Overall, there do not seem to be any strong patterns in the changes in follow-up home visits between baseline and midline.

Consistent with these findings, the average number of follow-up home visits among CHPS zones that conducted these visits in both rounds was similar at baseline and midline. However, there were large improvements in the average number of some other types of visits that CHPS zone staff conducted, in particular the average number of routine home visits carried out by CHPS in focal and all regions (increases


of 124 and 61 percent); and visits for clients with special needs (increases of 78 and 57 percent respectively), as shown in Table 10. In contrast, the increases in the average number of postnatal and school visits were small. For health centers in focal and all regions, the largest changes were increases of 70 and 52 percent respectively in the average number of routine home visits.

In qualitative interviews with clients, most indicated that CHPS staff follow up with clients through home visits. In areas where people live far from the facility, however, it is common for CHPS staff to ask the clients to come back to the facility for a follow-up visit.

After 3 days they [the CHPS staff] come to you to ask about your health. They ask whether you have…[taken] the medicine or not. When you … go there again, they will ask you whether you have taken the medicine, and how [much] of it is left. They ask [you] to show it, and when you show it to them; they may [say] …, “oh you haven’t taken the medicine as you should.” —Client, Central Region

According to qualitative interview respondents, facilities also use regular household visits and interactions with the community for formal and informal disease surveillance and monitoring. CHPS zones with an established formal protocol for monitoring diseases reported using the weekly Integrated Disease Surveillance report, or social media services such as WhatsApp to report to the district every Monday. Most CHPS use a less formal process, where any rumor in the community of an outbreak is reported to the district or the sub district officer.

Most SDHOs indicated that a prompt special investigation of potential outbreaks occurs even at the suspicion of a small number of cases and especially for their primary concern, cholera. Most agreed that meningitis and yellow fever were the second and third priorities. Some SDHOs reported formalized plans and procedures to respond to potential disease outbreaks, including an epidemic preparedness committee or a disease surveillance response team. In these instances, investigations are quickly undertaken with trained surveillance volunteers or staff from the community, sub district, or district going into the community, conducting questionnaires and taking blood and stool samples to send to the lab. Only a few SDHOs reported that critical equipment like syringes, needles and transportation to labs, were not always available or that they did not have the appropriate lab in their district.

When we use the investigation form …there will be the location of the person, where he comes from, where he lives … the date [of] onset, and then the date reported to the facility. So maybe we had two people within the same house, and the same community, then the investigation form will tell you that in this house there is something wrong, so we go to that house directly and see what is going on…[W]e. We use that investigation form to be able to track the source of the diseases. —SDHO, Northern

Community Health Volunteers, Community Health Meetings and Work in the Communities

CHPS zones and health centers are designed to be supported by CHVs, who help to mobilize the communities in CHPS Zones and provide community-based care. CHPS zones and, to a lesser extent, health centers, rely on CHVs to run optimally. The volunteers are approved by the communities they serve and should receive specialized training to support the basic services provided by the health facilities with which they work (CHPS Revised Implementation Guidelines 2014). They also receive other incentives for their service, but they are not paid. The key functions of CHVs can include conducting and supporting home visits, supporting CHOs in delivering basic care, conducting disease surveillance, supporting outreach and communication activities (including community meetings) and providing some basic community-based care (including first aid, family planning and providing health education).

The study examined the prevalence and roles of CHVs in the sampled facilities.21 As Table 12 shows, there were no significant changes between baseline and midline in the proportion of CHPS zones or health centers with at least one CHV (these rates were high at baseline, at more than 90 percent of all CHPS zones and more than 85 percent of all health centers). However, among facilities that had at least one CHV at both baseline and midline, there were large improvements in the range of health services offered by CHVs. For example, for CHPS zones in focal regions, there were significant increases in the proportion of facilities in which CHVs offered specific services for 10 of the 14 services that were asked about (the average increase

21 The role of CHVs is somewhat different in health centers and CHPS zones. The roles of CHVs in health centers are typically program specific and facility based, while the roles of CHVs in CHPS zones are multipurpose and include more engagement in home and community outreach.


in the proportion of facilities in which CHVs offered each of these specific services was about 10 percentage points). There were similar increases for CHPS zones in all regions and for health centers in focal and across all regions.

Survey data show that fewer CHVs were working with CHPS zones and health centers during midline than during baseline. There was an average change of one fewer volunteer per CHPS zone in both focal and all regions (or 14 and 11 percent fewer, respectively) and an average of two fewer volunteers per health center in both focal and all regions (or 19 and 18 percent). Qualitative respondents noted that participation by community volunteers is poor because there is no payment or motivational package.

Another aspect of community-based care in CHPS zones is regular meetings held by the CHPS staff in their communities to discuss important health topics. These community health meetings, also known as durbars, are typically organized by the CHO, with help from the CHC and CHVs, and are meant to be held on a regular basis (Revised CHPS Implementation Plan 2014). At midline, 88 and 85 percent of CHPS zones in focal regions and all regions, had held at least one community health meeting in the quarter before the survey.22 Among CHPS zones that had conducted a community health meeting in the previous quarter, 70 and 60 percent of CHPS zones in focal regions and all regions reported that the CHO was involved in the planning. There was a significant increase of 15 percentage points in the focal regions for this measure, but no change for all regions. In focal regions and all regions, there was a shift away from CHVs being involved in planning and an increase in CHC involvement.

These community health meetings are expected to focus on key health topics particularly relevant to a community. To explore the topics discussed, interviewees were asked about community health meetings that took place in the two months before the survey interview. Several health topics were addressed by a significantly larger proportion of CHPS zones during community health meetings at midline relative to baseline, in focal regions and all regions. For example, there were increases in the proportions of CHPS zones that held meetings on maternal and child health and newborn health between baseline and midline (Figure 12). These increases did not come at the expense of significant decreases in other topics.

When community leaders were asked in qualitative interviews what services the CHPS were supposed to provide, going into the communities to provide health education was one of the most common responses. This response was echoed by clients interviewed, especially for education in response to disease prevention and control. Many clients mentioned examples of CHOs counseling the community on prevention measures. Community members noted that, if diseases become prevalent, CHOs call community meetings to discuss prevention measures. There are also community meetings to provide services. For example, the most common types of CHPS child health services cited by clients in qualitative interviews were weighing children and immunizing them, which either take place on regular and pre-announced days in the community or at the CHPS compound, known as Child Welfare Clinics (CWCs).

22 This question was not asked in a comparable way at baseline.

10.0% 7.7%

25.3%

14.0%9.3%

15.8% 15.4%

33.9%30.3%

19.1%

9.9%7.2%

22.9%19.7%

11.1%

23.4%18.4%

43.5%

36.7%

19.0%

0%

10%

20%

30%

40%

50%

Expanded Programmeon Immunizations

Health Insurance Malaria (any topic) Maternal and childhealth

Newborn health

FIGURE 10. KEY TOPICS OF DISCUSSION DURING LAST COMMUNITY HEALTH MEETING AMONG CHPS ZONES

Focal regions Baseline Focal regions Midline All regions Baseline All regions Midline


D. Staff Training

Another important aspect of quality at facilities are staff attributes. Because this study does not have direct measures on quality of services provided, training received by staff was used as a proxy, in terms of training related to both caregiving and data tracking, management and logistics. Because training accompanied by supportive supervision is likely to be more effective than training alone, they were examined together. The study refers to this as quality training. This section also discusses challenges associated with improving staff training.

1. Training for Caregiving

Staff in CHPS zones and health centers are supposed to receive training to provide key caregiving services, including caregiving related to malaria, nutrition and maternal and child health.

Malaria training

Training on malaria at CHPS zones focuses on three key aspects: malaria case management, rapid diagnostic tests (RDTs) and malaria in pregnancy. The survey examined whether facility staff had received training in each of these three areas in the 12 months before the survey.23 In focal regions, there were some small increases between baseline and midline in the proportion of CHPS zones in which staff had received such training (Table 11). In all regions, these increases were larger for training in RDTs and malaria in pregnancy (8 and 6 percentage points). However, training in malaria case management was similar in baseline and midline for CHPS zones in both groups of regions. A similar situation in regard to malaria training existed among health centers, but the increases in training in RDTs and malaria in pregnancy in all regions were greater (19 and 12 percentage points).

The proportion of CHPS zones with at least one staff with training in all three key aspects of malaria care in the past 12 months was 60 percent at midline, up from 53 percent at baseline for focal regions (see figure 11). Among health centers in focal regions, about 62 percent had at least one trained staff in all three key aspects, which was up from 57 percent. The proportion of CHPS zones and health centers in focal regions with at least one staff member trained in any of the three key aspects of malaria care was about the same at both baseline and midline. It appears that training in key malaria topics is becoming more comprehensive.

The study analyzed supervisory visits for two aspects of malaria care in the midline, malaria case management and malaria RDTs24. As shown in Table 11, fewer than half of CHPS zones in focal regions received at least two clinical supportive supervision visits in these two topics in the previous year and these rates were only slightly higher in all regions (these indicators were not measured at baseline). Among health centers, these rates were above 50 percent in focal regions and closer to 70 percent in all regions. In addition, supervisory visits were analyzed related to malaria data collating and reporting and malaria supply chain management. The proportion of facilities receiving supervisory visits for data collating was similar to those that received such visits for malaria case management and malaria RDTs, and slightly smaller for malaria supply chain management.

The study also looked at the proportion of facilities that received training plus in malaria. For a facility to meet this definition, it must have at least one staff member trained in all three key aspects of malaria care mentioned above, complemented with supportive supervision visits on two of these aspects in the past 12 months. Overall, only about 30 percent of CHPS zones had received training plus in malaria at midline across focal and all regions (this indicator was not measured at baseline). Similarly, 41 and 58 percent of health centers in focal regions and all regions, had received training plus in malaria (Table 11). The only measure we have of supportive supervision with malaria training for staff that was captured at baseline and midline is the percentage of facilities that had at least one staff member trained in any aspect of malaria care (malaria-related topics in general) and who received supportive supervision in the previous 12 months. Among CHPS zones nationwide,

23 Responses regarding training frequency were not verified from record books although respondents were encouraged to use reports and documents to answer these questions. 24 We did not collect information on supervisory visits for the third key aspect, malaria in pregnancy.


thirteen percentage points fewer facilities reported this type of training with supportive supervision at midline compared to baseline. Likewise, for health centers there were 16 percentage points fewer facilities nationwide at midline compared to baseline that reported staff with training in any aspect of malaria who received supportive supervision .25

TABLE 11. STAFF TRAINING FOR MALARIA CAREGIVING (PERCENTAGE OF FACILITIES, UNLESS OTHERWISE INDICATED)


Facility had at least one staff member trained in the following key aspects of malaria care in the previous 12 months:a Malaria case management 79.5 78.6 -0.9 71.3 72.9 1.5 Malaria RDTs (including refresher training) 72.0 75.0 3.1 63.6 71.7 8.1*** Malaria in pregnancy 62.8 67.6 4.9 51.7 57.3 5.6**

Facilities receiving at least 2 clinical supervisory visits in the previous 12 months on Malaria case management n.a. 48.8 n.a. n.a. 51.6 n.a. Malaria RDTs (including refresher training) n.a. 40.8 n.a. n.a. 46.5 n.a. Malaria data collating and reporting n.a. 47.4 n.a. n.a. 51.2 n.a. Malaria supply chain management n.a. 36.7 n.a. n.a. 38.4 n.a.

Facility with at least one staff member receiving training plus in malaria treatmentb n.a. 29.5 n.a. n.a. 31.0 n.a.

Facility had at least one staff member trained in any aspect of malaria care and received supportive supervision in the previous 12 monthsc

58.5 42.8 -15.7*** 57.5 44.1 -13.4***

Facility had at least one CHV trained in malaria-related topics in the previous 12 monthsc 43.0 34.1 -8.9** 53.6 45.6 -8.0***

Facility had least 1 CHV trained in malaria-related topics and received coaching by supervisors to address documented errors in the last 12 monthsc

25.9 25.1 -0.7 36.7 31.5 -5.2*


Facility had at least one staff member trained in the following aspects of malaria care in the previous 12 months: a Malaria case management 85.6 79.6 -6.1 80.8 85.6 4.7 Malaria RDTs (including refresher training) 72.2 73.5 1.3 68.1 87.3 19.1*** Malaria in pregnancy 69.5 67.5 -2.0 65.7 77.6 11.9** Malaria microscopy 29.0 29.1 0.1 30.1 31.2 1.1

Facilities receiving at least 2 clinical supervisory visits in the last year on: Malaria case management n.a. 59.8 n.a. n.a. 72.6 n.a. Malaria RDTs (including refresher training) n.a. 53.7 n.a. n.a. 68.8 n.a. Malaria data collating and reporting n.a. 60.7 n.a. n.a. 72.6 n.a. Malaria supply chain management n.a. 53.8 n.a. n.a. 59.6 n.a.

Facility with at least one staff member receiving “training plus” in malaria treatmentb n.a. 40.6 n.a. n.a. 57.9 n.a.

Facility had at least one staff member trained in any aspect of malaria care and received supportive supervision in the previous 12 monthsc

66.5 34.6 -31.9*** 66.9 50.6 -16.3***

Source: Health, Population and Nutrition Office Health Systems baseline and midline survey data. a Key aspects of malaria care are malaria case management, malaria RDTs and malaria in pregnancy. b Training complemented by supportive supervision in all three key aspects of malaria care (malaria in pregnancy, malaria case management and RDTs). c Includes malaria-related topics in general, not specific topics. n.a. = not applicable (question not asked at baseline, or not comparable).

25 It is possible that the estimated midline levels of malaria “training plus” activities do not provide a complete picture given the survey asked about those activities only in reference to the year prior. This timeframe might have been too narrow a window since the training plus conducted by Systems for Health from 2015-2017 followed GHS scheduling guidelines (once every three years with accompanying supportive supervision). Therefore, many facility staff might have received training plus through Systems in the first year after baseline, which would not be captured in our data (Systems’ internal monitoring data suggest that 80 percent of facilities in the focus regions received training plus in malaria over the two year period between baseline and midline). The decrease at midline in the comparison of malaria training activities with supportive supervision between baseline and midline could also reflect the change in training frequency between the baseline and midline periods. The MalariaCare project, which implemented malaria training in the period leading up to the baseline, provided frequent training in malaria, which was captured in the baseline survey. In contrast, the less frequent training provided by Systems between baseline and midline could appear as less training without that being the case.


The proportion of CHPS zones with CHVs trained on some aspect of malaria in the previous 12 months decreased between baseline and midline (9 percentage points in focal regions and 8 percentage points in all regions).26

Per input from MalariaCare for indicator definition, “quality training” is defined as training with coaching by supervisors to address documented errors through added support such as outreach training and supportive supervision (OTSS) visits. OTSS is designed to provide long-term, ongoing support to strengthen services in health facilities by identifying areas that require improvement and providing support to staff (President’s Malaria Initiative 2010). Using this definition, there was no change in the percentage of CHPS zones in the focal regions that provided quality training for CHVs and a decrease of 5 percentage points in all regions. The study also examined the training provided to CHVs in CHPS zones for malaria-related caregiving.

Nutrition and maternal and child health caregiving training

The study also examined training on caregiving related to nutrition and maternal and child health services. Between baseline and midline, there were increases in the proportion of facilities in which staff had received training in the previous 12 months on several relevant topics in both CHPS zones and health centers, although the magnitude of these increases varied. (Table/Figure 12). The magnitude of the increases was particularly large for recent training on community management of acute malnutrition (CMAM) and management of acute malnutrition, across both types of facilities and both groups of regions. There were also large increases in the proportion of facilities that received recent training on these topics with supportive supervision. Nevertheless, recent training was not universal at midline, as about half of all CHPS zones and more than one-third of all health centers did not have staff who were trained in these two key areas in the previous 12 months, and about two-thirds of CHPS zones and almost half of health centers did not have staff who were recently trained in these areas and had received supportive supervision. Among other training topics, the most common was training in infant and young child feeding (IYCF), which was provided in about half of CHPS zones and two-thirds of health centers in the previous 12 months, similar to baseline levels. Health centers were generally more likely to have staff who had received training in various topics in the past 12 months than CHPS zones.

26 It should be noted that USAID project training in malaria focused on facility staff and, as such, did not involve CHVs.

34.3%

33.5%

32.4%

17.3%

6.4%

27.9%

19.5%

18.8%

13.0%

6.5%

0% 10% 20% 30% 40%

Infant and young child feeding (IYCF)

Community management of acute malnutrition (CMAM)

Management of acute malnutrition

Essential newborn care (ENC)

Active management of third stage of labor (AMTSL)

FIGURE 12A. PERCENTAGE OF CHPS ZONES IN WHICH STAFF HAVE RECEIVED SUPPORTIVE SUPERVISON IN MNCH AND NUTRITION IN PREVIOUS 12 MONTHS

(FOCAL REGIONS)


53.1%58.5%59.9%

42.8%

57.3%66.5%62.3%

34.6%

0%

20%

40%

60%

80%

At least one staff trained ineach of the three key aspects of

malaria care

At least one staff trained in anymalaria care area and received

supportive supervision

FIGURE 11. MALARIA TRAINING SUPPORT AT CHPS AND HC (FOCAL

REGIONS)




Similar to the earlier analysis of training plus for a set of malaria trainings, the study also examined quality training, as measured by training plus supportive supervision for other caregiving areas at midline (again, we did not measure this at baseline). For the purposes of this study, training plus in nutrition is defined as having staff trained in all key aspects of nutrition (IYCF, management of acute malnutrition and CMAM) complemented with supportive supervision. At midline, 20 and 26 percent of CHPS zones in focal regions and all regions, had staff that received training plus in nutrition, as did 26 and 33 percent of health centers. Similarly, having training plus in maternal and newborn and child health (MNCH) requires having staff who received training in three key aspects in MNCH (active management of third stage of labor, essential newborn care and anemia prevention control) complemented with supportive supervision visits. At midline, only 4 percent of CHPS zones had training plus in MNCH in focal regions and all regions, as did 11 and 16 percent of health centers.27 Nonetheless, between baseline and midline, there were some increases in training coupled with supportive supervision for individual nutrition topics for both types of facilities.

TABLE 12. STAFF TRAINING FOR NUTRITION AND OTHER KEY CAREGIVING SERVICES (% OF FACILITIES)


Facility had at least one staff member trained in the following in the previous 12 months: Infant and young child feeding (IYCF) 41.4 48.9 7.4* 47.7 49.3 1.6 Community management of acute malnutrition (CMAM) 29.6 48.0 18.4*** 34.3 50.5 16.2***

Management of acute malnutrition 31.0 47.3 16.3*** 29.8 48.9 19.2*** Essential newborn care (ENC) 24.2 29.4 5.3* 22.6 30.4 7.8* Active management of third stage of labor (AMTSL) 12.9 17.1 4.3* 16.2 17.0 0.8

Anemia prevention control n.a. 29.5 n.a. n.a. 29.1 n.a. Maternal, newborn and child health (MNCH) life-saving skills n.a. 27.7 n.a. n.a. 30.8 n.a.

Integrated management of neonatal childhood illness (IMNCI) n.a. 37.7 n.a. n.a. 33.7 n.a.

Facility had at least one trained staff member receive supportive supervision in the previous 12 months: IYCF 27.9 34.3 6.4* 33.8 39.1 5.3 CMAM or other undernutrition management practices 19.5 33.5 14.0*** 25.3 39.6 14.3***

Management of acute malnutrition 18.8 32.4 13.6*** 20.8 37.9 17.1***

27 If a facility does not have staff qualified to provide MNCH services, we might not expect any staff at that facility to receive training in certain MNCH topics. Therefore, we also examined training in MNCH topics among facilities that provided deliveries, which are more likely to have staff qualified to provide MNCH services. As expected, the proportion of facilities that received training in different aspects of MNCH increases with this sample restriction. In particular, the percentage of facilities reporting training in specific MNCH-related topics at midline increased by between 7 and 22 percentage points in CHPS zones and by between 1 and 4 percentage points in health centers relative to the full sample, with the increases varying by training topic and group of regions. Similarly, the percentage of facilities reporting training plus in specific MNCH-related topics increased by between 3 and 14 percentage points in CHPS zones and by between 0 and 4 percentage points in health centers (data not shown).

44.2%

37.2%

42.6%

39.5%

21.7%

41.6%

33.6%

32.3%

41.9%

25.9%

0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%

Infant and young child feeding (IYCF)

Community management of acute malnutrition (CMAM)

Management of acute malnutrition

Essential newborn care (ENC)

Active management of third stage of labor (AMTSL)

FIGURE 12B. PERCENTAGE OF HC IN WHICH STAFF HAVE RECEIVED SUPPORTIVE SUPERVISON IN PREVIOUS 12 MONTHS (FOCAL REGIONS)




ENC 13.0 17.3 4.3** 13.8 17.5 3.7 AMTSL 6.5 6.4 -0.2 9.2 7.7 -1.5 Anemia prevention control n.a. 19.0 n.a. n.a. 20.3 n.a. MNCH life-saving skills n.a. 11.2 n.a. n.a. 17.7 n.a. IMNCI n.a. 22.7 n.a. n.a. 23.0 n.a.

Facility with at least one staff member receiving training plus in nutritiona n.a. 19.5 n.a. n.a. 26 n.a.

Facility with at least one staff member receiving training plus in maternal and neonatal careb

n.a. 4.2 n.a. n.a. 4.5 n.a.


Facility had at least one staff member trained in the following in the previous 12 months: Infant and young child feeding (IYCF) 55.9 62.9 7.0 55.2 62.9 7.7 Community management of acute malnutrition (CMAM) 40.3 52.2 11.9* 39.7 57.2 17.6***

Management of acute malnutrition 37.5 56.8 19.3*** 38.3 58.3 20.1*** Essential newborn care (ENC) 60.2 58.8 -1.4 48.8 62.6 13.8*** Active management of third stage of labor (AMTSL) 46.0 43.9 -2.1 45.7 56.0 10.3*

Anemia prevention control n.a. 33.6 n.a. n.a. 37.6 n.a. Maternal, newborn and child health (MNCH) lifesaving skills n.a. 57.1 n.a. n.a. 62.4 n.a.

Integrated management of neonatal childhood illness (IMNCI) n.a. 44.9 n.a. n.a. 43.1 n.a.

Facility had at least one trained staff member receive supportive supervision in the previous 12 months: IYCF 41.6 44.2 2.6 45.3 49.2 4.0 CMAM or other undernutrition management practices 33.6 37.2 3.6 32.8 45.7 12.9**

Management of acute malnutrition 32.3 42.6 10.4* 34.0 48.5 14.5** ENC 41.9 39.5 -2.3 35.4 46.4 11.1** AMTSL 25.9 21.7 -4.3 29.9 34.9 5.0 Anemia prevention control n.a. 18.9 n.a. n.a. 28.4 n.a. MNCH lifesaving skills n.a. 30.8 n.a. n.a. 41.9 n.a. IMNCI n.a. 32.7 n.a. n.a. 33.4 n.a.

Facility with at least one staff member receiving training plus in nutritiona n.a. 25.8 n.a. n.a. 33.3 n.a.

Facility with at least one staff member receiving training plus in maternal and neonatal careb n.a. 10.7 n.a. n.a. 16.1 n.a.

a Training complemented by supportive supervision in critical skill areas in nutrition (IYCF, management of acute malnutrition and CMAM). Facilities that had missing information for one or more of the critical areas were included in the estimation. b Training complemented by supportive supervision in critical skill areas in MNCH (AMTSL, ENC and anemia prevention control). n.a. = not applicable (question not asked at baseline or not comparable).

2. Training for Data Tracking, Management and Logistics

In addition to providing health services, CHPS and health center staff are expected to track and manage data and perform key logistical and managerial tasks. Collating and reporting data related to malaria is a focus for GHS and USAID-funded projects and training is important to facilitate this. The proportion of CHPS zones with a nurse or CHO who received training on malaria data collating and reporting in the previous 12 months decreased slightly from baseline to midline and were small (Table 13). There were larger decreases in the proportion of CHPS zones with any staff member trained in malaria data collating and reporting in the previous 12 months—a decrease of 12 percentage points in the focal regions and 10 percentage points in all regions. The study observed a similar decrease among health centers in focal regions, but not in all regions together.

Training in other management topics such as supervision skills and supply chain and logistics management is also important to improve the provision of high quality care. From baseline to midline, there was a significant


increase in the proportion of CHPS zones in which staff had received training on supervisory skills in the previous 12 months (11 and 15 percentage points for focal regions and all regions, respectively) and smaller increases in whether they had received training in this area accompanied with supportive supervision visits (4 and 10 for focal and all regions, respectively). For health centers, there was a significant increase of 11 percentage points between baseline and midline in this indicator in all regions, but no significant change in focal regions. In contrast, there were no changes in the proportion of CHPS zones or health centers in which staff had recently received training on supply chain and logistics management in either focal or across all regions. Overall, despite some improvements, the levels of recent training combined with supportive supervision in these two management-related topics were quite low at midline. For example, nationwide, only about one-quarter of CHPS zones and one-third of health centers met these criteria for these two topics

TABLE 13. STAFF TRAINING FOR DATA TRACKING AND MANAGEMENT (PERCENTAGE OF FACILITIES)

Percentage of CHPS Zones Focal regions All regions

Baseline Midline Difference Baseline Midline Difference Training in malaria data tracking Facility had at least one nurse or CHO trained in malaria data collating and reporting in the previous 12 months

70.5 64.0 -6.5 70.1 63.3 -6.8*

Facility had at least one staff member trained in malaria data collating and reporting in the previous 12 months

78.6 66.6 -12.0*** 76.3 66.5 -9.8***

Training in other management topics Facility had at least one staff member trained in the following in the previous 12 months:

Supply chain and logistics management 33.6 35.1 1.5 30.4 36.0 5.6 Supervision skills 21.0 32.5 11.5*** 19.1 34.6 15.5***

Facility had at least one staff member who was trained and received supportive supervision in any of the following in the previous 12 months:

Supply chain and logistics management 23.7 22.5 -1.2 22.8 27.2 4.4

Supervision skills 11.7 15.8 4.0* 12.5 22.5 10.0*** Facility with at least one staff member receiving training plus in supply chain managementb

n.a. 53.9 n.a. n.a. 50.8 n.a.

Facility with at least one staff member receiving training plusc n.a. 4.0 n.a. n.a. 2.0 n.a.


Training in malaria data tracking Facility had at least one staff member trained in malaria data collating and reporting in the previous 12 months:

Nurses or CHOs 81.0 67.5 -13.6*** 77.1 77.0 -0.1 Outpatient department 55.3 65.0 9.6 46.6 71.3 24.7*** Records staff members 34.1 37.9 3.8 33.9 38.9 4.9 Lab staff members 28.8 33.2 4.4 30.0 40.4 10.4* Other staff members 16.0 28.5 12.5** 28.3 33.6 5.3

Facility had at least one staff member trained in malaria data collating and reporting in the previous 12 months

87.2 74.9 -12.3** 88.2 82.6 -5.6

Training in other tracking and management topics Facility had at least one staff member trained in the following in the previous 12 months:

Supply chain and logistics management 46.4 53.5 7.2 44.3 46.8 2.4 Supervision skills 29.0 32.4 3.5 30.2 41.7 11.4**


Supply chain and logistics management 29.7 38.9 9.2 32.3 38.2 5.9 Supervision skills 20.8 19.0 -1.9 24.5 30.7 6.2



Facility with at least one staff member receiving training plus in supply chain managementa

n.a. 71.5 n.a. n.a. 78.1 n.a.

Facility with at least one staff member receiving training plusb n.a. 7.7 n.a. n.a. 12.1 n.a.

Source: Health, Population and Nutrition Office Health Systems baseline and midline survey data. a Training complemented by supportive supervision in critical skill areas in supply chain management (including supervision skills). b Training complemented by supportive supervision in critical skill areas in malaria treatment (malaria in pregnancy, malaria case management and RDTs), nutrition (IYCF, management of acute malnutrition and CMAM) supply chain management (including supervision skills) and MNCH (AMTSL, ENC and anemia prevention control). n.a. = not applicable (question not asked at baseline or not comparable).

3. Training Challenges

An essential element of providing quality health care is the availability of staff and volunteers with the skills and resources to undertake the tasks required. The study team asked District Assembly members, DDHSs, SDHOs, CHC members and community leaders about the staff and volunteers in their CHPS and health centers. District-level respondents noted that staff in their facilities were being trained to improve quality of care and services and to introduce staff to new protocols. Many respondents mentioned USAID-funded projects that had provided training in their areas. RING and SPRING were noted for conducting many staff trainings for nutrition by a number of district-level respondents, which is consistent with the increase in facilities reporting recent trainings in some nutrition topics, as discussed above. Systems for Health was noted for building staff capacity in malaria case management and supportive supervision. District-level respondents expressed satisfaction with trained staff but noted that the continued scarcity of trained staff is problematic.

Providing training to current staff also comes with several challenges. First, finding funding for training can be difficult. Second, DDHSs noted that trainings for staff at facilities need to be scheduled better, so as not to burden districts by having all staff members attending trainings at the same time, possibly compromising care. As one noted,

If they want to train our staffs for us, they should try to reduce the numbers for the training, because if you want to train everybody then it means that other services in the district will not be carried out. So, what I think they should do is to liaise with the Regional Health Directorate to put a system in place with the regional training unit, and [then] you will know who will be attending what at a particular time. — DDHS, Northern

Third, after staff are trained, they can request transfer or be transferred and replaced with someone who does not have the same level of training.

There is difficulty when human resource management is in one hand, and capacity development is in another hand; you end up training nurses only… to see most of them … transferred elsewhere, and then people are brought in who are not trained. When they are trained the same way, you don’t see the gap, but when they are not trained, when you recently come to spend money and train nurses and then the next day the nurses are transferred or they are gone to school, then some fresh ones come and miss out on the training, and the quality of service you were looking for will be compromised. —DA, Northern

Personnel and staffing… is one of our biggest challenges. You have staff who will even go on study leave and they’ll come back only to say that they want to leave the district… We don’t have enough staff at our facilities or the various categories of skilled labor that we need. — DDHS, Western

Finally, respondents noted that the usefulness of trainings is diminished if the facilities lack the equipment and supplies to put them into practice. One example given regarded training on collating and reporting data in a district that lacks computers and connectivity so that staff could not make full use of what was learned.


E. Treatment Protocols and Sanitation and Infection Prevention

This section examines the availability of treatment protocols for client care and the extent to which facilities follow prescribed guidelines for sanitation and preventing infections. Both types of guidelines are key to good client care.

1. Availability of Treatment Protocols

Staff in CHPS zones and health centers are expected to follow basic protocols and guidelines when treating clients. Most SDHOs and DDHSs interviewed thought that facilities in their districts typically had the most up-to-date guidelines and written treatment protocols available including those for reproductive health, MNCH, prevention and control of infections and CMAM. SDHOs and DDHSs did note that some newly constructed CHPS compounds might not have protocols Respondents also noted that regional-level workshops or trainings are occasionally held when there were changes in protocols or when it was determined there was a need to have orientation or a refresher course on a protocol for relevant health facility staff.

Adhering to the protocols is essential for quality care. Several DDHSs and SDHOs expressed their beliefs that health facility staff applied protocols, based on monitoring and observing staff interactions, and sometimes getting feedback from staff reports. Others stated that although they had not done serious monitoring, they were still confident that staff adhered to most protocols. As one DDHS said,

We always advise them to use [them]; you’ll go there [and] you’ll see all the protocols there. So, what I can say to be the evidence that they are using [them] is the reduction of infections at …the sub district at the health centers level. Wound infections, staff infecting themselves, and all that—those ones have reduced drastically when you look at their indicators. — DDHS, Central

Nonetheless, some SDHOs did point out a few challenges with adherence to treatment protocols, including the need for further education. For example, they noted that some CHN prescribe the wrong medications despite protocols. Other challenges include lack of resources or infrastructure; for instance, the high costs of sterilization equipment can be a barrier to following infection prevention protocols and inadequate infrastructure can be a barrier to following certain protocols such as keeping new mothers at a facility for 24 hours.

While the quantitative survey provides some evidence of modest improvements in the availability of treatment protocols for certain key services in CHPS zones between baseline and midline, the changes for health centers were mixed (Table 14).

29.60%

39.70%

22.90%

35%42.70%

32.70%

81.70%

55.40% 58.60%

84.70%

54.20% 57.00%

0%

20%

40%

60%

80%

100%

Managing maternal and newborn care Managing acute undernutrition SOP manual - Supply chain

FIGURE 14. AVAILABILITY OF TREATMENT PROTOCOLS IN CHPS AND HC (ALL REGIONS)



Nonetheless, the midline findings suggest that most CHPS zones still did not have these written treatment protocols available at the time of the survey. For example, in focal regions, more than two-thirds of CHPS zones reported not having written MNCH protocols and more than one-half reported not having written acute undernutrition protocols (Table 14). The availability of these protocols at midline was higher for health centers, though still not universal. For example, about one-fifth of health centers in focal regions reported not having written MNCH protocols and about one-half reported not having written acute undernutrition protocols at midline. As mentioned previously, the qualitative findings suggest that there could be constraints to implementing treatment protocols even when they are available, such as limited staff training and inadequate infrastructure. Therefore, the percentage of facilities implementing these protocols correctly at midline is likely to be lower than the percentage that have them available.

TABLE 14. AVAILABILITY OF TREATMENT PROTOCOLS AT FACILITES (% OF FACILITIES)


Availability of written protocols for managing maternal and newborn care: No protocols 72.8 68.7 -4.1 70.4 64.9 -5.5*

Availability of written protocols for managing acute undernutrition: No protocols 62.2 54.5 -7.7*** 60.2 57.3 -2.9


Availability of written protocols for managing maternal and newborn care: No protocols 19.4 20.2 0.8 18.3 15.4 -2.9

Availability of written protocols for managing acute undernutrition: No protocols 31.9 46.2 14.2** 44.5 45.8 1.3


2. Sanitation and Infection Prevention Measures

The midline survey suggests that there are important gaps in basic water, sanitation and hygiene (WASH) infrastructure at CHPS zones.28 Only about one-third of CHPS zones in focal regions and all regions reported that they had access to piped water or borehole water at midline and only about one-half reported that they had a functional latrine or toilet (Table 15). Regarding the reported availability or use of various measures to prevent and control infections, there was an increase between baseline and midline along measures related to sanitation, sterilization measures, disposal measures and ways of dealing with contagious clients among both types of facilities29. Overall, many of the measures, examined were available in well more than half of CHPS zones at midline and for health centers many were available in about 90 percent of facilities or more.

28 The midline survey collected information on this infrastructure for CHPS zones only. It was assumed that almost all health centers would have this infrastructure, and the provision of infrastructure in CHPS zones is the programmatic focus. 29 Our analysis of these measures is based on facility self-reports; interviewers did not verify the availability and use of these measures.

39.0%

24.4%

9.5%

63.8% 65.2%

42.9%

60.7%

51.9%46.3%

96.2%99.2%

93.5%

0%

20%

40%

60%

80%

100%

Disinfectants Staff disinfectsinstruments

Staff sterilizesequipment

FIGURE 15. CHPS AND HCS WITH KEY STERILIZATION MEASURES IN PLACE FOR

PREVENTION AND CONTROL OF INFECTIONS (ALL REGIONS)




TABLE 15. SANITATION AND INFECTION PREVENTION (% OF FACILITIES)


Facility has access to water supply through piped water or boreholes n.a. 32.2 n.a. n.a. 30.0 n.a.

Facility has a functional latrine or toilet n.a. 50.8 n.a. n.a. 45.8 n.a. Key sanitation measures in place for prevention and control of infections:a

Hand-washing station/Veronica bucket 73.4 73.7 0.3 71.2 65.8 -5.4** Staff consistently wear gloves 68.0 78.5 10.5*** 62.5 75.4 12.9***

Key sterilization measures in place for prevention and control of infections:a Availability of disinfectants 45.3 70.8 25.5*** 39.0 63.8 24.9*** Protocol for mixing chlorine for disinfection 33.9 46.0 12.1*** 31.8 32.9 1.2 Staff disinfect instruments 27.4 73.6 46.2*** 24.4 65.2 40.8*** Staff sterilize equipment 10.5 52.8 42.3*** 9.5 42.9 33.4*** Availability of functioning sterilizing equipment such as boilers or autoclaves 10.8 10.9 0.1 7.5 9.2 1.8

Key disposal measures in place for prevention and control of infections:a Staff use a sharps container 75.7 96.4 20.7*** 71.5 87.4 15.8*** Separation of waste disposal 44.6 75.3 30.7*** 43.1 68.8 25.7*** Availability of a functioning incinerator 2.5 3.5 1.0 2.9 3.5 0.6

Key measures in place for dealing with contagious clients for prevention and control of infections:a Separating clients with contagious diseases from healthy clients 35.2 30.9 -4.3 36.5 34.4 -2.0

Separating sick newborns from healthy newborns 6.7 19.6 12.9*** 7.4 21.6 14.2***


Key sanitation measures in place for prevention and control of infections:a Hand-washing station/Veronica bucket 97.5 96.4 -1.1 98.8 97.6 -1.3 Staff consistently wear gloves 87.2 87.8 0.6 93.4 92.8 -0.6

Key sterilization measures in place for prevention and control of infections:a Disinfectants 53.7 91.9 38.2*** 60.7 96.2 35.6*** Protocol for mixing chlorine for disinfection 55.3 73.5 18.2*** 61.4 81.0 19.6*** Staff disinfect instruments 49.2 98.3 49.2*** 51.9 99.2 47.3*** Staff sterilize equipment 34.9 88.9 54.0*** 46.3 93.5 47.2*** Functioning sterilizing equipment such as boilers or autoclaves

40.8 59.2 18.4*** 48.6 70.3 21.7***

Key disposal measures in place for prevention and control of infections:a Staff use a sharps container 80.7 98.0 17.3*** 83.7 99.1 15.4*** Separation of waste disposal 55.9 87.2 31.4*** 60.8 93.1 32.2*** Availability of a functioning incinerator 11.4 18.3 6.9* 15.9 20.8 4.9

Key measures in place for dealing with contagious clients for prevention and control of infections:a Separating clients with contagious diseases from healthy clients

57.2 60.3 3.1 64.4 61.8 -2.6

Separating sick newborns from healthy newborns

19.2 50.8 31.6*** 23.1 49.1 25.9***

Source: Health, Population and Nutrition Office Health Systems baseline and midline survey data. a Because multiple responses were possible (except for none), percentages sum to more than 100. n.a. = not applicable (question not asked at baseline or not comparable).

F. Access to Supplies and Equipment

CHPS zones and health centers are expected to have essential supplies and equipment available to enable them to provide high quality care. This section examines the systems in place for managing supply chains, describes the extent to which specific supplies and equipment are available and looks at the availability of communication technology in these facilities.


1. Supply Chain Management

Effective management of supply chains is important to ensure that essential medicines, commodities and other supplies are available in health facilities. In qualitative interviews, DDHSs and SDHOs in the focal regions were asked for their impressions of supply chain management and whether these systems function adequately in facilities. Combined with data from the survey, the study identified several major challenges to the effective operation of the supply chain at midline. These include financial constraints (specifically, delays from the NHIS in reimbursing health facilities for services and supplies) and stock-outs at the regional level. Despite these challenges, other links in the supply chain appear to have improved in the past two years, including effective tracking of supply and medicine levels in facilities and understanding of and proficiency with supply chain logistics.

Some of these improvements might be due to better use of the early warning systems that have been put into place since 2011 at most health facilities. This helps facilities determine minimum stock levels of essential commodities. The early warning system operates by health facility staff sending weekly text messages from their mobile phones or via a web interface (e.g. email) to report the stock levels of a subset of their managed commodities. The information reported is displayed on a web-based dashboard that provides several reports related to stock availability and reporting rates, allowing decision makers at the higher levels of the supply chain to see the information in real time and in an easily understandable format.30 In addition, there has also been increased investment is supply chain management training and supportive supervision.

Tracking the levels of supplies and medicines

The first step to effective supply chain management is to accurately track the levels of supplies and medicines so they can be ordered as needed to maintain required stock levels. All SDHOs and DDHSs interviewed indicated that facilities practice inventory control measures to maintain stock balances and that they perceive these measures to be effective to monitor stock commodities. These measures include having designated staff to monitor supplies and using ledger books and tally/bin cards to keep track of stock balances, maximum stock levels, minimum/reorder levels and/or emergency reorder forms. In addition, some SDHOs mentioned separate tracking systems for some commodities. For example, an SDHO in the Central region described the early warning system they use for family planning, antiretroviral therapy and malaria commodities, in which the CHPSs submit weekly stock data so they will be prompted if they should reorder.

Most SDHOs interviewed described similar procedures for re-order when medicines and supplies run low, i.e. the staff member in charge of supplies uses a Report Requisition Issue and Receipt Voucher (RRIRV) to request a purchase from the District Health Authority. The staff in charge of supplies varies by facility; in health centers, it might be the SDHT leader or a nurse. Interviews with SDHOs suggested that, in practice, a variety of health center staff, including pharmacy technicians, dispensary technicians and public health nurses, can be involved in tracking and ordering. If the facility head endorses the RRIRV and the DDHS approves it, the items are purchased at the regional medical store (RMS) or the district medical store. Some CHPS are even supplied through the sub districts. One SDHO noted there was a move to strengthen this system, so that more CHPS could get supplies from sub districts instead of the regional or district stores. The survey data suggest that, at midline, 55 percent of CHPS zones in focal regions and 51 percent in all regions together used an RRIRV to reorder commodities based on consumption in the previous two months, as did 73 percent of health centers in focal regions and 83 percent in all regions (Table 16, Appendix D).

Most DDHSs indicated stock monitoring procedures have remained the same over the past two years; however, a few innovations were mentioned. SDHOs in two regions said that, when facilities have too much of a soon to expire drug, they distribute it to nearby facilities. DDHSs and SDHOs also noted that they used to wait for all their supplies to run out before reordering, but now they track minimums and set reorder levels to help avoid stock-outs. The DDHSs in two regions indicated that this was introduced in the past two years. In addition, at least one DDHS noted that the district introduced a monthly reporting system from facilities to the district using a social media platform (WhatsApp) to communicate if they are running low on 30 http://pdf.usaid.gov/pdf_docs/PA00K7CC.pdf

http://pdf.usaid.gov/pdf_docs/PA00K7CC.pdf


certain drugs. Finally, there has been a shift in some areas from facilities traveling to pick up medicines to RMSs delivering them, thus reducing the financial burden on facilities (Central Region). A DDHS in Northern Region noted that the RMS is still setting up a scheduled delivery system in which a facility only needs to send their requisition early enough for the store to package it.

Overwhelmingly, DDHSs and SDHOs noted that problems in the supply chain are not in the monitoring system, but caused by shortages of supplies at the district and regional levels. Respondents reported that, if a commodity is available at the district or regional store, the system works well; however, usually the quantity facilities receive is not the quantity requested due to shortages at the stores. If the store does not have the supply, facilities must wait for it to be available, or get a non-availability form from the RMS so it can be sourced on the open market. Using the form is a very long process, however, and many facilities struggle with having cash to pay for medications in the open market due to financial constraints driven by delays in reimbursements from the NHIS. Therefore, facilities usually are forced to wait until the item is available at the RMS. Also, interviewees reported that logistics and difficulties with transport prevent frequent trips for supplies, so facilities often let drugs run out or run low to consolidate trips.

Most DDHSs and SDHTs interviewed noted there are designated staff in facilities to monitor supplies. The survey data support there being some improvement in the monitoring and tracking of supplies over the past two years, with an increase between baseline and midline in the percentage of facilities that have a person dedicated to ordering supplies. As Table 18 shows, in CHPS zones, this increase was 13 percentage points in focal regions and 12 percentage points in all regions. In health centers, these increases were 8 percentage points31 in focal regions and a 13 percentage points among all regions. At midline, in both the focal regions and all regions, only about 2 in 10 CHPS zones and 1 in 10 health centers still did not have a dedicated person to order supplies.

There is also some evidence of modest improvements between baseline and midline in the percentage of facilities that have a standard operating procedures manual, which outlines the procedures for supply chain management. However, at midline, more than one-half of CHPS zones and more than one-third of health centers in focal regions still did not have a standard operating procedures manual; these fractions were even larger for all regions.

TABLE 16. AVAILABILITY AND USE OF TOOLS AND MECHANISMS FOR SUPPLY CHAIN MANAGEMENT (% OF FACILITIES)


Facility has dedicated person responsible for ordering supplies.

68.3 81.1 12.7*** 64.0 75.9 11.9***

Standard operating procedures (SOP) manual: No SOP manual 64.1 57.7 -6.3* 77.1 67.3 -9.8***

Facility has utilized RRIRV to reorder commodities based on consumption n.a. 54.8 n.a. n.a. 50.9 n.a.

Frequency with which facility cannot supply clients’ needs due to a stock-out: Once or more per week 10.8 7.1 -3.7** 8.2 8.4 0.2

31 Finding was weakly statistically significant at 10 percent level.

8.4%

8.3%

50.5%

25.0%

8.2%

6.1%

32.9%

52.8%

0% 10% 20% 30% 40% 50% 60%

Once or more per week

Once every two or three weeks

Once per month

Less often than once per month

FIGURE 16. FREQUENCY OF CHPS ZONES EXPERIENCING STOCK-OUTS (ALL

REGIONS)

Baseline Midline


Once every two weeks 3.7 4.6 0.9 3.4 4.7 1.4 Once every three weeks 4.1 4.8 0.7 2.7 3.6 0.9 Once per month 31.3 47.4 16.1*** 32.9 50.5 17.5*** Less often than once per month 50.1 27.1 -23.0*** 52.8 25.0 -27.8***


Facility has dedicated person responsible for ordering supplies. 81.4 89.8 8.4* 80.8 93.3 12.5***

Standard operating procedures (SOP) manual: No SOP manual 31.6 35.8 4.3 41.4 43.0 1.6

Facility has used RRIRV to reorder commodities based on consumption. n.a. 73.2 n.a. n.a. 82.7 n.a.

Frequency with which facility cannot supply clients’ needs due to a stock-out: Once or more per week 6.2 7.9 1.7 5.2 5.2 0.1 Once every two weeks 4.3 1.7 -2.6 4.0 2.2 -1.8 Once every three weeks 8.6 8.3 -0.3 5.0 4.6 -0.4 Once per month 28.7 55.3 26.7*** 32.0 54.4 22.4*** Less often than once per month 52.2 22.2 -30.0*** 53.8 28.0 -25.9***

Source: Health, Population and Nutrition Office Health Systems baseline and midline survey data. a Because multiple responses were possible, percentages sum to more than 100. n.a. = not applicable (question not asked at baseline, or not comparable).

Facilities typically are expected to use control cards (e.g., inventory control cards, bin cards, tally cards, or supply cards) to track the levels of medicines and supplies. The results from the quantitative survey indicate that there was a large improvement between baseline and midline in the availability of control cards among CHPS zones, for almost all commodities (Table 19). The average increase in the percentage of CHPS zones with control cards across all commodities was 15 percentage points in the focal regions and 11 percentage points in all regions. In both cases, there were very few commodities examined for which there was not a significant increase in the availability of control cards. At midline, control cards for all immunization commodities were available in at about half of CHPS zones; control cards for most nutrition, malaria and family planning commodities were available in an even higher share of CHPS zones.

There also were large increases in the percentage of CHPS zones that had control cards for nutrition and immunization commodities that were updated in the last 30 days before the survey (Table 19). In addition, although there was still a gap between the percentage of facilities with a specific control card and the percentage with an updated control card at midline, this gap was smaller in percentage terms than at baseline. For example, at baseline, 20 percent of CHPS zones in focal regions had a control card for Vitamin A, but only 10 percent had an updated control card, suggesting that about one-tenth control cards were updated. At midline, these percentages were 60 and 50 percent, suggesting that about fifty percent of control cards for Vitamin A were updated. There is a similar pattern for other nutrition and immunization commodities. This suggests not only that control cards for these commodities were more commonly available than at baseline, but also that they were more frequently up-to-date. Nevertheless, the availability of control cards, including updated control cards, was far from universal among CHPS zones at midline. For example, in focal regions, an average of only 43 percent of CHPS zones had an updated control card.32

For health centers, there also was a broad increase between baseline and midline in the availability of control cards and updated control cards. Except for immunization commodities, the magnitude of the increases was smaller, in general, than for CHPS zones, possibly reflecting that the baseline prevalence of control cards was higher in health centers, so that there was less scope for improvement. The average increase in the percentage of health centers with control cards was 14 percentage points in the focal regions. In all regions, the average increase was 16 percentage points. Overall, the availability of most control cards exceeded 80 percent in health centers at midline for most commodities, with most exceptions consisting of family planning and basic emergency obstetric and newborn care (BEmONC) commodities (the latter were not measured at baseline). Similar to CHPS zones, the relative gap between availability of control cards and

32 These averages were estimated using a more comprehensive list of commodities than the one shown in Table 19. This applies to other averages in this section as well. See tables in the Appendix for full data.


updated control cards also narrowed for nutrition and immunization commodities between baseline and midline, suggesting these cards were more likely to be up-to-date.

TABLE 17. MANAGEMENT OF ESSENTIAL SUPPLIES (% OF FACILITIES)33


Availability of control cards for specific commodities Facility has control card for the following commodities related to nutrition, diarrhea and infectious diseases:

Oral rehydration salts and zinc tablets 58.6 73.8 15.2*** 48.8 60.4 11.6*** Vitamin A 20.1 59.4 39.3*** 22.5 53.2 30.7***

Facility has control card for the following immunization commodities: Rotarix 33.0 51.1 18.1*** 31.9 46.5 14.7*** Pentavalent 32.6 53.0 20.4*** 32.9 45.8 12.8***

Facility has control card for the following malaria commodities: Artesunate and amodiaquine 61.2 66.5 5.3** 53.7 57.6 3.9* Artemether and lumefantrine 61.5 73.9 12.4*** 49.6 63.2 13.6*** Malaria RDTs 48.3 72.1 23.9*** 43.9 59.7 15.8***

Facility has control card for the following family planning commodities, among facilities providing contraception: An injectable contraceptive 68.6 76.8 8.2 62.5 72.0 9.5 Condoms 53.6 60.3 6.7 52.1 48.8 -3.3

Availability of updated control cards for specific commodities Facility has control card for the following nutrition commodities that was updated in the previous 30 days:


Facility has control card for the following immunization commodities that was updated in the previous 30 days: Rotarix 25.3 44.8 19.5*** 23.2 37.5 14.3*** Pentavalent 23.4 45.1 21.6*** 23.1 35.4 12.3***

Facility has control card for the following malaria commodities that was updated in the previous 30 days: Artesunate and amodiaquine n.a. 46.8 n.a. n.a. 39.0 n.a. Artemether and lumefantrine n.a. 55.9 n.a. n.a. 43.9 n.a. Malaria RDTs n.a. 62.5 n.a. n.a. 48.9 n.a.

Facility has control card for the following family planning commodities that was updated in the previous 30 days, among facilities providing contraception:

An injectable contraceptive n.a. 67.1 n.a. n.a. 58.4 n.a. Condoms n.a. 45.1 n.a. n.a. 33.4 n.a.


Availability of control cards for specific commodities Facility has control card for the following commodities related to nutrition, diarrhea and infectious diseases:

Oral rehydration salts and zinc tablets 88.3 90.0 1.7 85.2 93.6 8.4** Vitamin A 44.3 73.5 29.1*** 41.0 77.6 36.6***

Facility has control card for the following immunization commodities: Rotarix 59.6 85.0 25.4*** 60.2 87.7 27.6*** Pentavalent 57.2 86.2 29.1*** 59.9 88.1 28.2***

Facility has control card for the following malaria commodities: Artesunate and amodiaquine 87.2 81.8 -5.4 86.9 88.8 1.9 Artemether and lumefantrine 86.2 93.0 6.8* 86.4 96.0 9.6*** Malaria RDTs 75.1 84.3 9.2 75.5 89.1 13.7***

Facility has control card for the following family planning commodities, among facilities providing contraception: An injectable contraceptive 79.9 93.2 13.3** 69.8 91.5 21.7*** Condoms 75.8 85.1 9.3 65.2 72.8 7.6

Facility has control card for the following BEmONC commodities, among Health Centers: Parenteral antibiotics n.a. 46.2 n.a. n.a. 51.0 n.a. Magnesium sulfate for preeclampsia and eclampsia n.a. 46.8 n.a. n.a. 51.3 n.a.

33 This table lists the more important commodities in each category; for a full listing of all commodities in the study, see Table19A & B in Appendix D.



Availability of updated control cards for specific commoditiesa Facility has control card for the following nutrition commodities that was updated in the previous 30 days:


Facility has control card for the following immunization commodities that was updated in the previous 30 days: Rotarix 49.5 78.6 29.2*** 46.2 73.4 27.2*** Pentavalent 46.0 76.7 30.7*** 44.6 70.8 26.2***

Facility has control card for the following malaria commodities that was updated in the previous 30 days: Artesunate and amodiaquine n.a. 57.7 n.a. n.a. 70.1 n.a. Malaria RDTs n.a. 71.2 n.a. n.a. 79.3 n.a.


An injectable contraceptive n.a. 73.4 n.a. n.a. 72.3 n.a. Condoms n.a. 55.9 n.a. n.a. 51.5 n.a.

Facility has control card for the following BEmONC commodities that was updated in the previous 30 days, among Health Centers: Parenteral antibiotics n.a. 42.6 n.a. n.a. 44.6 n.a. Magnesium sulfate for preclampsia and eclampsia n.a. 37.6 n.a. n.a. 35.8 n.a.

Source: Health, Population and Nutrition Office Health Systems baseline and midline survey data. n.a. = not applicable (question not asked at baseline, or not comparable.

Financial challenges to the supply chain

According to DDHS respondents, cash flow is an increasing challenge to ensuring the regular availability of supplies. Lack of timely payments from the health insurance authorities to the facilities to reimburse claims especially causes problems in facilities’ ability to access drugs and supplies from the regional and district medical stores. One interviewee noted that the NHIS has not reimbursed the facility for over a year. Moreover, non-payments by the NHIS affect procurement of even free medications like vaccines from the RMSs, because facilities lack funds to pay for transport and other associated costs of procurement. As one SDHO summarized:

[It’s been] about 12 to 13 months now they [NHIS] have not paid anything to the facility. That has been another major problem. Because if you have the money, you have the will, you have the power. But, [we] don’t have [the money], and we need to buy things on credit, and that is more expensive.—SDHO, Northern

The lack of cash in health facilities also makes it difficult for the regional and district medical stores to procure medicines and supplies, because health facilities have not had funds to pay them. One DDHS reported that health facilities in his region owed the RMS more than 7 million Ghana cedis.

2. Availability of Supplies and Equipment

The study examined next the availability of key supplies and equipment in health facilities. Quantitative survey data served to assess the frequency of stock-outs of key supplies, as well as the availability of supplies and equipment on the day of the survey, using the list of essential supplies and equipment from the 2014 CHPS Implementation Guidelines. The list below included priority supplies and equipment, with the full list found in Table 20 in Appendix D. This section also presents findings from the qualitative data related to equipment maintenance and repairs.

And then provision of oxygen, we are challenged… the resources to procure these things has been a problem due to the inability of the national health insurance to meet their part of the obligation — they haven’t met their indebtedness half way for the previous year. So we are constrained with funds to provide oxygen and some other equipment.—DDHS, Northern


Stock-outs

The study asked facility respondents whether they had experienced any stock-outs in the previous two months of commodities for which they had control cards.34 To examine changes between baseline and midline for each commodity, the analysis focuses on the sample of facilities that reported having the control card at both baseline and midline, so that changes in the sample would not bias the findings.35 Changes in the prevalence of stock-outs between baseline and midline were mixed: out of 22 commodities, among CHPS zones in focal regions, the prevalence of stock-outs increased for two commodities, decreased for five and did not change much for 15 commodities (see Table 18A and 18B in Appendix D for the full list of commodities). There was no statistically significant change in the prevalence of stock-outs for any of the four nutrition commodities measured in both survey rounds for CHPS zones in focal regions (Figure 18A), an indicator of one of USAID’s funded projects. This was also true for change in the prevalence of stock-outs for any of the immunization, malaria and family planning commodities measured in both survey rounds for CHPS zones in focal regions (Figures 18B and 18C). The changes in the prevalence of stock-outs between baseline and midline were mixed for both CHPS zones and health centers in all regions.

TABLE 18. STOCK-OUTS FOR SPECIFIC COMMODITIES IN PREVIOUS TWO MONTHS, AMONG FACILITIES WITH RELEVANT CONTROL CARDS

(% OF FACILITIES)


Baseline Midline Difference Baseline Midline Difference

Facility experienced stock-out of the following nutrition commodities, among facilities with relevant control cards: Oral rehydration salts (ORS) and zinc tablets 33.1 35.0 1.9 29.6 25.6 -4.0

Vitamin A 17.6 9.7 -7.9 20.9 6.8 --14.1** Facility experienced stock-out of any of four nutrition commodities measured at baseline and endline (Albendazole, Iron and Folic Acid tablets, ORS and zinc tablets, Vitamin A).

69.4 68.0 -1.4 62.1 56.5 -5.6

Facility experienced stock-out of the following immunization commodities, among facilities with relevant control cards: Rotarix 2.5 1.6 -0.8 9.7 4.9 -4.8

Pentavalent 18.5 6.4 -12.1** 23.0 3.0 -20.0***

Facility experienced stock-out of any of eight immunization commodities. 44.1 39.2 -4.9 50.5 38.0 -12.5**

Facility experienced stock-out of the following malaria commodities, among facilities with relevant control cards: Artesunate and amodiaquine 25.4 31.0 5.6 19.7 29.5 9.7* Artemether and lumefantrine 24.4 24.1 -0.3 24.3 20.6 -3.7 Malaria RDTs 24.3 15.8 -8.5* 23.9 14.7 -9.2**

34 There were 94 facilities without any control cards, which included 12 percent of focal region CHPS, 33 percent of nonfocal region CHPS, and 2 percent of focal region health centers. 35 For example, if facilities that adopted control cards between the baseline and midline were less familiar with how to use them effectively and were more likely to experience stock-outs as a result, adding these facilities to the midline sample would artificially increase the prevalence of stock-outs. In practice, however, the estimates of stock-outs at midline were broadly similar whether or not these new adopters were included, suggesting that they did not have a systematically different level of stock-outs than facilities that already had control cards.

69.4% 68.0% 70.6%

53.2%

0%

20%

40%

60%

80%

FIGURE 18A: FACILITY EXPERIENCED STOCK OUT OF ANY OF 4 NUTRITION

COMMODITIES (ALBENDAZOLE, IRON AND FOLIC ACID TABLETS, ORS AND ZINC

TABLETS, VITAMIN A) (FOCAL REGIONS)





Facility experienced stock-out of any of five malaria commodities measured at baseline and endline (Pediatric syrup paracetamol, Adult paracetamol, Artesunate and amodiaquine, Artemether and lumefantrine, Malaria RDTs).

66.2 61.8 -4.4 63.3 57.6 -5.6

Facility experienced stock-out of the following family planning commodities, among facilities with relevant control cards: An injectable contraceptive 18.8 6.5 -12.3*** 13.9 7.3 -6.5** Condoms 12.8 18.0 5.2 15.3 11.7 -3.6

Facility experienced stock-out of any of six family planning commodities measured at baseline and endline.

73.6 79.0 5.3 74.8 83.2 8.4

Percentage of Health Centers Focal regions All regions


Facility experienced stock-out of the following nutrition commodities, among facilities with relevant control cards: Oral rehydration salts (ORS) and zinc tablets 37.4 32.0 -5.4 23.0 26.0 3.0

Vitamin A 31.4 0.0 -31.4** 22.0 3.1 -18.9* Facility experienced stock-out of any of 4 nutrition commodities measured at baseline and endline (Albendazole, Iron and Folic Acid tablets, ORS and zinc tablets, Vitamin A).

70.6 53.2 -17.4** 49.3 50.6 1.3

Facility experienced stock-out of the following immunization commodities, among facilities with relevant control cards: Rotarix 6.8 0.0 -6.8 2.8 0.0 -2.8 Pentavalent 17.8 14.0 -3.8 12.6 7.5 -5.1

Facility experienced stock-out of any of eight immunization commodities. 45.4 40.8 -4.6 36.2 43.9 7.7

Facility experienced stock-out of the following malaria commodities measured at baseline and endline, among facilities with relevant control cards:

Artesunate and amodiaquine 23.5 47.8 24.3** 10.1 35.1 25.0*** Artemether and lumefantrine 32.2 23.0 -9.1 24.9 15.9 -9.1** Malaria RDTs 29.4 28.6 -0.8 23.0 26.9 3.9

Facility experienced stock-out of any of five malaria commodities (Pediatric syrup paracetamol, Adult paracetamol, Artesunate and amodiaquine, Artemether and lumefantrine, Malaria RDTs),

78.7 72.0 -6.7 57.7 61.1 3.4

Facility experienced stock-out of the following family planning commodities, among facilities with relevant control cards: An injectable contraceptive 19.6 9.8 -9.8 15.2 10.4 -4.8 Condoms 23.1 7.1 -16.0* 19.3 8.5 -10.9

Facility experienced stock-out of any of six family planning commodities measured at baseline and endline.

60.5 67.1 6.6 65.0 65.2 0.2

Facility experienced stock-out of the following BEmONC commodities, among Health Centers with relevant control cards: Parenteral antibiotics n.a. 15.3 n.a. n.a. 12.3 n.a. Magnesium sulfate for preeclampsia and eclampsia n.a. 12.1 n.a. n.a. 12.1 n.a.

Source: Health, Population and Nutrition Office Health Systems baseline and midline survey data. a Not reported because of small sample sizes (fewer than 10). n.a. = not applicable (question not asked at baseline, or not comparable).


Each finding above applies only to health facilities with a control card for the commodity (and, more specifically, those with control cards at both baseline and midline) and might not reflect the change in the stock-out situation in all facilities. Therefore, the study also asked all facilities more generally how often they were unable to provide prescribed medicines, vaccines, or other supplies clients needed due to a stock-out (Table 18). Facilities were more likely to report more frequent stock-outs at midline relative to baseline. In particular, there was a large decrease in the percentage of CHPS zones and health centers that reported that stock-outs occurred less frequently than once a month (most

reported that it now occurred about once a month). This decrease was between 23 and 30 percentage points, depending on the regions and type of facility. It suggests that, in general, stock-outs were occurring more frequently at midline in facilities in which they had been the least frequent at baseline.

DDHSs interviewed reported that the number and duration of stock-outs were either the same as or worse than at baseline. Respondents noted that stock-outs leave clients without critical commodities or force them to seek these elsewhere; this reduces convenience and increases costs for clients. Other reasons cited for increased stock-outs were lack of monitoring supplies (e.g., antenatal books), difficulty in obtaining non-availability certificates and finding drugs on the open market, and the worsening financial situation of facilities because of non-payments from health insurance. Some interviewees also noted that they do not have refrigerators to store medications, which worsens the situation, especially for vaccines. One DDHS noted that, during immunization drives, staff from some facilities must use different health centers with refrigerators to keep their vaccines. Some drug shortages only last for a short period, but some can last longer; for example, two DDHS respondents noted that a syphilis test routinely administered to pregnant women had been in shortage for more than five months.

The clients interviewed were divided in their perceptions of the availability of supplies for treatment. Many clients noted that their CHPS compound had all the necessary supplies for their treatment, while others

18.8%

12.8%

18.3%15.3%

8.9%6.5%

18.0%

9.8%

34.0%

41.1%

19.6%23.1% 22.1%

4.8%

17.8%

9.8%7.1%

14.9%

29.2%

16.3%

0%

10%

20%

30%

40%

50%

An injectablecontraceptive

Condoms A hormonal implant (e.g.Implanon, Jadelle, or

Norplant)

Combined oralcontraceptive pills

Progestogen-only pill

FIGURE 18C. STOCK-OUTS FOR SPECIFIC FAMILY PLANNING COMMODITIES (FOCAL REGIONS)


47.8%

23.0%

28.6%

23.5%

32.2%

29.4%

31.0%

24.1%

15.8%

25.4%

24.4%

24.3%

0% 10% 20% 30% 40% 50%

Artesunate and amodiaquine

Artemether and lumenfantrine

Malaria RDTs

FIGURE 18B. STOCK-OUTS FOR SPECIFIC MALARIA COMMODITIES IN PREVIOUS TWO MONTHS

(FOCAL REGIONS)



noted that supplies sometimes run short. Clients were understanding, in general, despite frustrations at having to pay for drugs and supplies that are listed as being covered by NHIS.

Sometimes if the clients come and are given drugs like [amoxicillin], they are asked to pay for it, but they may have health insurance. We’ve had problems in this town where a patient will come out and be shouting that they were asked to pay. - CHC, Northern

The implications of stock-outs for clients continue beyond having to pay for drugs that insurance should cover. They include additional time and effort, which sometimes results in clients not following through and discourages clients from coming to the facility again. One client explained the extra steps involved:

The fact is that they don’t have the drug. So once they prescribe it for you, you need to go and buy. They will even tell you to come and show it to them when you buy it, so that they can give you the dosage and make sure you have the right thing. - Client, Greater Accra

Stock-outs are especially problematic when clients arrive at facilities with urgent needs and the proper medications are not available. If they are referred to a larger facility, they can face transportation constraints. When ambulances are not available and clients do not have other readily available transportation options, some clients do not follow through on their referrals. Finally, the lack of supplies and equipment makes some clients want to seek care at other facilities first, because they think they will not find the necessary medicines and care locally or that they will need to be transferred. Some SDHOs’ worry that frequent stock-outs will lower motivation for clients to seek care at their facilities. As two SDHOs said:

When clients come to some of the CHPS zones, and those at the facility don’t have drugs, one person will just go and spread … that there [are] no drugs at the facility. And clients, they don’t like to patronize it when there are no drugs, so our main problem is shortage of drugs. SDHO, Volta

The nurses also treated me well, just that the medicine and the injection was a problem. Though I was with the health insurance they asked me to buy them. - Client, Central

Availability of supplies on day of survey

The survey also assessed among the facilities with control cards the availability of key malaria, family planning, nutrition and immunization commodities on the day of the visit.36 For analysis, again the sample was restricted to facilities that had control cards for a given commodity at both baseline and midline, to avoid changes in the sample driving the estimated changes.37 Similar to the findings on stock-outs, changes in the availability of specific commodities between baseline and midline were mixed, although most changes were small (Table 19 and Figure 19). Overall, the level of availability of these commodities at midline among facilities with control cards was high. Among the individual commodities examined, the average commodity was available in more than 80 percent of CHPS zones and almost 90 percent of health centers.

36 Survey respondents were able to answer questions about stock-outs, updates to inventory cards, and the availability of each commodity that day with the inventory card in hand, and based on any other information they knew or looked up. 37 Similar to the analysis of stock-outs, we restricted the sample to facilities that had control cards for a given commodity at both baseline and midline to avoid changes in the sample driving the estimated changes. Again, however, in practice the estimated availability of supplies at midline were broadly similar whether or not the new adopters of control cards were included, suggesting that they did not have a systematically different level of availability than facilities that already had control cards.

45%

55%

68% 72%

0%

20%

40%

60%

80%

Figure 19. Facilities with all key immunizations available (asles, Polio,

Pnuemo, Rotarix, Pentavalent, Tetanus toxiod, yellow fever, Bacillus Calmette-

Guerin) (All Regions)



For nutrition commodities, a related indicator examined at midline was whether facilities met the minimum competency criteria for delivery of IYCF, which combines availability of commodities with other requirements.38 Almost no CHPS zones or health centers met all the criteria.

Also examined was whether facilities with control cards were effectively using them to monitor the expiration of key basic commodities. At midline, more than 90 percent of CHPS zones and health centers with control cards for at least one of the key commodities (vitamin A, pentavalent, uterotonic drugs, malaria RDTs, artesunate and amodiaquine and injectable contraceptives) had expired commodities. This suggests that the high levels of availability described above might be inflated somewhat by the availability of expired commodities.

TABLE 19. AVAILABILITY OF ESSENTIAL SUPPLIES AMONG FACILITIES (% OF FACILITIES)



Among facilities with relevant control cards Facility has the following nutrition commodities available:

Oral rehydration salts and zinc tablets 68.3 69.4 1.1 74.9 78.4 3.5

Vitamin A 86.3 97.6 11.3** 88.2 89.9 1.6 Facility has the following four nutrition commodities available: Albendazole, Iron & Folic Acid tablet, ORS & zinc tablet, Vitamin A

0.0 27.6 27.6*** 0.0 28.5 28.5***

Facility has the following immunization commodities available: Rotarix 97.2 95.6 -1.6 91.6 95.2 3.6 Pentavalent 91.7 93.4 1.8 84.8 93.5 8.7*

Facility has all of target immunization commodities available. 54.8 57.6 2.9 45.0 54.6 9.7

Facility has the following malaria commodities available: Artesunate and amodiaquine 83.2 67.4 -15.8** 85.6 72.3 -13.2*** Artemether and lumefantrine 81.5 77.9 -3.5 84.5 83.4 -1.1 Malaria RDTs 85.2 96.3 11.1*** 90.7 96.2 5.5**

Facility has the following five malaria commodities available: Pediatric syrup paracetamol, Adult paracetamol, Artesunate and amodiaquine, Artemether and lumefantrine, Malaria RDTs

45.3 37.4 -8.0 52.8 44.8 -8.0

Facility has the following family planning commodities available: An injectable contraceptive 94.3 94.8 0.6 93.5 96.5 3.0 Condoms 88.4 86.8 -1.5 84.3 87.2 2.9

Facility has no expired commodities (among vitamin A, Pentavalent, uterotonic drugs such as Oxytocin or ergometrine, malaria RDTs, Artesunate + amodiaquine and injectable contraceptives), according to control cardsa

n.a. 7.7 n.a. n.a. 5.6 n.a.


Among facilities with relevant control cards Facility has the following nutrition commodities available:

38 This is defined as (1) availability of all essential equipment in working order (six items): mid-upper-arm circumference tape, hanging scale, bathroom weighing scale, infantometers, hemoglobin test kit; (2) existence of at least one staff trained in the last 12 months in IYCF; (3) quality record keeping - completeness of infant records based on spot check of three records randomly pulled; (4) availability of all nutrition commodities and supplies (five items): Vitamin A capsules, Oral rehydration salts, Iron and Folic Acid tablets, IYCF registers, and nutrition counseling materials (any of counseling cards, key messages leaflets, nutrition pamphlets, or other nutrition materials).



Oral rehydration salts and zinc tablets 72.0 66.2 -5.8 84.6 69.5 -15.1**

Vitamin A 77.4 100.0 22.6* 87.1 100.0 12.9* Facility has the following four nutrition commodities available: Albendazole, Iron and Folic Acid tablets, ORS and zinc tablets, Vitamin A

1.7 32.6 30.9*** 0.8 34.2 33.5***

Facility has the following immunization commodities available: Rotarix 100.0 98.3 -1.7 98.4 99.3 0.9 Pentavalent 92.9 98.1 5.2 93.9 94.2 0.3

Facility has all of the target immunization commodities available.

74.4 75.3 0.9 68.0 71.5 3.4

Facility has the following malaria commodities available: Artesunate and amodiaquine 81.7 79.3 -2.5 89.4 87.0 -2.4 Artemether and lumefantrine 86.8 83.7 -3.1 86.5 90.7 4.2 Malaria RDTs 78.1 95.3 17.2*** 83.0 89.8 6.8

Facility has the following 5 malaria commodities available (Pediatric syrup paracetamol, Adult paracetamol, Artesunate and amodiaquine, Artemether and lumefantrine, Malaria RDTs)

41.1 44.7 3.6 54.5 53.9 -0.7

Facility has the following family planning commodities available: An injectable contraceptive 80.5 91.6 11.1 86.6 91.8 5.2 Condoms 75.8 98.2 22.4*** 83.8 90.0 6.3

Facility has the following BEmONC commodities available (among Health Centers): Parenteral antibiotics n.a. 86.4 n.a. n.a. 83.9 n.a. Magnesium sulfate for preeclampsia and eclampsia n.a. 73.9 n.a. n.a. 77.9 n.a.

Facilities with one or more expired commodities (among vitamin A, Pentavalent, uterotonic drugs such as Oxytocin or ergometrine, malaria RDTs, Artesunate + amodiaquine and injectable contraceptives) according to control cardsa

n.a. 8.7 n.a. n.a. 5.7 n.a.

Source: Health, Population and Nutrition Office Health Systems baseline and midline survey data. a Sample includes all facilities with a control card for at least one of these commodities. n.a. = not applicable (question not asked at baseline, or not comparable)

Availability of essential equipment

Also examined was the availability of functional essential equipment needed for delivery, nutrition assessment and counseling and storage in the facilities on the day of the survey and how this changed between baseline and midline. For CHPS zones, the changes in availability of equipment were mixed within and across categories of equipment (Tables 20A and 20B; Figures 20A and 20B). For example, for CHPS zones in the focal regions, the availability of essential equipment for delivery among CHPS zones conducting deliveries increased significantly for pre-eclampsia and eclampsia packs and did not change significantly for the remaining four types of equipment. The changes in availability of nutrition assessment equipment across CHPS zones in focal regions were similarly mixed, but were more consistently negative for the availability of storage equipment (with an average decrease of 6 percentage points) and the availability of a generator (a decrease of 22 percentage points). This pattern of findings is similar for CHPS zones among all regions. Overall, because only a few types of equipment increased in availability and these increases were typically modest, baseline gaps in availability of equipment among CHPS zones persisted, in general, at midline.


TABLE 20A. AVAILABILITY OF ESSENTIAL EQUIPMENT AMONG CHPS ZONES (% OF CHPS ZONES)


Facility has the following items for childbirth/delivery available and in working order, among facilities that conduct deliveries:

Domiciliary midwifery kit n.a. 46.1 n.a. n.a. 51.4 n.a. Sterile delivery Kit n.a. 64.7 n.a. n.a. 65.6 n.a. Suturing set n.a. 50.3 n.a. n.a. 54.4 n.a. Postpartum hemorrhage, or PPH, pack for post-partum management

18.5 24.5 6.0 35.6 38.9 3.3

Pre-eclampsia and eclampsia pack for management of eclampsia

8.3 18.6 10.3 20.0 27.3 7.3

Resuscitation kits for resuscitating babies

46.0 48.7 2.7 52.2 63.4 11.2**

Facility has the following items for nutrition assessment and counselling available and in working order: A mid-upper arm circumference measuring tape, also known as a MUAC tape

57.2 64.9 7.7** 48.2 68.5 20.4***

A tape measure 71.7 79.5 7.8** 69.3 72.7 3.3 A hanging scale or Salter weighting scale 95.6 82.1 -13.5*** 89.6 78.6 -11.1***

A baby-weighing scale or a newborn- or infant-weighing scale 46.8 38.7 -8.1** 49.3 39.1 -10.1***

An Integrated Management of Neonatal and Childhood Illnesses chart booklet

48.9 48.2 -0.7 35.6 36.7 1.0

An IYCF register 34.4 45.0 10.5** 31.9 46.0 14.1*** Facility has the following storage equipment available for use:

A vaccine refrigerator 34.9 34.4 -0.6 29.4 23.9 -5.6** A vaccine fridge thermometer 40.8 31.2 -9.5*** 31.8 20.8 -10.9*** An up-to-date temperature-monitoring sheet 33.6 25.8 -7.8*** 24.9 17.3 -7.5***

Ice packs 70.5 65.7 -4.8 57.8 55.4 -2.5 A cold box 35.6 29.1 -6.5** 31.5 22.7 -8.8***

Facility has the following basic supplies available for use: A generator 26.7 4.6 -22.1*** 24.1 4.4 -19.7***

Facility meets minimum competency criteria for delivery of IYCF.a n.a. 0.3 n.a. n.a. 0.2 n.a.

Source: Health, Population and Nutrition Office Health Systems baseline and midline survey data. Note: Percentages are weighted to adjust for sampling probabilities. a Includes quality service provision in the following areas: (1) availability of all essential equipment in working order (six items): mid-upper-arm circumference tape, hanging scale, bathroom weighing scale, infantometers, hemoglobin (HB) test kit; (2) existence of at least one staff trained in the last 12 months in IYCF; (3) quality record keeping - completeness of infant records based on spot check of three records randomly pulled; (4) availability of all nutrition commodities and supplies (five items): Vitamin A capsules, Oral rehydration salts (ORS), Iron and Folic Acid tablets (IFAs), IYCF registers and nutrition counseling materials (any of counseling cards, key messages leaflets, nutrition pamphlets, or other nutrition materials). n.a. = not applicable (question not asked at baseline, or not comparable).

TABLE 20B. AVAILABILITY OF ESSENTIAL EQUIPMENT AMONG HCS (% OF HCS)


Facility has the following items for childbirth/delivery available and in working order: Domiciliary midwifery kit n.a. 63.2 n.a. n.a. 73.2 n.a. Sterile delivery kit n.a. 92.7 n.a. n.a. 95.8 n.a. Suturing set n.a. 87.8 n.a. n.a. 90.0 n.a. Postpartum hemorrhage, or PPH, pack for post-partum management

53.4 74.0 20.5*** 66.2 82.1 15.9***

Pre-eclampsia and eclampsia pack for management of eclampsia

44.2 63.1 18.9** 60.8 74.5 13.6***

Resuscitation kits for resuscitating babies 79.5 94.4 14.9*** 81.4 91.1 9.7** Facility has the following items for nutrition assessment and counselling available and in working order:



A mid-upper arm circumference measuring tape, also known as a MUAC tape

72.3 86.2 13.9*** 60.2 82.3 22.1***

A tape measure 99.2 95.3 -3.9* 95.5 96.5 1.0 A hanging scale or Salter weighting scale 98.9 96.7 -2.2 94.9 96.5 1.6 A baby-weighing scale or a newborn- or infant-weighing scale

86.1 89.2 3.1 89.9 89.9 0.0

An Integrated Management of Neonatal and Childhood Illnesses chart booklet

71.7 70.9 -0.8 63.3 52.5 -10.8**

An infant and young child feeding register 59.9 62.3 2.4 49.6 55.1 5.5 Facility has the following storage equipment available for use:

A vaccine refrigerator 90.1 84.5 -5.6 82.8 83.5 0.7 A vaccine fridge thermometer 88.1 81.4 -6.7* 86.6 79.6 -6.9** An up-to-date temperature-monitoring sheet

87.8 77.5 -10.3** 81.7 76.0 -5.7

Ice packs 97.5 96.4 -1.1 94.5 98.3 3.8 A cold box 69.1 65.2 -3.9 74.1 71.3 -2.9

Facility has the following basic supplies available for use: A generator 42.6 29.8 -12.9*** 49.2 26.7 -22.5***

Facilities meeting minimum competency criteria for delivery of IYCF.a

n.a. 0.0 n.a. n.a. 0.0 n.a.

a Includes quality service provision in the following areas: (1) availability of all essential equipment in working order: six items - Mid-upper-arm circumference tape, hanging scale, bathroom weighing scale, infantometers, hemoglobin (HB) test kit; (2) existence of at least one staff trained in the last 12 months in IYCF; (3) quality record keeping - completeness of infant records based on spot check of three records randomly pulled; (4) availability of all nutrition commodities and supplies (five items): Vitamin A capsules; Oral rehydration salts (ORS), Iron and Folic Acid tablets (IFAs); IYCF registers; and nutrition counseling materials (any of counseling cards, key messages leaflets, nutrition pamphlets, or other nutrition materials). We looked at commodities available the day of visit and commodities with bin card. n.a. = not applicable (question not asked at baseline, or not comparable).

For health centers, the availability of most types of equipment was similar at baseline and midline. However, there is some evidence of a systematic increase in the availability of essential equipment for delivery. In particular, there were large increases in the availability of most equipment for delivery measured at baseline and midline (these increases were larger in the focal regions than among all regions). In addition, there also was a large decrease in the availability of a generator in health centers, similar to the situation in CHPS zones.

Many of the DDHSs and SDHOs interviewed noted that facilities do not always have the functional equipment necessary to treat clients. Examples of broken or missing equipment mentioned included weighing scales, thermometers, oxygen tanks, autoclaves, and delivery kits. Many health centers also lack functioning laboratories. They reported that this lack of equipment also pushes facilities to refer clients to larger facilities further away.

63.2%

92.7%

87.8%

46.1%

64.7%

50.3%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Domiciliary midwifery kit

Sterile Delivery Kit

Suturing set

FIGURE 20A. AVAILABILITY OF ESSENTIAL EQUIPMENT IN FOCAL REGIONS(MIDLINE ONLY)

CHPS HC


Equipment maintenance and repairs

Even when equipment is available, a system for maintenance and repairs is needed to keep it in good working order. Some DDHSs and SDHOs reported that they monitor small equipment supply and functionality in an inventory book, but most interviewees reported that they did not regularly collect this type of data. These procedures were less common and less consistent than the systems for monitoring supplies and medicines and were not different than they were at baseline.

Also similar to baseline, most respondents reported that, when equipment breaks down, they send it to the store officer or the district mechanic for repair. If the equipment cannot be repaired, facilities request a replacement from RMSs. Some stated that small equipment is repaired or replaced promptly and felt that their system of repairing or replacing equipment works well. However, others noted that equipment is not always in stock at the RMSs and sometimes they must make do without working equipment. Cash flow also affects whether a facility can repair or replace small equipment like blood pressure cuffs and stethoscopes.

3. Availability of Communication Technology

The availability of communication technology could contribute to health facilities operating more effectively and efficiently—for example, by enhancing record keeping and access to online health information. The facility survey assessed the availability of cell phones and computers/tablets in CHPS zones and health centers. As Figure 21 show, for CHPS zones, the availability of cell phones with or without internet access

23.1%18.5%

8.3%

46.0%

13.6%24.5%

18.6%

48.7%43.1%53.4%

44.3%

79.5%

38.5%

74.0%63.1%

94.4%

0%

20%

40%

60%

80%

100%

Hand held vacuumextractor

Postpartum hemorrhage,or PPH, pack for post-partum management

Pre-eclampsia andeclampsia pack for

management of eclampsia

Resuscitation kits forresuscitating babies

FIGURE 20B. AVAILABILITY OF ESSENTIAL EQUIPMENT (FOCAL REGIONS)


34.9%40.8%

35.6%

22.2%

89.2%

34.4% 31.2% 29.1%

15.9%

81.3%90.1% 88.1%

69.1%

53.1%

98.9%

84.5% 81.4%

65.2% 62.1%

97.2%

0%

20%

40%

60%

80%

100%

A vaccinerefrigerator

A vaccine fridgethermometer

A cold box An emergencystorage plan

A vaccine carrier

FIGURE 20C. AVAILABILITY OF STORAGE EQUIPMENT (FOCAL REGIONS)



was similar at baseline and midline; nearly all CHPS zones still did not have access to cell phones at midline.39 There is evidence of an increase in the availability of computers and computers with internet access in CHPS zones between baseline and midline. These measures increased by 10 and 5 percentage points, respectively, in focal regions; they increased by a 13 and 7 percentage points, in all regions. Still, only about one in five CHPS zones had a computer and only about one in 10 had a computer with internet access at midline. The limited availability of communication technology could, in part, reflect the limited cell phone and internet connectivity available in some of the rural areas in which these facilities are located.

For health centers in the focal regions, the changes in the availability of cell phones and computers between baseline and midline were all small, although the levels of computer availability in health centers were substantially higher than in CHPS zones. The availability of cell phones in health centers increased by 10 percentage points in all regions and the availability of computers with internet access decreased by 14 percentage points.

G. Client Satisfaction

A key measure of the quality of care in facilities is the level of client satisfaction. The qualitative interviews asked clients, community leaders, SDHOs and District Assembly members, about their satisfaction with the care and services of the facilities in their area and their perceptions of others’ satisfaction. This section summarizes their views of CHPS zones and then of health centers.

1. Perceptions of Quality at CHPS Zones

Overall, most of the clients interviewed had a very positive opinion of the CHPS zones, as during the baseline. Respondents noted the following strong points of health services offered at CHPS zones: hard-working staff, care available 24 hours a day and seven days a week, and community engagement. Clients across districts mentioned in particular very good care of pregnant women and children.

Their treatment is very good and when you take your baby for weighing they take very good care of them. I like their services. If the children are growing well, they tell you, and if their growth is declining, too they alert you. They advise you on how to take care of the children and what to do so that they don’t fall sick.… Other health facilities treat us harshly, but when we visit, this CHPS doesn’t exhibit such characters.—Client, Central

Most clients reported that waiting times were reasonable and that CHPS staff took time to interact with them, listened and answered questions. Overwhelmingly, clients felt satisfied with the treatment they received and reported feeling understood.

39 This included personal cell phones of facility staff that could be used for work. We also examined changes in the availability of cell phones with specific features such as SMS, cameras, multimedia service, or smart phone capabilities, and the findings were broadly similar to those for cell phones in general.

13.4%6.2% 8.4%

2.5%

16.6%8.7%

18.5%

7.6%

19.2%11.1%

66.4%

50.4%

20.6%

10.1%

69.2%

45.6%

0%

20%

40%

60%

80%

Working cell phone Working cell phone withInternet access

Working computer/tablet Working computer/tabletwith Internet access

FIGURE 21. AVAILABILITY OF COMMUNICATION TECHNOLOGY (FOCAL REGIONS)



I can say my staff, especially the midwives, the nurses and midwives, they are very good. Even outreach services, without vehicle, they are able to mobilize and do it. So the staff are very good. They are hard-working.—DDHS, Greater Accra

Some respondents noted that impressive attendance numbers supported the overall assessment of the quality of care provided by CHPS. Some respondents attributed a decrease in child mortality rates to the quality of CHPS care.

Respondents thought that access to quality health care was increasing quickly through an increase in the number of health facilities and their coverage.

We have seen tremendous increase in CHPS coverage; primary health care has been taken to the doorsteps of the clients now.—DDHS, Volta

In particular, district-level respondents in the Northern and Western regions noted expanded health service access due to construction of CHPS facilities in the past two years. Clients expressed their satisfaction with this increase.

I am very happy because when the health center was not around, we were suffering a lot. Taking pregnant woman on bicycle, taking malaria child on bicycle … we use to take them on bicycle from here to Tolon…Nowadays, we [do] not because of the benefit of this CHPS compound, so I am very happy for the service that has been brought to this place. —Client, Northern

Clients commonly noted they prefer seeking services through a CHPS instead of a hospital due to proximity, not having to worry about transportation and shorter waiting times. However, respondents in all regions noted CHPS care could still be improved. While most respondents reported they thought steps were being taken to improve the quality of care, areas identified for improvement included standards that are inconsistent across facilities, the need for infrastructure additions and renovations, some CHPS staff’s attitudes and insufficient staffing. Many clients voiced the desire for a doctor on the premises and additional nurses and midwives. Improved infrastructure needs included labs, accommodation for nurses, additional space and furnishings for the compounds, such as beds and chairs. Additional challenges were that medication was often not available at the CHPS and had to be procured elsewhere, more complex cases had to be transferred to other facilities and distance and transport were persistent problems for clients.

2. Perceptions of Quality at Health Care Centers

Almost one-third of the clients interviewed said they had contact with a health center within the previous 12 months. These clients were asked about their perceptions of various aspects of the quality of care delivered by health centers. Responses indicated that there was a marked improvement in satisfaction with staff since the baseline. Clients reported satisfaction with the quality of care at health centers and that they felt the center staff had time to listen to them, treated them well and understood them. As one community leader and one client noted,

When you visit the clinic they welcome you and enquire about your sickness, by the time they are done you feel that the doctors [health care providers] have really taken care of you. They stop whatever they are doing and attend to patients quickly.—Community Leader, Western

District- and sub-district-level respondents noted other improvements over the past two years, including more midwives, which they reported had led to more women giving birth in the health centers instead of with traditional birth attendants. Some district- and sub-district-level respondents credited this with decreased maternal and neonatal mortality rates and higher rates of child immunizations.

We have only two doctors who are serving a district of a population of about 133,000, and then most of the health centers need to be upgraded to urban hospitals.—DA, Central

Clients, DA members, SDHOs and community leaders also described desired improvements for health centers, which were similar to those for CHPS: more staff; better supply of medication; improved transport;


and upgraded facilities and improved infrastructure, including expanded wings, delivery wards and accommodations for nurses and security guards.

I will give my health center 70 percent; for staffing I will give 70 percent, but for procedures to be performed I will go 50 to 55 percent because when I came most of the things that we need to make some procedures here we don’t have them … like you want to give a patient a kind of treatment, you cannot. If you do the person is obliged to buy it outside and bring it here.—SDHO, Central

3. Infrastructure and Transportation

The study asked Community leaders, District Assembly members, DDHSs, SDHOs and CHC members about the strengths and weaknesses of the infrastructure of CHPSs and health centers. This section summarizes their views of the infrastructure supporting CHPS zones and health centers and how infrastructure affects clients’ receipt of and satisfaction with health care services.

There has been a recent effort to construct CHPS compounds—structures in which CHOs provide services and sometimes include accommodations for CHPS staff—to expand access to health care in CHPS zones. Respondents affected by this construction have been pleased with the opportunities this infrastructure provides, including accommodations for staff, which increases the time staff are available to serve the community. However, almost all respondents noted that expanded building infrastructure is needed for CHPS compounds, including additional rooms and facilities to deal with overcrowding of clients and to separate clients such as children, laboring women and infectious clients; renovated and upgraded facilities; additional dedicated lab space and toilet facilities; and expanded wings, such as children’s wards and nurses’ accommodations.

Especially when women come to deliver, you have to discharge the person after six or more hours if the condition is OK. Because if you have to retain the person, there is no toilet facility, there is no bath house for the person to clean himself or herself.—DDHS, Greater Accra

As you can see when you were passing through the OPD [outpatient department], you saw how the whole place was congested, lab people are waiting…those going to the dispensary, record and consulting room, all inclusive, so that’s the main challenge now.—SDHO, Greater Accra

With the female nurses there are two people to one room, and with the males, they are three in one room. They don’t feel comfortable so the nurses’ quarters is our main target.—CHC, Northern

Transportation systems were another common theme touched on by respondents, including roads; ambulances, cars, motorbikes and public transportation; and money for upkeep, gas and fares. Respondents often mentioned the staffs’ need for transportation to conduct outreach and for supplies. Motorbikes are often provided to CHOs in CHPS zones, but maintenance, fuel and passable roads can make them ineffective. The lack of ambulances was frequently mentioned as a problem in transporting very ill clients or women facing complex births, whose families have transported them in extremely inadequate manners, including via bicycle, or foregone treatment altogether.

If they [CHPS staff] see that the sickness is more than they can handle, they tell you to go to this place [another health facility], and that is why I said they don’t have any car to rush the people. Unless you hire your own car or stand at the roadside and stop a car, before you will get a car and go with that.—Community Leader, Greater Accra

H. Health Promotion

GHS and the MoH relaunched a health promotion campaign, “GoodLife, Live It Well” in July 2016 throughout the country. Through television, radio, social media and print materials, the campaign attempts to promote positive health behaviors in family planning; MNCH; malaria prevention and treatment; and water, sanitation and hygiene. The interviewers documented whether health facilities displayed GoodLife, Live it Well campaign materials and asked if staff used them during health promotion activities. Interviewers also asked clients about their exposure to these messages and their perceptions of changes they have made due to the campaign. This section summarizes the health facility data and clients’ experiences and reported behaviors regarding the campaign.


1. Awareness of the GoodLife, Live It Well campaign

The study examined the display and use of GoodLife, Live It Well campaign materials by facilities at midline. More than half of CHPS zones in both focal regions and all regions displayed these materials and about three-quarters of CHPS zones reported using them during health promotion activities (Table 21). More than three-quarters of health centers in both focal regions and all regions displayed these materials and a similar fraction percentage reported using them.

TABLE 21. HEALTH PROMOTION USING CAMPAIGN MATERIALS (% OF FACILITIES) Percentage of CHPS Zones Focal Regions Midline All Regions Midline

Facility displays GoodLife, Live It Well campaign materials 61.9 59.2 Facility uses GoodLife, Live it Well campaign materials during health promotion activities

77.3 72.3

Percentage of Health Centers Focal Regions Midline All Regions Midline Facility displays GoodLife, Live It Well campaign materials 83.3 81.8 Facility uses GoodLife, Live it Well campaign materials during health promotion activities

77.2 79.4

Source: Health, Population and Nutrition Office Health Systems Midline Survey Data.

Most clients interviewed through the qualitative research in the focal regions indicated they had heard or seen GoodLife, Live It Well campaign messages on the radio, on television, or in posters at a health facility. Some had also been coached by CHNs and facility staff on the messages, or had been given GoodLife, Live It Well calendars to keep. The most commonly recalled messages included the need to wash hands, sleep under treated bed nets, and cover food to avoid contamination by flies, breastfeed children, immunize children, drink clean water, eat a proper diet and keep one’s surroundings clean. Clients were able to describe pictures on posters sending visual messages on these topics and describe stories of what they heard or saw on television with similar messaging.

It was about malaria and diarrhea. The malaria it was two people, one was sleeping outside and had malaria and the other was sleeping in the mosquito net and didn’t have malaria. One went to toilet and didn’t wash his hands and had the diarrhea, and the other after the toilet washed his hands with soap, so didn’t have the diarrhea.—Client, Northern

There are so many types of GoodLife: bathe your child, wash the clothing, sweep around your house, wash your utensils, clean pure water, good food, give the child rest, not giving too much work. Life is very important so all these I mentioned are part of GoodLife.—Client, Northern

2. Changes in Behavior Associated with Campaign

Almost all clients interviewed who were exposed to messages from GoodLife, Live It Well reported changing behaviors due to the campaign.40 The most often-cited changes were increased handwashing, especially after using the toilet, and sleeping under treated bed nets. People also indicated they changed their diets, kept a clean home and environment and covered food and water, among other changes. One client even said he gave up alcohol after learning about healthy lifestyles.

Formerly we the villagers when we return from the farm we don’t even wash our hands before we eat, but because of these teachings we wash our hands with soap and water and the children, too. We take care of them well. So it has really helped us.—Client, Central

What I have learnt is that, now we have mosquito nets, so you don’t have to wait for mosquitoes to bite you and you fall sick before you go to the hospital. There is a saying that ‘Prevention is better than cure’ so when you have the net, you just fix it and use. At first when we finish using the toilet we are always in a rush, we don’t wash our hands but from the GoodLife advert they teach us that when we use the toilet we should wash our hands. They also encourage us to exercise because exercising is good for us and also we should watch the food we eat, we should eat less for improved health.—Client, Greater Accra

40 Although this cannot be considered definitive evidence of the impacts of the program given the relatively small sample of clients and the possibility that clients reported desirable responses, it does suggest knowledge and attitudes were affected, and seemingly behaviors as well.


IV. CULTURE OF QUALITY ASSURANCE (QA) AND QUALITY IMPROVEMENT (QI)

To improve the quality of health care, the GHS has worked with facility-based health staff to provide them with the essential knowledge and skills to plan and implement QA at all service delivery points, especially at the sub-district-level health centers (Healthcare Quality Assurance Manual for Sub-districts 2004). QA is a set of activities that seeks to improve quality of care by setting standards and monitoring to see whether these standards are met; QI involves addressing gaps identified by QA. One particularly important dimension of effective QA and QI at the facility level is collecting and using high quality health data, a focus of both the Systems and MalariaCare projects.

This chapter examines the extent to which a culture of QA and QI exists in CHPS zones and health centers in Ghana, focusing on the collection and use of data. This chapter begins by describing the QA and QI activities conducted at these facilities. Then it examines how facilities assure data quality, especially for the DHIMS2; and the extent to which facilities and district level actors use data for monitoring and making decisions.


• Modest improvements occurred in formal quality assurance/quality improvement (QA/QI) activities between baseline and midline; however, facilities continue to conduct a range of QA/QI activities even without formal plans, including those related to sanitation and infection prevention, nutrition services, and up-to-date supplies. • District- and sub-district-level stakeholders perceive that the quality of DHIMS2 data has improved over the past two years. Most facilities collect and validate data, with almost 90 percent of CHPS and 95 percent of health centers nationwide validating DHIMS2 reports with source documents. • DAs, DDHSs, and SDHOs use DHIMS2 data for planning and decision-making. Stakeholders generally reported that DHIMS2 data quality had improved over the past two years, although the lack of access to computers and the Internet remains a challenge to collecting accurate and timely data.

A. QA and QI Activities at Facilities

Health centers are expected to have a team of staff focused on QA and QI activities; these teams should meet on a regular basis to discuss potential improvements and the status of current QI efforts. In contrast, CHPS zones are not expected to have QA/QI teams, because they are typically too small to support them. Instead, representatives from CHPS zones typically join the health center QA/QI team. The facility survey suggests a modest increase between baseline and midline in the percentage of health centers that reported having an active QA/QI team, as well as an active QA/QI team that met at least once in the three months before the survey.

In addition to having a QA/QI team, it is important that both types of facilities have QA/QI plans in place and are acting on those plans. There is some evidence of a modest decrease between baseline and midline in the percentage of both types of facilities reporting that they do not have a 2016-2017 QA/QI action plan in place. Table 22 reports the percentage of health centers that have an active QA/QI plan—defined as having both a QA/QI plan in place and a QA/QI team that met at least once in the three months before the survey. At midline, about 32 percent of health centers in focal regions and 35 percent in all regions together met this criterion, representing a small increase relative to baseline (the baseline levels were 23 and 28 percent, respectively). Overall, these findings provide some suggestive evidence of improvements in formal QA/QI activities between baseline and midline, but these improvements seem to have been modest at best.41

41 Although not a focus of this study, Systems for Health engaged in systems strengthening (and QI) at regional and district levels, building the skills of GHS regional and district managers by training them as improvement coaches, emphasizing the importance of being champions and facilitators for QI


TABLE 22. EXISTENCE OF QA/QI TEAMS AND PLANS AMONG FACILITIES


Facility has no QA/QI action plan in place 53.4 48.5 -4.9 51.7 45.2 -6.5* Facility had used QA/QI nutritional information to improve services in the previous two months, among facilities with nutrition included as a topic in their action plan

41.5 80.9 39.4** 31.5 76.3 44.8***

Facility has implemented a malaria QI action plan in the previous two months, among facilities with malaria included as a topic in their action plan

n.a. 81.0 n.a. n.a. 81.1 n.a.

Percentage of Health Centers Facility has an active QA/QI team 44.4 47.8 3.4 44.1 54.3 10.2 Facility has an active QA/QI team that met at least once in the previous three months 29.1 34.1 5.0 35.0 44.5 9.5*

Facility has no QA/QI action plan in place 51.8 44.9 -6.9 48.4 41.3 -7.1 Facility has an active QA/QI plana 23.4 31.5 8.1 28.2 34.9 6.6 Facility had used QA/QI nutritional information to improve services in the previous two months, among facilities with nutrition included as a topic in their action plan

-- b -- b -- b 40.4 93.6 53.2**

Facility has implemented a malaria QI action plan in the previous two months, among facilities with malaria included as a topic in their action plan

n.a. 81.4 n.a. n.a. 92.4 n.a.

Source: Health, Population and Nutrition Office Health Systems baseline and midline survey data. a Defined as having an active QA/QI team that met at least once in the previous three months and a QA/QI action plan in place. b Not reported because of small sample sizes (fewer than 10). n.a. = not applicable (question not asked at baseline or not comparable).

All but one SDHO interviewed had some experience with QA and/or QI. Some noted that they have a QA and/or QI plan, although a few of those plans were oral rather than written and some had or were forming a QA team. Supervision can be very important in ensuring that health facilities implement QA/QI plans. SDHOs reported that different staff oversee QA and QI plans and activities in the various health centers. Some indicated that they provide this oversight themselves, others noted it is the responsibility of the District Health Management team (DHMT), the district focal point, the QA team, or others. SDHOs also reported that facilities conduct a wide variety of QA/QI activities and integrate them into their daily work in several ways, such as work plans; daily action plans; QA checklists for drugs, uniforms and so on; and as part of the CHPS curriculum.

Yea we have a check list for quality assurance. “Where [are] your drugs, uniform, the little things that you need to work with?” -- There is a place for that, and we even do monitoring on that.—SDH\T leader, Central

SDHOs noted that they train facility staff on QA measures, especially on infection prevention measures. Staff also apply QA through activities such as ensuring drugs are not expired and sterilizing equipment. Many respondents appreciated the results of the QI associated with these activities.

interventions; and supporting a wide-range of data-driven regional and district-specific QI interventions and projects. At the time of the midline, that work had covered approximately 80 districts. Many of these efforts were focused around the district hospitals, but sub-district staff are often involved in implementation. This will not necessarily show up via evidence of QI teams from facility-level interviews; however, Systems thinks it is improving service delivery data.

29.1%

23.4%

34.1%31.5%

35.0%

28.2%

44.5%

34.9%

0%

10%

20%

30%

40%

50%

Has active QA/QI team(met in last 3 months)

Has an active QA/QIplan

FIGURE 22. QA/QI ACTIVITIES IN HEALTH CENTERS

Focal regions Baseline Focal regions Midline

All regions Baseline All regions Midline


Yes, for what we can do we’ve integrated it into our activity. Daily. Because we see that at least we should prevent infection to our patients and to ourselves as much as possible. So we do it, washing of hands, using of gloves, cleaning or changing of beds for the other patients, disposal of refuse, and other things.—SDHO, Greater Accra

SDHOs did point out a few challenges with implementing monitoring (QA) and improving adherence to protocols (QI), including the need to educate staff on treatment protocols to counteract practices such as CHN prescribing the wrong medications. Other barriers to improving adherence to protocols are financial, such as the high costs of sterilization equipment, or due to inadequate infrastructure to follow protocols, such as keeping new mothers at a health facility for 24 hours. As one SDHO noted, to improve sterilization quality, a QI step, they must use equipment at another facility to sterilize their instruments and materials, perhaps leading to this being done less frequently than protocol might demand.

We … sterilize our instruments and our gauze at the hospital. It’s once in a month. Before it wasn’t done, we didn’t have anything to sterilize our instruments. Now we do our best, at least once in a month, especially the labor cases. We sterilize our instrument and gauze.—SDHO, Northern

B. Collecting High-Quality Data

Collecting high quality data is important to inform daily decisions regarding priorities, monitor progress on goals and plan and budget for local needs. In addition, GHS’s DHIMS2, which collects and provides routine health data, is populated through data aggregated from local facilities, including CHPS zones and health centers. Each level of the health hierarchy analyzes and uses this health information for management and policy decisions; it offers a comprehensive look at health needs and resources. For the DHIMS2 to be useful, health information—including administrative, demographic and clinical data—must be routinely transmitted and accurately aggregated upward through the health system from CHPS zones to the sub-district, district, regional and national levels.

In qualitative interviews with SDHOs, all but one indicated that they collected multiple types of data to submit to the DHIMS2. The data enabled facilities to track local issues, such as current stocks of commodities, the incidence of diseases, vaccinations and referrals. The SDHOs explained that the data are first captured in various registers and then combined into reporting templates which, after going through validation checks, are submitted into the DHMIS2. The large majority of SDHOs reported that data quality was good, largely because facilities use the GHS guidelines for data reporting and they validate data before submitting them to DHIMS2. DDHSs agreed that over the past two years, the quality of DHIMS2 data has improved.

Data from CHPS zones are generally sent to either the sub-districts or district levels for validation and aggregation into DHIMS2. All but one SDHO reported that data received at the sub-district level are validated before being entered into the DHMIS2. Some SDHOs said that CHPS zone data should always go through the sub-districts, to ensure it is validated before going into the DHIMS2. Other SDHOs noted, however, that if the data are sent directly to the district level, they are validated there. The validation process uncovers and corrects errors within the data. Moreover, the DHMIS2 has built-in data checks that reduce the possibility of human error. The quantitative survey data show that the vast majority of facilities also reported validating DHIMS2 reports using source documents before transmitting the data to higher levels. About 88 percent of CHPS zones in focal regions and 89 percent in all regions reported doing so at midline, as did 94 percent of health centers in focal regions and 95 percent in all regions (Table 23).

TABLE 23. DATA VALIDATION AMONG FACILITIES

Percentage of Facilities Focal regions Midline All regions Midline

CHPS zones validated the DHIMS2 reports using source documents 88.1 88.8

Health centers validated the DHIMS2 reports using source documents 93.6 95.0



The SDHOs mentioned two main challenges in the process of trying to collect and report high quality data. The first is ensuring the data collected and tabulated at the facility level are correct. For example, when clients lose their client ID cards, which occurs frequently, it is difficult to track them and staff inadvertently create multiple files for the same client. Several SDHOs also noted that CHPS staff often incorrectly tally their facility’s report numbers and miscalculate, creating errors that they then have to rectify. Moreover, when multiple staff are in charge of entering data, validation becomes more difficult as it is not clear who should address questions. More training might help avoid some of the data errors and reduce the amount of data cleaning necessary at later stages. Some SDHOs took it upon themselves to build capacity within the CHPS zones to correctly compile data reports. Some CHPS zones also have a coordinator to serve as the point person on validation concerns.

The use of DHIMS2 has been an improvement, and a typical example is the use of … the treated mosquito net. I think somewhere last year, our data was so bad, and [we’re] talking about regional and national levels, and so they had to find out what was happening here in this district, and we gathered that we were not reporting well. And apart from not reporting well, some facilities were not getting their stock [of nets], so [at] their antenatal clinics, when they come, the pregnant women were not able to get their mosquito net. But using the DHIMS2 and rectifying those mistakes, we are now able to give at least a better estimate of how much each facility needs. And for malaria, our report is now better than it used to be … last year.—DDHS, Western

As discussed in Chapter III.E, lack of access to computers and lack of reliable Internet connectivity is another challenge facilities face. Technology enables facilities at various levels to collect and keep their data electronically and send the data to the sub-district or district level via the Internet, which speeds the process for their work and to physically deliver their reports to the health center each month. Technology would also make data timelier and reduce data entry errors at the sub-district or district levels. For distant sub-districts, SDHOs noted that data submission to the DHMT can be delayed because leaving to deliver the data would mean closing the facility. Others noted that CHPS zones have to photocopy the data due to lack of computers, which can be burdensome because they lack photocopy machines.

C. Use of Data

The qualitative interviews suggest that data are being used for decision-making at several levels. At the district level, the DA is responsible for deciding to provide support, including financial and logistical support, to the health system. The overwhelming majority of DA members interviewed noted that they use data to inform their decision-making processes, though the frequency and formality of the process varied across districts. Some DA members reported getting data from the DDHS in their district, others reported getting data from facilities themselves. Many DA members discussed the use of data by the subcommittee devoted to development planning, the District Planning Coordinating Unit. This subcommittee seeks data from various heads of departments to inform its medium-term development plans, which are outlines of goals for each four-year cycle, and annual action plans, which address issues on a more frequent basis. Moreover, data inform decisions for emergency situations, such as during disease outbreaks, and to develop the health budget.

In the planning stages, you don’t just write asking that ‘I need this.’ You have to prove to us and convince us, and the only way to convince us [is] to provide your data. If you tell us that you will need fuel to move around, we need to know your outreach, the number of communities you want to visit. We need to know that. Your funds to purchase some drugs for … some conditions, we need to know what informed you to project for those quantities of drugs. If you want us to do training, you have to tell us what will be the impact and the scale of the impact and the beneficiaries. All these things tell us whether we should or not, because we don’t have sufficient resources. So, we’ll try and find out areas that when funds are applied will bring greater impact. DA, Northern

For example, HIV/AIDS, which is 3 percent in our district, is a cause for alarm. So, with these data … they say they need money to go into the district and educate the people on … HIV … and how best they can prevent the disease. The assembly intervenes and gives them the money. DA, Greater Accra

All DDHSs interviewed reported using DHIMS2 data on a regular basis to track performance of CHPS zones and health centers and to inform decision-making. They take action steps based on the issues identified in the data. For example, one DDHS noted that the DHMIS2 data in her district showed low rates of facility deliveries, which prompted her to bring a midwife to the district. Another DDHS noted that the DHMIS2


data revealed that although rates for treatment of malaria were high, testing for malaria was low. This knowledge triggered her to conduct data audits and train facilities on the use of RDTs. Another DDHS shared this example:

What we want is to give them [clients] the best service. And we can only do that if we are able to identify what we have in our DHIMS…We realize that the still delivery had improved for that area. So, I called the midwife and I said, “Madam, what is the secret?” And then she said, “Director, I’ve been going on home visits with my CHNs [community health nurses]. So, she’s able to identify the pregnant women within her community. DDHS, Western

Many DDHSs agreed that the quality of the DHIMS2 data has improved over the past two years, enabling more well-informed decision-making. Consistent with reports by SDHOs at the sub-district level, DDHSs in four of the five focal regions mentioned that Internet and network issues present a problem to accessing and using the data. Moreover, in two of these regions, DDHSs indicated that the lack of functioning computers and routers also impede their work.

At the sub-district level, SDHOs reported actively using data for monitoring, QA/QI and making decisions. They reported many examples of identifying potential disease outbreaks and gaps in coverage, prompting action such as increasing or shifting services conducted at their facilities and conducting outreach activities such as community health meetings with their communities. Among the examples, one SDHO noted that he identified clients lost to follow up and referrals of HIV clients sent for advanced retroviral therapies who were not accounted for through the data. Another SDHO noted,

In the last two months, when we did our performance review, our family planning acceptor rate was too low. We quickly organized a durbar to educate … [the community] on the importance of family planning.… We are now getting to the peak of meningitis, so we will be doing school health to create awareness.—SDHO, Northern

Those who can access the data online greatly appreciate having an electronic system. This enables SHDT leaders to easily disaggregate data to the facility level so they can easily compare achievements versus targets.

Because it’s electronic you just open it, and after a glance, you just get what you want. Unlike the hard copy.… Without data we wouldn’t know whether [we] are going forward or backward. So, it’s the data that will guide you to know where actually you are going, because you have set a target…the data will guide you to know whether you are going towards it, or you are going back. So it’s good, without data you can’t do anything.—SDHO, Central

The survey data support SDHOs’ reports that facility-level data are useful. For example, more than half of CHPS zones had used data they collected to plan community outreach, improve supply chain logistics, allocate resources and develop action plans within the 12 months before the survey (Figure 23.1). Health centers used facility-level data collected to an even greater extent for these purposes. These proportions are similar to those in the baseline survey, suggesting data use has changed little in the past two years.

Qualitative interviews revealed that community leaders in all but one focal region reported using facility-level data to create their community health action plans (CHAPS), through which communities identify and document goals and action steps. The types of data used and extent of their use varied across areas. In the Central region, one community leader indicated that high neonatal mortality statistics drove them to implement a scheme to transport pregnant women to facilities. Other communities used data to identify and confront issues such as teenage pregnancy, HIV/AIDS, malaria and malnutrition in their CHAPS. However, these data are not universally available. Many of the community leaders who did not use data in creating their CHAPS did not have access to the data, at least when the CHAPS was being created.

You see … if you want to analyze the data by facility level …you just select that facility, then you do the aggregate data, then you’ll analyze it. So after analyzing, based on the data that you have, you can use it to make decision at … the CHPS zone’s catchment.—SDHO, Central


Maintaining up-to-date data and comparing indicators over time can help facilities assess their performance. For CHPS zones, there was an increase between baseline and midline in the percentage of facilities displaying data on maternal, child, or reproductive health (13 percentage points in focal regions and 12 percentage points in all regions), so that about one-quarter of CHPS zones displayed such data at midline (Table 24). There was a smaller increase in the percentage of CHPS zones displaying data on the Expanded Program on Immunizations, which about half of the CHPS zones did at midline. Less than 20 percent of CHPS zones displayed malaria-related data at midline (this indicator was not measured at baseline). For health centers, there was an increase in the percentage of facilities displaying data on maternal, child, or reproductive health (12 percentage points in both focal regions and all regions), but no statistically significant change in the percentage displaying data on the Expanded Program on Immunizations. Health centers displayed each type of data at higher rates than CHPS zones, although this was still far from universal.

The study team also examined changes in the percentage of facilities that displayed any graphs or tables with data from the month before the survey, which could indicate whether these facilities regularly update their data and use it for monitoring. Although these changes were negative for some types of facilities and regions, the changes were all relatively small, suggesting that this measure was largely unchanged relative to baseline.

TABLE 24. DISPLAY OF DATA AND INFORMATION AMONG FACILITIES


Facility has the following graphs or tables displayed:a Maternal and child health or reproductive and child health

15.3 28.3 13.0*** 15.1 27.1 12.0***

Expanded program on immunization 47.4 54.1 6.7** 48.0 52.5 4.6 Malaria- or insecticide-treated net distribution

n.a. 16.9 n.a. n.a. 16.4 n.a.

Facility has at least one graph or table with data from past month

22.4 18.9 -3.5 24.2 17.8 -6.4*

Percentage of Health Centers

Facility has the following graphs or tables displayed:a Maternal and child health or reproductive and child health

37.6 49.2 11.5* 36.1 48.1 12.0**

Expanded program on immunization 80.9 73.3 -7.5 79.8 82.5 2.7 Malaria- or insecticide-treated net distribution

n.a. 22.3 n.a. n.a. 27.9 n.a.

Facility has at least one graph or table with data from past month

39.6 40.6 1.0 39.8 36.3 -3.5

Source: Health, Population and Nutrition Office Health Systems baseline and midline survey data. a Because multiple responses were possible, percentages sum to more than 100. n.a. = not applicable (question not asked at baseline or not comparable).

65.5% 61.7%56.1% 51.8%

43.3%

17.7%

59.6% 54.4% 55.2% 53.4%43.8%

24.6%

79.4%81.2% 78.3%

70.3% 69.2%

30.8%

83.3% 78.8% 83.4%

67.7%61.3%

30.2%

0%

20%

40%

60%

80%

100%

Plan communityoutreach

Help allocateresources

Improve supplychain andlogistics

Help developaction plans

Identify trainingneeds

Plan or decideanything else

FIGURE 23.1: PERCENT OF FACILITIES WHICH USED GENERATED DATA FOR MONTHLY REPORTS FOR THE FOLLOWING PURPOSES IN

LAST 12 MONTHS (FOCAL REGIONS)



V. COMMUNITY AND GOVERNMENTAL SUPPORT FOR CHPS

The primary health care system, especially at the community level, depends on community and volunteer support, governmental backing and linkages between communities and the government to ensure they both know and recognize the needs of CHPS zones. This chapter, examines the nature and scope of community- and district-level government support for CHPS zones, by describing one of the main community-to-health-care linkages—the community health committees (CHCs)—and examining community engagement in and support of CHPS zones. This section then examines the support for CHPS zones from DAs, as well as collaboration between USAID and district entities.


• There has been a large increase in the proportion of CHPS zones with a CHC since baseline; at midline, more than 90 percent of CHPS zones nationwide had a CHC, although many are not fully functioning according to official guidelines.

• At midline, CHCs continue to face several challenges: the lack of financial and other incentives for CHVs and CHC members to work, limited strategic engagement of community members with CHPS, and political disputes among communities served by a single CHPS zone.

• Community members report good relations with CHPS staff at midline, and are aware that they possess health rights, although few are able to name specific rights.

• DA members support CHPS zones primarily by providing funding; however, securing sufficient funds remains an important challenge.

• District Directors of Health Services (DDHSs) and DA members have strong working relationships with USAID and are familiar with a number of USAID-funded projects they report have had positive effects on their communities.

A. Community to Health Sector Linkages

The CHPS system decentralizes Ghana’s health system by allocating more resources directly in communities and involving communities in important health decisions. This aligns with the local government act of 1993, which emphasizes the important role of local communities in decision-making. CHCs have been set up to play a key role in promoting the linkages between the communities and the health sector. The section below describes the role that CHCs play, followed by community engagement with CHPS zones and the extent of awareness of patients’ rights in communities.

1. Existence and Function of CHCs

CHCs, made up largely of volunteers selected from the communities in each CHPS zone, are the link between the formal health sector and communities. Their main role is to oversee the health system at the community level and manage CHVs, who are another part of the health sector to community link (CHPS Revised Operational Policy 2013). According to the CHPS Operational Policy, CHCs are expected to perform six main functions: (1) carry out community advocacy and diplomacy for CHPS, (2) develop community health action plans (CHAPs) and mobilize the community for health action, (3) collaborate with the CHO and support CHPS service delivery, (4) monitor and support CHVs in their work, (5) mobilize resources for CHPS compound and service delivery and (6) organize community health meetings (durbars) and provide feedback to communities on health issues together with the CHO.

The survey data showed that there was a very large increase between baseline and midline in the percentage of CHPS zones that had a CHC. Between baseline and midline, the proportion of CHPS zones with a CHC increased from 54 to 91 percent in focal regions and from 63 to 94 percent in all regions (Figure/table 25). The qualitative data also reflected this. Almost every community leader interviewed in the qualitative


interviews in the Northern, Volta and Central regions reported the existence of CHCs in their communities. Qualitative respondents in the Western and Greater Accra regions had more mixed responses and the survey data also suggested there might be fewer CHCs in Greater Accra. Only about three-quarters of CHPS zones in Greater Accra had a CHC; in other focal regions, more than 90 percent of CHPS zones had CHCs. This is similar to the pattern at baseline, where Greater Accra also lagged other regions in number of facilities with CHCs.

Qualitative interviews revealed that CHCs were formed in different ways, including community members’ initiative, community leader or DA member initiative, through help from NGOs like “Plan Ghana,” or through reinstatement after a previous CHC broke up or failed. Selection of members also was reported to occur in different ways. Some members were chosen by chiefs, elder community members, or initial CHC members. In other places, community meetings were held to ask for volunteers; in some cases, the chief asked each community or clan to elect people to represent them in the CHC. Often, a number of positions were reserved for each community. When selecting people to join the CHC, it was often based on a perception that they were committed and could handle the job.

Despite the introduction of more CHCs since baseline, it appears that many are not functioning per GHS guidelines. The qualitative data collection field report notes that many CHCs in the selected communities in the focal regions either were not meeting or, being newly reconstituted, were meeting infrequently. Two of the 20 selected communities had no CHC to interview. The qualitative transcripts reveal that, among CHCs interviewed, most reported meeting every two weeks or monthly and meeting more frequently if there was an emergency, such as a disease outbreak. However, some CHCs indicated they met infrequently due to the committee just starting or difficulty finding times to meet in farming communities.

One way that CHCs, community leaders and community members can support CHPS zones is by developing and enacting CHAPS, through which communities identify and document goals and action steps. The study examined the percentage of CHPS zone respondents to the quantitative survey who reported that their CHC played a leading role in the previous 12 months in developing a CHAP. Focusing on CHPS zones that had a CHC at both baseline and midline to avoid sample selection bias, the percentage of these respondents who reported that their CHC played a leading role in the previous year in developing a CHAP decreased by 27 percentage points in focal regions between baseline and midline and by 18 percentage points in all regions. At midline, less than one-quarter of CHPS zones with CHCs in focal regions and less than one-third in all regions reported that their CHC played such a role.42

About two-thirds of the community leaders and one-third of CHCs interviewed indicated they had a CHAP, which was again fewer than during the baseline. Where CHAPs do exist, CHCs and community leaders reported that some combination of community members, leaders and CHC members developed them through a collaborative process. They also revealed that, except for the Western region, community leaders use facility-level data to inform the plans. Most plans were developed one to two years before the midline 42 These levels (and the other indicators in Table 28) are similar if the sample is broadened to include all CHPS zones with a CHC at midline, including those that did not have one at baseline. This suggests that new CHCs were functioning similarly to existing ones.

53.8%49.3%

90.9%

22.4%

62.3%

48.1%

93.9%

29.7%

0%

20%

40%

60%

80%

100%

CHPS has CHCs CHCs played a leading role indeveloping a community health

action plan (in the last 12 months)

FIGURE 25. COMMUNITY SUPPORT FOR CHPS ZONES

Focal region Baseline Focal region Midline

All regions Baseline All regions Midline


interviews and a few noted that the plans were updated annually or every two years. One CHC member explained the process they used:

We came for one of the CHC meetings and decided that at a certain period, we will come and draw an action plan. Thereafter, we went to the opinion leaders, i.e. the chief and his elders, and told them that we have to draw an action plan for this year. So at the beginning of the year, we had a durbar and drew the action plan. —CHC, Volta

Qualitative respondents identified several challenges CHCs face. First, some respondents reported political disputes among communities that share a CHPS, including about where CHPS compounds should be placed in communities. The qualitative field report supports the notion of community disagreements, noting that some CHCs lacked representatives from all areas covered by their CHPS, which is weakened support for the CHPS. Second, there is a lack of incentives for CHC members to carry out their duties. Some former CHC members mentioned they thought their voluntary service was a waste of time, because they did not get paid or reimbursed for the daylong meetings in which they participated. CHCs face further challenges in carrying out their work, as members throughout the regions highlighted that CHVs, who CHCs are supposed to manage and support, also were not paid, creating a lack of incentive for them to work. Third, there is a reported lack of interest on the part of some community leaders regarding the activities of the CHPS zones. Some community leaders interviewed did not know whether there was a CHC or whether the community had a CHAP. At a few of the CHPS zones, there was no relationship at all between community leaders and the CHPS.

In contrast, there is some quantitative evidence of improved perceptions on other dimensions of CHCs’ activities by respondents in the CHPS facilities. As shown in table 26, there was a decrease in the percentage of respondents who rated their CHCs’ effectiveness at mobilizing CHPS resources for service provision to the community as poor (the lowest possible ranking, with the others being fair, good, very good, or excellent). The same was true of respondents’ ratings of CHCs’ effectiveness in sensitizing and mobilizing the community for health action. At midline, most respondents in focal regions and all regions reported the CHC’s effectiveness in these activities as being good or better, but a substantial minority still reported their effectiveness as poor or fair. In the qualitative data, most community leaders interviewed thought that support for CHPS through CHCs had increased in the past two years.

TABLE 25. COMMUNITY SUPPORT (PERCENTAGE OF CHPS ZONES)



Rating of CHCs’ effectiveness at mobilizing resources for the CHPS to provide services to the community, among those with CHCs:

Excellent 5.1 3.2 -1.9 5.4 3.6 -1.8

Very good 7.9 9.7 1.7 8.2 12.8 4.6*

Good 34.4 39.9 5.5 29.6 44.3 14.6***

Fair 25.0 28.2 3.2 24.6 20.5 -4.1

Poor 26.3 16.8 -9.5** 30.0 17.4 -12.6***

CHCs do not do this at all. 1.2 2.3 1.1 2.2 1.3 -0.8

Rating of CHCs’ effectiveness at sensitizing and mobilizing the community for health action, among CHPSs with CHCs: Excellent 3.0 1.4 -1.6 3.2 2.3 -0.9

Very good 11.7 19.4 7.7* 13.2 19.1 5.9*

Good 41.5 46.5 5.1 41.5 51.0 9.5**

Fair 23.4 19.2 -4.2 21.3 18.0 -3.3

Poor 17.8 10.2 -7.6** 18.1 8.3 -9.8***

CHCs do not do this at all. 2.8 3.3 0.6 2.8 1.3 -1.5


We act as the mediators between the CHPS and the community leaders so that if there is anything that is not going on well here, we report it to the community leaders and then they can help out.—CHC, Central


The roles and responsibilities the CHC members interviewed described aligned, in general, with what was reported at baseline and the goal set by the GHS—to assist health workers in caring for the community. While CHVs help with practical health care tasks, some of the main roles and responsibilities of CHC members mentioned included acting as a liaison between community members and health workers, performing health care tasks such as assisting with weighing children and administering vaccines and educating communities on topics such as breastfeeding, how to prevent the spread of disease and proper sanitation. Many CHC members mentioned they were responsible for other tasks, such as encouraging and accompanying community members, especially pregnant women, to visit the facility, keeping the area around the health facility clean and safe and mobilizing funds. Moreover, they report engaging regularly with the community through the activities previously mentioned and others such as distributing mosquito nets through community durbars and house-to-house visits. This variety of tasks illustrates the roles and the responsibilities of the position developing to meet the needs of the community and perhaps being shaped by the skills and interests of CHC members and resources available, within the broad parameters of the work they are supposed to perform:

Our main role or responsibility is to support the CHPS to improve their work. We educate them and make them aware that the CHPS zone here is for them, it is for their use and so we help to build a relationship between the staff and the communities.—CHC, Central

I am one of the CHC members, and we realized that the CHPS compound wasn’t regular [working as it should], so we decided to sit and take ideas for the CHPS compound in the community in order to improve it. So, we organized ourselves and came to see the doctors, worked with them hand in hand. We are here all the time with the doctors to assist them at any point in time if there is the need.—CHC, Northern

2. Community Engagement with CHPS Zones

For CHPS zones to be successful, they require the support and engagement of the communities they serve, which in turn requires good relationships. CHC members who participated in qualitative interviews were asked about the relationship between community members and the CHPS zone. Nearly all indicated that there is a good relationship among the community, community leaders, the CHPS and CHC members. Several described the relationship as being part of “one family” and stated that, whenever a community member had a problem, they felt comfortable bringing it up to the CHC and the CHPS staff. Common adjectives used to describe the relationship included “cordial,” “strong,” and “free.” Nearly all CHC members also indicated that community members can approach their CHO freely to discuss any problem, although some indicated that, for certain matters, they go through the CHCs or assemblymen first. CHC members highlighted that CHOs’ regular interactions with the community creates a comfortable environment. Most respondents also indicated that CHOs attend all durbars.

There is a very cordial relationship between the community and the CHPS compound. We are very friendly. You just don’t go there because you are sick, but you can just pay them a visit to know how they are doing. Anytime they are also free, they can go to the community and educate them.—CHC, Northern

They are very regular with home visits. Thus, they know the names of many people in the village, even more than we the citizens. They know the health conditions of almost every family in every corner of this village.—CHC, Volta

CHC members noted that, if community members have quarrels or misunderstandings with the CHO, they go through the CHC or DA member to resolve them. When asked how to improve the relationships between communities and CHPS staff, respondents indicated that there could be more meetings, communication and education and that CHPS staff and volunteers should sustain and increase household visits, among others.

That said, when community members were asked about CHCs, their knowledge about CHCs’ responsibilities and concrete actions was mixed. Some community members could name a few CHC members in their community, but others could not name any. In addition, most community members across regions could not say what a CHC was supposed to do; however, most could give examples of the work they did do within the community. The type of CHC work community members commonly listed was helping the CHPS by supervising nurses and helping with weighing children, making announcements for the CHPS, keeping the compound clean through weeding, settling disputes between community members and nurses and educating the community. Many also cited that they believe their CHC is doing a good job. Lack


of familiarity with particular CHC members and their responsibilities does not appear to impede community members’ ability to voice their opinions and feel comfortable with CHPS staff and leaders.

3. Awareness of Patients’ Rights

To be able to support and affect community-level health services, it is important for community members to understand their rights and responsibilities as health clients. The GHS has developed a patients’ charter that outlines the rights of all health clients in the country. These include the right to accessible, equitable and comprehensive care; the right of the patient to determine his or her own health care plan; and the right to freedom from discrimination (Ghana Health Services: The Patient’s Charter 2015).

Similar to baseline, in midline qualitative interviews, clients, community leaders and CHC members were asked what rights they thought health clients had. Among clients, nearly all interviewed stated that everyone in the community has the right to seek health care provided by the CHPS zones, which aligns with the right to accessible, equitable and comprehensive care. However, most respondents were not aware of the more specific health rights developed in the charter (although, with prompting, many clients also thought that it was their right to receive health care free from discrimination).

Likewise, all CHC members and most community leaders were aware of Ghanaians’ right to accessible, equitable and comprehensive care, without prompting. Most also mentioned or agreed when prompted that facilities cannot discriminate. Some CHC members also mentioned other rights, such as the right to have your personal health information kept confidential. Most CHC members and community leaders reported they thought community members knew their rights; however, some were not convinced they knew some of the more specific rights, such as the right not to be discriminated against. This minority opinion was not isolated in one geographic area, but was voiced in at least three regions. CHC members who did not agree noted that some people do not know their rights because they are not educated.

Most of the people here, excuse me to say, are illiterate, or some of them too are semi-illiterate, so going to the real details of the legality involving health rights, they may not know much. But, in the lay man’s view, they know that they have equal access irrespective of their religion, tribe and ethnicity to access the health facility.—Community Leader, Western

On the other hand, several CHC members explained that community members knew their rights because the CHC educated them. Community leaders’ and clients’ sources of this information included the radio, television, health workers, CHPS, leaders (such as chiefs and DA members) and others.

B. District-Level Support

In addition to communities’ engagement and ownership, support from the top down is an important element to promote strong health systems at the community level. The section below summarizes the findings from district-level stakeholders on the support they provide related to community health and their engagement and collaboration with USAID.

1. Support from District Assemblies

DAs are expected to support CHPS zones, health centers and the health system as a whole in their districts. DA members interviewed overwhelmingly reported that they support CHPS and health centers, mainly by providing funding. DAs have responsibilities for the construction of CHPS compounds and equipping them with the infrastructure and equipment necessary to carry out their work. They also are supposed to support the health system by providing vehicles and funding such programs as immunization, sensitization and radio programs. However, nearly all DA members interviewed highlighted that securing sufficient funds remains a big challenge.

CHC members interviewed also overwhelmingly highlighted the expectation that the DA would support CHPS with funding, but that securing funds was a major challenge.


The reason why the involvement of the assembly members is not that much is because here we have to form a group called the area council, and they are supposed to collect taxes for the maintenance of the CHPS zone. But, the area council is not able to function properly, and so the assembly members stand as individuals. The assembly members are sometimes not paid and they don’t even get their allowances, and if they offer any help at all it is from their own pocket. So until … there is a nicely built area council--but it has not been inaugurated yet for people to start collecting funds there.—CHC, Central

DA members interviewed explained that, to support health facilities, they raise their needs to the health directorate, after which their requests go to the social service subcommittee, the executive committee and its chair, the district chief executive and finally to the general assembly for approval. The frequency of health projects being discussed at quarterly DA meetings varied across districts. Some respondents indicated that they are discussed at every meeting; others noted that, in their district, assembly meetings are hardly ever conducted anymore. DA members highlighted that answers to requests depend on prioritization of the request and available funds. Several DAs explained that community action plans are used to inform their district action plans. One DA noted that all of the health systems’ needs are brought up when developing the annual action plan and, except for emergencies, it is difficult to allot further funds to the health system outside of the agreed upon plan. DA members did agree that funds do become available in emergencies, like disease outbreaks.

The district has never come in before. I can’t remember….Even, we ask the assemblyman to write to them to come and help, but they haven’t. The shade [structure] too, we haven’t finished. We have to fence it and raise the floor so that when it rains you can do the weighing there. So, for a whole lot of things the district is not responding.—CHC, Greater Accra

Sometimes you have emergency situations that you have to go out of the normal directives or laid down procedures … .There are times that you go out of that. If there is cholera outbreak, you don’t wait.—DA Member, Central

Relationships between CHCs and DA members vary, with some CHCs indicating they have no relationship at all with the DA and others noting there are assembly members who are members of the CHC or with whom they interact every day. Perhaps unsurprisingly, those DA members with increased interaction with CHCs also are reported to help the CHPS more often with activities such as CHPS expansion and maintenance, small donations and support for CHOs.

2. Collaboration Between District-Level Officials and USAID

Nearly all DDHSs and most DAs interviewed reported having strong working relationships with USAID. Most reported having had external funds invested in health programs in their districts in the last two years, citing several USAID grantees and programs in their areas, including Systems for Health, RING and SPRING. Plan Ghana also was mentioned as an external source of funding. DDHSs expressed appreciation for these programs and emphasized that the programs have made great impacts in their communities.

DAs and DDHSs both cited strategies that could improve the work of USAID and their relationship with it. Many noted that USAID mainly communicates and conducts trainings at the regional level and suggested that filtering the trainings downward to the district level could be beneficial, making them more relevant and the information more accessible to staff at that level. Similarly, several district-level respondents noted that interventions could be contextualized and made more appropriate with more input from the district level. For example, in the Western region, the DDHS noted that they were trained in data management, but are unable to employ what they learned due to lack of computers at the district level.

For me the training has been good because those who have gone over the training, you’ll see improvement … And then when it comes to monitoring, it has helped us as a district …. when you go to the sub district, we are able to give supportive supervision….. So it has been very good.—DDHS, Western

Maybe … down streaming some of the activities to the district level. It seems like most of the things are done from the regional level. So that we have a feel and then we can also do most of the monitoring here because when they are trained at the regional level, at the district level what do we know?—DDHS, Central


VI. HEALTH INSURANCE

In 2003, the Government of Ghana passed the National Health Insurance Act, which abolished the existing cash-and-carry system of health delivery and replaced it with the National Health Insurance Scheme (NHIS). The goal of the NHIS is to provide equitable access and financial coverage for basic health care services to Ghanaian citizens (NHIS 2015). Because the NHIS represents a substantial change in the public health care environment in Ghana, understanding health insurance could be important for the implementation of USAID’s health projects in Ghana. This chapter describes health insurance in Ghana; the level of membership in health insurance; and perceptions of the association between health insurance and the location, quality and type of care among facility clients.

A. Health Insurance in Ghana

Health insurance in Ghana under the NHIS has three main categories. The first and most prevalent is the district mutual health insurance scheme, which operates in every district in Ghana. Any resident of Ghana can register for this public scheme. It is funded primarily from the central government’s National Health Insurance Fund, as well as by premiums paid by members. The other two categories of health insurance in Ghana are private commercial health insurance schemes and private mutual health insurance schemes. Neither receives subsidies from the National Health Insurance Fund. The cost of membership in an NHIS scheme depends on the applicant’s category: annual premium paying member or a member of an exempt group. Exempt groups include pregnant women, people living in poverty, children up to the age of 18, people over 70 years of age and people with a mental disorder.

With membership in an insurance scheme, health insurance members are entitled to seek treatment in any public health facility in the country and can use their insurance to obtain approved services free. Without insurance, clients typically are required to pay at every point of service delivery before services are rendered. Accredited pharmacies and licensed chemical shops are also supposed to provide approved prescribed drugs without charge to members. However, the NHIS continues to face challenges paying claims from health providers—the NHIS acknowledges this issue and reported in August 2017 on its website that “[T]he NHIS has…experienced persistent and increasing annual deficits since 2009…with the strong commitment shown by Government to a robust NHIS and Universal Health Coverage,43 the time is opportune for…reform to be undertaken” (NHIS 2017). As discussed in Chapter III, the slow payments from NHIS continue to negatively affect the supply chain for medicines and supplies at CHPS and health centers.


• Membership in national health insurance schemes (NHIS) at midline appears to be widespread, but slow payment of claims to facilities continues to be a challenge.

• Facilities remain involved in the NHIS system: at midline, about two-thirds of CHPS zones and more than 90 percent of health centers nationwide had recently submitted NHIS claims.

• The NHIS covers many, but not all, of the most common health care services and medications offered at CHPS zones; more services and medications are covered at health centers.

B. Membership in Health Insurance and Claims Submission by Facilities

Qualitative interviews with clients and community leaders revealed that enrollment in an NHIS scheme is widespread throughout the focal regions. Most clients interviewed were insured and reported planning to

43 Universal health coverage would provide everyone in Ghana with financial protection from the costs of using health care and ensuring access to the quality health services they need (World Health Organization 2010).


renew their insurance when it expires. Most clients interviewed thought that the rate of insured community members is increasing, now that insurance is perceived to be “working better.”44 However, a sizable number were dissatisfied and thought the number enrolled would not increase or would decrease. Enrollment and renewals were reported to be tied to some extent to the convenience of enrolling and renewing. Clients and CHC members reported that communities where NHIS sent staff to enroll and renew members had many enrollees, while distance and travel cost were mentioned by clients as reasons for not being enrolled. Even when staff do come to communities to enroll members in district plans, it is not easy to get everyone enrolled. However, a striking number of clients noted that, although not all adults enroll, parents make sure that their children are insured:

I do not joke when it comes to renewing that of my children. I prefer to sacrifice mine so that my children can have access to it. When the NHIS officials come here for registration you will see a lot of people around. The personnel sleep here just to assist the people, but even with that they are not able to exhaust the population. --Client, Northern

Submission of NHIS claims by health facilities indicates facility clients being NHIS members and whether health facilities accept NHIS insurance. According to our survey data, there was a decrease between baseline and midline in the percentage of CHPS zones that reported submitting at least one NHIS claim in the two months before the survey. However, the magnitude of this decrease was relatively small—only 4 percentage points in focal regions and 8 percentage points in all regions. There was also a decrease in this measure for health centers, but this was also small.45 It is conceivable that the challenges NHIS faces paying claims from health providers could affect the number of facilities making claims.

Across all regions, about two-thirds of CHPS zones and about 90 percent of health centers reported submitting NHIS claims in the two months before the midline survey. There was also a large increase between baseline and midline in the percentage of CHPS zone respondents that reported being aware of some services not covered by NHIS, possibly reflecting their greater familiarity with the program over time and experience with medications not covered in CHPS zones; there was no equivalent change for health centers (Tables 26, Figure 26).

TABLE 26. HEALTH INSURANCE AMONG FACILITIES (% OF FACILITIES)


Facility submitted at least one NHIS claim in previous two months. 76.1 72.3 -3.8*** 74.3 66.7 -7.5***

Facility’s respondent is aware of at least some health services not covered by NHIS. 51.2 66.4 15.2*** 54.8 64.1 9.3**

Percentage of Health Centers Facility submitted at least one NHIS claim in previous two months. 95.6 91.5 -4.1 96.1 92.7 -3.4*

Facility’s respondent is aware of at least some health services not covered by NHIS. 62.7 59.4 -3.2 66.8 68.1 1.3

Source: Health, Population and Nutrition Office Health Systems Baseline and Midline Survey Data.

44 The midline survey only measured very short-term changes in the number of facility clients who were members of NHIS from which we cannot draw conclusions about the overall baseline-midline trend in membership. 45 Finding was weakly statistically significant at 10 percent level.

76.1% 72.3%

95.6% 91.5%

0%20%40%60%80%

100%

FIGURE 26. PERCENTAGE OF FACILITIES THAT SUBMITTED AT LEAST ONE NHIS CLAIM IN LAST TWO MONTHS (FOCAL

REGIONS)

Baseline (CHPS Midline (CHPS)



C. Health Insurance and the Location and Quality of Care

Most clients interviewed reported that they received comparable prompt, quality treatment at CHPS zones and health centers regardless of their insurance status.46 The main difference noted was that, with insurance, the cost of care was lower.

That said, at midline, some challenges to receiving the expected care due to insurance guidelines caught insured clients unaware and at times changed the location and quality of care received. CHPS staff explained that NHIS regulations restrict the medications and treatment different types of facilities can be reimbursed for providing, and clients often do not know this. Therefore, as mentioned in Chapter III, insured clients must unexpectedly pay for some medications and treatments, or be referred to another facility where these are covered. Antibiotics are one example of a medication not covered if provided at CHPS zones, so CHPS zone clients must pay for them or go to a health center to receive them free. In addition, some clients found that, when stock-outs occurred, they were charged for covered medicines, likely because they were purchased in the market by the CHPS zone (and for which the CHPS would therefore not be reimbursed by NHIS), or clients would be sent to buy the medication or supply in the market and return to the facility with it. These unexpected subtleties caused frustrations for some insured clients. The following quotes from clients show that most did not find health insurance affected the location or quality of care they received and that they had positive experiences with insurance (although a minority did not):

When I didn’t have health insurance, I had to pay before I was treated. But now I don’t need to pay. They treat me very quickly. We only pay when there’s the need to pay, but it’s always better to have health insurance. If you have health insurance and you go to the hospital, you are treated warmly and quickly, but without health insurance it’s not good as compared to those that have.—Client, Volta

Not from here but where I come from, many doctors and nurses when you have insurance they treat you like you are not human, because they like money more than the life of humans. That’s why I don’t like insurance. Those with insurance complain that when they go to the hospital they don’t give them good medicine except Paracetamol and they prescribe the rest for them to go and buy it from the pharmacy.—Client, Northern

VII. SUMMARY AND CONCLUSIONS

This chapter briefly summarizes the key findings from the midline evaluation in each of the four thematic areas into which the research questions are organized. These findings are used to highlight specific successes and challenges in each area, which can inform programming strategies focused on improving the health system. Finally, outlined is the timeline for the endline evaluation.

A. Quality of Care and Services

This study examined several aspects of the quality of care and services at CHPS zones and health centers and how these have changed in the two years since the baseline study. One of these aspects is the referral system. The midline, found an increased use of technology, such as short message service (SMS) and the WhatsApp platform, to communicate referral information across facilities. Although more than half of CHPS zones nationwide still did not maintain formal referral records at midline, it was found there had been substantial increases since baseline in the percentage of clients referred from CHPS zones who returned with completed referral feedback notes, which are important to maintain the continuum of care upon the client’s return. However, despite these increases, more than half of clients in the average CHPS zone did not return with completed feedback notes at midline.

Both CHPS zones and health centers improved service provision in several key areas between the baseline and midline. First, the provision of comprehensive family planning services improved, largely through increases in providing contraceptives to complement the existing family planning counselling. Second, there was a large

46 This study was not able to compare the rate of service usage among the insured and non-insured, but other research suggests that the non-insured rely mainly on informal care, while more than 80 percent of those with NHIS coverage visit a public or private formal provider for care (Fenney et al. 2015.). This could be due to the lower cost of care for the insured.


increase in the proportion of CHPS zones that conducted deliveries and a desire by stakeholders for an even greater increase in the future, although infrastructure and human resource capacity constraints (especially the lack of midwives) might limit deliveries. Third, the range of services provided by CHVs in CHPS zones increased broadly and the average number of certain types of home visits conducted by facilities increased. However, some important gaps in service provision remain unchanged at midline, such as appropriate malaria testing and treatment (constrained by the limited availability of RDTs and labs for testing) and others, such as maintenance of key child anthropometric information, worsened. Qualitative interview data suggest an ongoing need for additional physical infrastructure investments that could improve the quality of service in CHPS zones (for example additional rooms to serve different types of clients, toilet facilities and staff accommodations), whereas a lack of transportation for outreach, supplies and transporting clients to facilities continues to be an important challenge to service provision.

Changes in staff training between baseline and midline, which could affect the quality of care, were mixed. The proportion of facilities in which staff had recently received high quality training, defined as training conducted in conjunction with supportive supervision, decreased between baseline and midline for training in malaria topics in general but increased for training in some key nutrition topics. Persistent barriers to conducting and benefiting from more staff trainings include a lack of funding, scheduling difficulties, transfers of trained staff and lack of equipment and supplies to implement learning from trainings.

Also examined was the availability of guidelines for treatment of clients and the extent to which facilities follow prescribed guidelines for sanitation and preventing infections. Despite modest improvements in the availability of written treatment protocols for MNCH and child undernutrition, in CHPS zones between baseline and midline, most CHPS zones still did not have these protocols available at midline. However, both CHPS zones and health centers substantially increased compliance with standard measures related to sanitation, sterilization, waste disposal and ways of dealing with contagious clients between baseline and midline. Overall, many of these measures were available in well more than half of CHPS zones and about 90 percent of health centers at midline (Table 15).

Maintaining adequate stocks of medicines and supplies continues to be one of the most significant obstacles facing CHPS zones and health centers. The midline survey suggests that supply chain management significantly improved in both CHPS zones and health centers between baseline and midline, most notably through increased availability and use of control cards. However, there were no accompanying systematic decreases in the level of stock-outs or increases in the availability of essential supplies over the same period. Key ongoing challenges to maintaining adequate stocks include financial constraints and stock-outs at the regional level. Baseline gaps in availability of functional essential equipment needed for delivery, nutrition assessment and counseling and storage among facilities also generally persisted at midline, as did the absence of an efficient and effective system for equipment maintenance and repair.

B. Culture of QA and QI

There is some suggestive evidence of improvements in formal QA and QI activities between baseline and midline, but these improvements seem to have been modest. At midline, almost half of health centers still did not have an active QA/QI team and almost half of both types of facilities did not have a QA/QI plan. Many facilities of both types continue to conduct a range of QA and QI activities, including those related to infrastructure, supplies, staff, client satisfaction, data quality and community outreach, even in the absence of formal plans. Nevertheless, on the whole there is still substantial scope to set standards more formally and monitor and address gaps systematically.

High quality data collection is important for QA and QI purposes, as well as to inform local needs and feed into the DHIMS2 data. District- and sub-district-level stakeholders reported that data quality was good and has improved over the past two years, largely because facilities used the GHS guidelines for data reporting; they also conducted validation against source documents before submitting data to DHIMS2. However, the lack of access to computers and reliable Internet connectivity continue to hamper the accurate and timely collection, storage, compilation and transfer of data. Data are used at the district, sub-district and facility levels to inform decision-making and planning. At the district level, data users have benefitted from the improved quality of the


DHIMS2 data over the past two years. However, the midline facility survey did not identify major changes since baseline in data use at the facility level.

C. Community and Governmental Support for CHPS

CHCs, largely composed of volunteers selected from the communities within each CHPS zone, are designed to serve as the link between the formal health sector and communities. Their main role is to oversee the health system at the community level and monitor and support CHVs. According to the midline facility survey, the proportion of CHPS zones with a CHC between baseline and midline increased substantially, so that more than 90 percent of CHPS zones nationwide had a CHC at midline (Table 26). However, many CHCs do not function fully according to official guidelines—for example, many do not meet regularly or play a major role in developing CHAPS in their communities. CHCs also continue to face several challenges that hamper their effectiveness. These include political disputes among the communities served by the CHPS zone, the lack of financial incentives for CHVs and CHC members to perform their required tasks and limited familiarity of and strategic engagement with CHCs by community members.

DA members are informed about and interested in supporting CHPS zones and health centers in their districts. They continue to support CHPS zones, primarily through providing funding; however, securing sufficient funds remains an important challenge. DDHSs and DA members have strong working relationships with USAID and are familiar with a number of USAID-funded projects they report have had positive effects on their communities, including RING, SPRING and Systems for Health.

D. Health Insurance

Ghana introduced the NHIS more than a decade ago; it seeks to provide equitable access and financial coverage for basic health care services to Ghanaian citizens. Membership in NHIS at midline appears to be widespread, but the trend in enrollment could not be ascertained from this study. Most CHPS zones and the vast majority of health centers regularly submit NHIS claims, although slow payments from NHIS continue to negatively affect the supply chain for medicines and supplies at CHPS zones and health centers. Coverage restrictions and limited supplies sometimes mean that insured clients have to unexpectedly pay for medicines or visit other facilities for treatment.

E. Evaluation Time Line

The midline findings in this report examined changes in key indicators relevant to USAID Ghana’s health portfolio about two years after the 2015 baseline. Although these findings cannot fully be attributed to the impact of USAID interventions, they do inform our understanding of changes in the Ghanaian health system coinciding with the projects. The midline levels of key indicators, together with findings from qualitative data, also highlight some important remaining gaps in the coverage and quality of health care in CHPS zones and health centers at midline. The endline survey, planned for early 2019, will similarly enable us to assess changes in key indicators about four years after the baseline. By then, some interventions will have ended and other ongoing interventions will have been implemented for a longer period; the endline study will therefore capture the changes associated with more complete implementation of the interventions (along with other external changes since the baseline). The endline study could also provide a springboard for future interventions by GHS and other donors to address remaining gaps in facility-based health care in Ghana.


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Ghana Health Service. “Regional and District Administration.” Available at: http://www.ghanahealthservice.org/ghs-subcategory.php?cid=2&scid=44. 2015. Accessed July 8, 2015.

Ghana Health Service: “The Patient’s Charter.” 2015. Available at: http://www.ghanahealthservice.org/ghs-subcategory.php?cid=2&scid=46. Accessed February 11, 2015.

Ghana Health Service. “Community Health Planning and Services (CHPS): The Operational Policy.” Ghana Health Service Policy Document No. 20. Accra, Ghana: GHS, May, 2005.

Ghanaian Ministry of Health. “National CHPS Policy.” MOH. March 2016.

GHS and Teaching Hospitals Law. Act 525. (Section 3.) 1996. Available at: http://laws.ghanalegal.com/acts/id/140/ghana-health-service-and-teaching-hospitals-act. Accessed July 27, 2015.

“Healthcare Quality Assurance Manual for Sub-districts.” July 2004. Available at: http://dendrytes.com/Blog/wp-content/uploads/2011/06/Healthcare_Quality_Assurance_Ghana.pdf.

“Implementing Partners Annual Reports FY2016.”

“Monitoring and Evaluation Plan GHS 2010-2013.” Available at: http://www.nationalplanningcycles.org/sites/default/files/planning_cycle_repository/ghana/monitoring_and_evaluation_plan_ghana_health_service_2010-2013_0.pdf.

National Health Insurance Scheme. 2017. Available at: http://www.nhis.gov.gh/nhisreview.aspx. Accessed August 3, 2017.

National Health Insurance Scheme. 2015. Available at: http://www.nhis.gov.gh/. Accessed July 23, 2015.

President’s Malaria Initiative (PMI). “FY 2010 Annual Report. Improving Malaria Diagnostics.” Available at: http://www.pmi.gov/docs/default-source/default-document-library/implementing-partner-reports/improving-malaria-diagnostics-(imad)-cooperative-agreement-annual-report-fy2010.pdf?sfvrsn=4. Accessed July 31, 2015.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4796516/

http://www.nhis.gov.gh/nhisreview.aspx


President’s Malaria Initiative (PMI). “FY 2015 Ghana Malaria Operational Plan.” Available at: http://www.pmi.gov/docs/default-source/default-document-library/malaria-operational-plans/fy-15/fy-2015-ghana-malaria-operational-plan.pdf?sfvrsn=3. Accessed July 29, 2015.

“Quality Assurance Strategic Plan for GHS 2007-2011, Sept 2007.” Available at: http://www.ghanaqhp.org/fileadmin/user_upload/QHP/GHS_Quality_Assurance_Strategicplan_FINAL.pdf.

“USAID/Ghana’s Country Development Cooperation Strategy 2013-2017.” Available at: https://www.usaid.gov/sites/default/files/documents/1860/Ghana_CDCS_fy2013-17.pdf. Accessed July 26, 2015.

“USAID/Ghana: Health, Population, & Nutrition Office Health Systems Baseline Survey Report 2015.” Available at: http://pdf.usaid.gov/pdf_docs/PA00KW1F.pdf. Accessed July 10, 2017.

Velyvis, Kristen, Justice Ajaari, Evan Borkum, Frank Nyonator, Deborah Orsini, Catherine Pak and Divya Vohra. “USAID/Ghana Health, Population and Nutrition Office Health Systems Baseline Survey Focal Region Compendium.” Arlington, VA: Management Systems International, November 2015. Available at: http://pdf.usaid.gov/pdf_docs/PA00KW1F.pdf.

World Bank. “Data: Contraceptive Prevalence (% of women ages 15-49).” Available at: http://data.worldbank.org/indicator/SP.DYN.CONU.ZS/countries accessed July 25, 2015.

World Health Organization. Health System Financing: The Path to Universal Coverage. The World Health Report 2010. Geneva: WHO, 2010.

World Health Organization. “Ghana: WHO Statistical Profile.” January 2015. Available at: http://www.who.int/gho/countries/gha.pdf?ua=1. Accessed July 25, 2015.

http://pdf.usaid.gov/pdf_docs/PA00KW1F.pdf.%20Accessed%20July%2010

http://pdf.usaid.gov/pdf_docs/PA00KW1F.pdf

QUALITY OF HEALTH SERVICES MIDLINE STUDY REPORT 2017 A1


Appendix B. Sampling, Data Collection, and Analysis Approach

B.1. Sampling Approach for the Quantitative Survey

We used a sampling strategy in which districts were the primary sampling unit (PSU). Based on a sample

frame of health facilities in Ghana received from GHS before the baseline, we identified 202 eligible

districts in Ghana’s 10 regions. Districts are highly suitable as PSUs because they represent well-defined

clusters of health care facilities and are sufficiently numerous to permit us to draw a representative

sample.

We randomly sampled districts from each region, sampling 39 percent of districts in each of the five

focal regions and 25 percent of districts in each of the five nonfocal regions. We used these proportions

because they allowed us to meet our targeted sample size while accounting for oversampling in the focal

regions. In addition, by proportional sampling within each type of region, we minimized the need for

weighting for the five-focal-region estimates. The sampling yielded an average of 8.4 districts per focal

region (between 5 and 10 districts each) and an average of 5.0 districts per nonfocal region (between 3

and 7 districts each). Nationwide, our sample consisted of 67 districts (Table B.1).

After we had a random sample of districts in each region, we randomly sampled three subdistricts from

each district (districts contain about 4 subdistricts on average, varying between 1 and 10), resulting in a

total sample of 188 subdistricts within the selected districts (Table B.1). We then targeted for the

survey all health centers and community-level CHPS zones in each sampled subdistrict listed in our

sample frame. Our sample resulted in 610 facilities (470 CHPS zones and 140 health centers), which is

about 23 percent of the full number of 2,643 of these facilities across Ghana. Figure B.1 shows the

locations of the sampled facilities.

TABLE B.1. TARGET SAMPLE AND RESPONSE NUMBERS

Region

Target sample Number of completed

surveys at baseline

Number of completed

surveys at midline

Dis

tric

ts

Su

bd

istr

icts

Su

bd

istr

icts

/ d

istr

ict

CH

PS

Healt

h

cen

ters

To

tal

facilit

ies

CH

PS

Healt

h

cen

ters

To

tal

facilit

ies

CH

PS

Healt

h

cen

ters

To

tal fa

cilit

ies

Central 8 21 2.6 67 17 84 58 17 75 65 19 84

Greater

Accra 5 15 3 41 7 48 41 7 48

41 6 47

Northern 10 28 2.8 49 16 65 47 18 65 48 17 65

Volta 10 30 3 74 34 108 70 34 104 76 32 108

Western 9 26 2.9 64 14 78 64 14 78 63 15 78

Ashanti 6 16 2.7 47 14 61 45 16 61 46 15 61

Brong Ahafo 6 13 2.2 31 11 42 30 12 42 28 14 42

Eastern 7 21 3 52 13 65 52 13 65 52 13 65

Upper East 3 9 3 29 6 35 29 6 35 29 6 35

Upper West 3 9 3 16 8 24 16 8 24 16 8 24

TOTAL 67 188 2.8 470 140 610 451 146 597 464 145 609

Sources: Policy, Planning, Monitoring and Evaluation (PPME) Division of GHS provided the Evaluate team with the sample frame

data pulled from DHIMS2.

Note: Focal regions are highlighted in grey.


MAP 1. MAP OF FOCAL REGION DISTRICTS


The baseline data collection teams found the sample frame to be fairly accurate in the field, finding most

facilities listed, and not finding many not listed. Some adjustments to the sample frame had to be made,

however, including some health facilities listed in the frame that were closed down or did not exist, and

others where CHPS zones had been upgraded to health centers. There also were two CHPS zones

listed that were actually one zone. At midline, similar, additional issues were encountered, including

facilities that had been upgraded or downgraded, and a facility that was privately owned. Data collection

at midline was extremely successful, with interviews at all facilities in the sample conducted, resulting in

a response rate of 100 percent of targeted facilities. The midline survey also clarified that 132, or 29

percent, of the CHPS zones did not have CHPS compounds. Therefore, the assigned CHOs operated

from adjacent zones or health centers and provided services as outreach. Because these CHPS zones

did not have permanent structures, and in line with CHPS policy, these zones used alternative facilities

(such as churches, homes, or kiosks) when available, and access to extensive data and records often was

lacking in these cases.

B.2. Data Collection

Research team

The Evaluate team oversaw quantitative and qualitative data collections for the baseline and the midline.

TNS, a local data collection firm subcontracted for this work, conducted the baseline data collection.

DevtPlan Consult, another local data collection firm, conducted the midline data collection. For the

midline, DevtPlan was responsible for hiring experienced interviewers with backgrounds in health

research for both data collections, which were fielded simultaneously. The project team consisted of the

project director, two field managers, six supervisors, 24 enumerators for the survey, and six

interviewers for the qualitative data collection. Most of the enumerators, interviewers, and supervisors

and one of the field managers hired for the project had worked on the baseline evaluation under TNS.

Most have tertiary education, extensive experience in research data collection, and strong skills in

survey administration in health and related social research. The six supervisors were retired senior

employees of GHS with practical experience in health facilities across the nation. Their presence in the

field was helpful in gaining entrance to health facilities and for guiding the interviewing teams. The

enumerators were divided into six teams, and the qualitative interviewers made up a seventh team. The

careful composition of the team enhanced the assimilation of training materials and their understanding

of the questionnaire, as well as accurate interviewing and efficient data collection.

Ethics committee approval and informed consent

Consent forms, a permission letter from the Director General of Health, and a letter from the Ethical

Review Committee were provided and made available again to the midline teams. These documents are

provided at the end of this appendix.

Training

For the midline data collections, all interviewers were trained in the survey or qualitative interview

guides and relevant data collection protocols between January 23 and February 4, 2017. The trainings

were facilitated by Evaluate, with sections on the context of the Ghana health sector and technical

insights facilitated or supported by members of GHS, including Mr. Emmanuel Ayire Adongo.

The survey pilot was conducted on the fourth day of survey training in the Ewutu Senya District in the

Central region and the Shai Osudoku District in the Greater Accra region. After a detailed debriefing,

the survey was revised. Because the pilot was conducted using the programmed tablets, the pilot

allowed for refining the programming as well. The qualitative team also piloted the interview guides on


the fourth day of the qualitative training at Ga-Dangbe. After debriefing, all six guides were revised based

on our field experiences.

Data collection, processing, management, and procedures

Midline data collection began on February 6, 2017, and was completed on March 5, 2017. The teams

moved throughout the country in vehicles rented for the fieldwork period. Quantitative facility

interview data were collected via computer-assisted personal interviewing (CAPI) using tablets

programmed by the local data collection team, and were uploaded to the DevtPlan server daily, unless

connectivity issues interfered. If so, data were uploaded as soon as possible. Paper questionnaires were

provided to interviewers as backup in case issues with the tablets should prevent electronic data

collection. Only three interviews needed to be conducted on paper because the tablets were not

working. The paper surveys were later transferred to the electronic format—no data were lost.

Evaluate staff preceded the team into the field and facilitated the qualitative interviews by conducting

introductory visits following entry protocol at the various district health directorates, DA offices. These

meetings wre used to share baseline findgins with District health management teasm, DA officers and

explained the purpose of the midline stuady to them. These visits expedited entry of the qualitative data

team and provided it with contact information and appointments that simplified data collection.

The qualitative interviewers conducted were audio recorded in the field and copied from recorders to a

laptop at the end of each day’s work. Using a Mi-Fi for internet connection, the audios were uploaded

onto a DevtPlan server as often as was feasible. Backups of the recordings were stored on a pen drive.

Recordings were translated into English (when necessary) and transcribed by a separate team of about

10 freelance transcribers after being uploaded, concurrent with the data collection activity. Each

qualitative team member had two audio recorders, so that one could serve as a backup.

The DevtPlan team followed data-checking and -cleaning protocols and shared data with clients as

scheduled. The Evaluate team identified minor issues, which they addressed. The quantitative and

qualitative data were provided to the Evaluate team, and Mathematica conducted coding, analysis, and

report writing.

Supervision plan and quality control

All teams were visited in the field and monitored by DevtPlan staff. Evaluate staff also provided external

monitoring on process and quality of work. Monitoring also made data collection easier by providing

extra vehicle support for the teams who covered large geographic areas. Accompanying interviewers

also offered the opportunity to provide additional training, if needed, to ensure data were valid and

reliable.

DevtPlan also has internal, independent quality control (QC) staff who report directly to DevtPlan

management and discuss findings with field teams for redress. The QC team verified, by telephone,

more than 22 percent of the interviews conducted. No fraudulent data were identified, and most issues

identified were minor (including omission and incorrect entries such as incomplete telephone numbers

and incorrect respondent/facility names). Some of these issues were corrected in the field.

B.3. Analysis Approach

Quantitative data

Using the survey data, the analysis for this report seeks to describe the baseline and midline

characteristics of the sample across key indicators for the group of five focal regions and the country as


a whole, to estimate the changes for these indicators between baseline and midline, and to assess

whether those differences are statistically significant (at the 1, 5, or 10 percent level of significance).

The sample for each indicator is restricted to facilities that reported the indicator in both baseline and

midline, to ensure a consistent sample over time and avoid comparing means between different samples.

Without this restriction, the estimated changes over time could, in part, reflect changes in the sample

from baseline to midline, in addition to true changes in the underlying indicator, making it difficult to

interpret the estimates. For cases in which an indicator was measured in the midline but not in the

baseline survey, or was measured in a noncomparable way in the baseline survey, the sample includes all

facilities that reported the indicator at midline, and we present only the midline levels.

The quantitative data analysis accounted for the sampling design. The reported means have been

weighted to account for different sampling probabilities, largely driven by different proportions of

districts sampled in the focal and nonfocal regions.1 These weights ensure that the results are

representative of all CHPS zones or health centers in the focal and nonfocal regions, as well as for all

regions combined. The baseline and midline data were analyzed in Stata version 14 (StataCorp) using the

appropriate “svy” set of commands to obtain the correct standard errors for the estimated differences,

taking the sampling approach into account.

Qualitative data

For the qualitative data, the Mathematica team used NVivo to code the qualitative transcripts by

question number, which were matched to analytic categories. Mathematica staff analyzed the coded data

for each relevant concept by triangulating information from multiple sources and identifying major

themes that emerged from the data related to the research questions. This analysis enabled us to

develop a key set of qualitative findings that took into account similarities and differences in perspectives

across different participant types, providing a comprehensive picture of concepts of interest and enabling

us to address the key research questions.

1 There also was some variation in the number of subdistricts in each district, and some rounding approximations.


ETHICS COMMITTEE APPROVAL PROCESS: CONSENT FORM

Introduction

Ghana’s current investments in health are notable and, in particular, have resulted in substantial

reductions in child mortality and malnutrition and increases in life expectancy at birth. However, Ghana

continues to confront unmet need for both expanded access to quality services and strengthened

community-based health systems (USAID/Ghana’s Country Development Cooperation Strategy 2013-

2017). To meet these challenges, USAID/Ghana seeks to contribute to the following improvements in

the Ghanaian health system: increased access to integrated health services, expanded availability of

community-based resources, strengthened and responsive health systems, and improved health sector

governance and accountability. These improvements are intended to contribute to USAID’s overall

health development objective of achieving equitable improvements in health status in Ghana.

Since 2014, the Evaluate for Health (Evaluate) project has been providing overall monitoring and

evaluation support to USAID’s health portfolio in Ghana by establishing baselines; building monitoring

and evaluation capacity of implementing partners, including Government of Ghana institutions;

developing and implementing studies and evaluations; building the research capacity of Ghana’s research

institutions; implementing operations research to respond to evolving empirical evidence or country

circumstances; and assessing health portfolio performance data in order to guide continual program

improvement.

The aim of this midline health services study is to guide USAID/Ghana health program implementation

and target setting. The midline data collection activities described here will:

1. Gather primary data from health care facilities and stakeholders with respect to the quality of

Ghana’s health services and care.

2. Document the health system’s quality assurance and quality improvement culture.

The proposed midline study will also provide insight into geographic equity through sample coverage in

the 10 regions of Ghana, including poorly served areas such as in the Northern Region.

You are being invited to participate in this midline study that will be conducted in communities in all 10

regions of Ghana.The midline study will utilize both quantitative and qualitative assessment methods and

will focus on:

Quality of Care and Services

Culture of Quality Assurance and Quality Improvement

Community support for CHPS

Health Insurance

Selection: You have been contacted because your district, sub-district or community was randomly

selected among USAID focal regions for the USAID/MSI midline study.

Follow-ups: You will be visited in your community by the study team. In instances where the team is

unable to complete its work in your community on a given day, a follow up visit may be arranged with

you at an appropriate date for the completion of the interview in its entirety in your community.

What are the risks in participating in the assessment? There is minimal risk to you if you

participate in the midline study. There is a risk that the data collection process may take longer than

envisaged, but the study’s experienced data collectors will ensure that any potential discomfort is

minimized during data collection.


What are the benefits of participating in the assessment? The midline study will be used to

assess the performance of the USAID Health Portfolio and will inform future USAID health

programming. The study might lead to intensification of efforts in areas where health shortcomings are

identified. Your community’s health needs may also be clarified which might lead to potential support to

improve health services in your community. However there is no guarantee of direct benefits to you or

your community.

Will you be compensated for participating in this study? There is no compensation for

participating in this study, but in certain cases if you must travel to participate in the interview, you will

be refunded for the cost of traveling.

How will my confidentiality be maintained? If you decide to participate in the midline study, the

study team will collect your views about health services delivery as part of the research. We will

summarize your responses along with those of other people we interview and share them with the

people who work for or with USAID, the Ghana Health Service and its Ethics Review Board (ERB), but

your identify will not be associated with your responses. All information collected from you will be kept

strictly confidential and will be stored in a secure location.

Voluntary withdrawal from the study: You may withdraw from the study at any point during or

after the study. You will not be required to give a reason for this action. However, any information

collected from you will be used as part of the study’s analysis.

What if I have questions about the study regarding my rights as a research participant? If

you have any questions about this study, if there are things that you do not understand about the study,

or if you are in any way offended by the study team, please contact: Dr. Frank Nyonator, Project

Director of USAID/Ghana Evaluate for Health Project on 0267727478 or 0244727478 or

[email protected] and/or Emmanuel Mahama, Senior Evaluation Advisor of USAID/Ghana

Evaluate for Health Project on 0208933496 or [email protected]. Both are located at MSI-

Ghana office at Number F25B/8 Abafun Crescent, Labone, Accra.

If you have any questions about the midline study and participants’ rights, please contact Hannah

Frimpong, administrator of the GHS Ethics Review Board on 0302 681109 or 244 516482

or [email protected]

Statement of understanding: I consent to participate in this study. I confirm that I have read the

statements in this informed consent form or that its contents were explained to me by the interviewer.

I have been given time to read the information carefully or to have it explained to me, to ask any

questions about it, and to decide whether I will take part in this study. Any questions I had were

answered to my satisfaction by the interviewer.

I understand the conditions and procedures of participation and know what the possible risks and

benefits are for me from participation in this study, per the statements in this form. My participation is

voluntary and I may decide to discontinue my participation or to withdraw from the assessment at any

time without penalty. The study may be discontinued without my consent by the team conducting the

study or by USAID.

I hereby give my voluntary informed consent to participate in the study. I understand that I do not give

up any of my legal rights by signing this form. I will be given a copy of this informed consent form to

keep for my information.

Name and Signature/Thumbprint of Study Participant Date

Name and Signature of Interviewer Date

mailto:[email protected]




ETHICS COMMITTEE APPROVAL PROCESS: LETTER FROM THE DIRECTOR GENERAL OF HEALTH


Appendix C: Additional Tables

Table A. Characteristics of respondents of the facility survey (percentage of facilities)

CHPS Health centers

Focal regions All regions Focal regions All regions

Job titlea

Community health officer (CHO) 32 34 2 3

Community health nurse or enrolled nurse 57 55 16 15

Midwife or public health nurse midwife 11 12 36 35

Medical or physician assistant in charge of the full facility 0 0 28 26

Health care assistant clinical 1 1 1 1

Other 4 4 21 25

Respondent has worked in his or her role at the facility for at least one year 81 81 79 79

Sample size 293 464 89 145

Source: Health, Population, and Nutrition Office Health Systems midline survey data. a Because respondents could hold more than one job title, multiple responses were possible. Therefore, percentages sum to more than 100.


Table B. Focal and non-focal regions for USAID’s health investments in Ghana

WESTERN CENTRALGREATER

ACCRAVOLTA NORTHERN EASTERN ASHANTI

BRONG-

AHAFO

UPPER

EAST

UPPER

WEST

1 RING (Global Communities)

2 Systems for Health (URC)

3 SPRING (JSI)

4 MalariaCare (PATH)

5 MCSP (JHPIEGO)

6 WASH for Health (Global Communities)

7 Communicate for Health (FHI360)

8 GHSC- PSM (CHEMONICS)

9 Africa Indoor Residual Spraying (IRS) (Abt)

10Ghana Information for Improves Health

Performance (GIIHP) – Boston University

11 Ghana Social Marketing Program (PSI)

12 HealthKeepers Network

13 Health Finance and Governance (Abt)

14 People for Health (SEND)

15 PreMaND (NHRC- Navrongo)

16 RISK (WAPCAS)

17 Saving Maternity Homes (Banyan Global)

18Sustaining Health Outcomes through

Private Sector (SHOPS) (Abt)

19 United States Pharmacopeia (USP)

20 Strengthening the Care Continuum (JSI)

21 Vector Works/PMI (JHU)

FOCAL REGIONS NON FOCAL REGIONS

Key M

idlin

e S

tud

y I

Ps

Oth

er I

Ps

Implementing Partners


Appendix D: Comprehensive Midline Tables

This appendix presents a comprehensive set of tables that show the baseline and midline levels of

all key indicators measured in the HPNO Health Systems survey, as well as the average facility-level

change from baseline to midline for each indicator and whether this is statistically distinguishable from

zero. The appendix presents each table first for CHPS zones in panel A and then for Health Centers in

panel B. All tables display estimates for the focal regions (including the Central, Greater Accra,

Northern, Volta, and Western regions), the non-focal regions (including the Upper East, Upper West,

Ashanti, Brong Ahafo, and Eastern regions), and all regions combined. The estimates are weighted using

weights that adjust for sampling probabilities to ensure that the results are representative of all CHPS

zones or Health Centers in the focal and non-focal regions, as well as for all regions combined.

The sample for each indicator is restricted to facilities that reported the indicator in both baseline

and midline, to ensure a consistent sample over time and avoid comparing means between different

samples. Without this restriction, the estimated changes over time could partly reflect changes in the

sample from baseline to midline in addition to true changes in the underlying indicator, making it difficult

to interpret the estimates. For those cases in which an indicator was measured in the midline but not in

the baseline survey, or was measured in a non-comparable way in the baseline survey, the sample

includes all facilities that reported the indicator at midline and we present only the midline levels.

Although all respondents were administered the same survey instrument, the response rate to

different questions varied at both baseline and midline. In addition, some questions were only applicable

to a subset of respondents (for example, questions on births at a facility were only relevant to facilities

that offered delivery services, in which case the sample restriction above implies that the analysis sample

was restricted to facilities that offered these services at both baseline and midline). As a result, in most

cases the size of the samples used for our analysis within a table will vary slightly; in order to simplify the

way we display the information, we present sample size ranges in the tables.


TABLES FOR CHPS AND HEALTH CENTERS

I. HEALTH FACILITY CHARACTERISTICS

TABLE 4. SCALE OF SERVICE PROVISION AT FACILITIES

CHPS Health Centers

Focal

regions

Non-focal

regions All regions

Focal

regions

Non-focal

regions All regions

Average (mean) number of clients facility has seen in previous two months:

At Out Patient Department 181 141 159 1000.1 1206 1110

By the midwife 171 18 87 298 184 237

For family planning 68 38 52 184 192 188

Who were children 311 239 272 819 689 749

At Prevention of Mother-to-Child Transmission of HIV and

Early Infant Diagnosis unit 13 7 10 82 43 61

At Adolescent Health and Development center 14 13 14 90 46 66

At Nutritional Rehabilitation Center 82 15 46 461 66 247

Median number of clients facility has seen in previous two months:

At Out Patient Department 144 54 91 696 954 886

By the midwife 12 0 5 150 92 128

For family planning 42 27 32 115 88 95

Who were children 225 199 207 583 538 553

At Prevention of Mother-to-Child Transmission of HIV and

Early Infant Diagnosis unit 0 0 0 33 33 33

At Adolescent Health and Development center 0 0 0 0 15 5

At Nutritional Rehabilitation Center 0 0 0 0 0 0

Sample sizea 269--278 167--171 437--448 82--89 53--56 135--145

Source: Health, Population, and Nutrition Office Health Systems baseline and midline survey data

Note: Means and medians are weighted to adjust for sampling probabilities. a Sample sizes are reported as ranges because variables have different response rates.


II. QUALITY OF CARE AND SERVICES

A. Integration of Care: Referrals and Follow-Up Care

TABLE 5.1. REFERRALS OUT OF AND INTO THE FACILITY AMONG CHPS (PERCENTAGE OF FACILITIES, UNLESS

OTHERWISE INDICATED)

CHPS Zones Focal regions Non-focal regions All regions

Baseline Midline Difference Baseline Midline Difference Baseline Midline Difference

Percentage of facilities with referral records:

Records exist and seen 49.5 51.0 1.4 53.1 45.9 -7.2 51.5 48.3 -3.2

Records exist, but not seen 11.0 6.2 -4.8** 5.1 1.0 -4.1* 7.8 3.4 -4.4***

No records 39.4 42.8 3.4 41.8 53.1 11.3** 40.7 48.4 7.7**

Sample size 277 164 441

Percentage of facilities with referral record for the most recent referral:

Record exists and seen 45.1 49.2 4.1 47.4 45.9 -1.5 46.3 47.4 1.1

Record exists, but not seen 8.3 6.5 -1.8 4.4 0.5 -3.9** 6.2 3.3 -2.9**

No record 46.6 44.3 -2.3 48.3 53.6 5.3 47.5 49.3 1.8


Referrals in previous two months:

Average percentage of all clients seen who were

referred out of the facility

4.0 4.8 0.8 4.6 6.0 1.4* 4.3 5.4 1.1**

Average percentage of clients who were referred

out who returned with feedback notes, among

facilities that referred clients out

21.0 41.5 20.6*** 31.6 47.5 15.9** 25.8 44.3 18.4***

Sample sizea 117--177 53--91 170--268

Source: Health, Population, and Nutrition Office Portfolio Health Systems baseline and midline survey data

Note: Percentages are weighted to adjust for sampling probabilities.

*** Statistically significant at the 1 percent level; ** statistically significant at the 5 percent level; * statistically significant at the 10 percent level. a Sample sizes are reported as ranges because variables have different response rates and because some variables apply to different subsets of respondents.

n.a. = not applicable (question not asked at baseline, or not comparable).


TABLE 5.2. REFERRALS OUT OF AND INTO THE FACILITY AMONG HCS (PERCENTAGE OF HCS, UNLESS


Focal regions Non-focal regions All regions


Percentage of facilities with referral records:

Records exist and seen 75.6 82.6 6.9 93.7 98.8 5.1 85.4 91.3 5.9*

Records exist, but not seen 12.3 5.3 -7.0* 0.0 0.0 0.0 5.7 2.5 -3.2*

No records 12.0 12.1 0.1 6.3 1.2 -5.1 8.9 6.2 -2.7


Percentage of facilities with referral record for the most recent referral:

Record exists and seen 74.5 81.5 6.9 91.1 96.5 5.4* 83.5 89.6 6.1**

Record exists, but not seen 12.3 5.3 -7.0** 2.6 2.3 -0.3 7.1 3.7 -3.4*

No record 13.2 13.2 0.1 6.3 1.2 -5.1 9.5 6.8 -2.7


Referrals in previous two months:


referred out of the facility 11.9 12.5 0.6 18.0 23.6 5.6 15.4 18.9 3.5


referred into the facility n.a. 0.1 n.a. n.a. 0.2 n.a. n.a. 0.1 n.a.

Sample sizea 77 56 133



*** Statistically significant at the 1 percent level; ** statistically significant at the 5 percent level; * statistically significant at the 10 percent level.

TABLE 5.3. COMMON REASONS FOR REFERRALS AMONG CHPS

(PERCENTAGE, AMONG CHPS CONDUCTING REFERRALS)



Common reasons for referrals out of the facility in the previous two months, as documented among facilities conducting referrals:a

Malaria or severe malaria 46.0 55.1 9.2 48.2 56.5 8.3 47.0 55.8 8.8

Pregnancy-related complications 37.0 42.2 5.2 60.1 46.2 -13.9* 47.7 44.1 -3.6

Other n.a. b 34.3 n.a. b n.a. b 49.7 n.a.b n.a. b 41.8 n.a.b


Anemia 27.9 29.6 1.8 28.1 33.5 5.4 28.0 31.4 3.4

Hypertension 14.4 23.6 9.2** 19.3 26.2 6.9 16.6 24.8 8.1**

Accidents and injuries, such as snake

bites, burns, and cuts

16.6 12.8 -3.8 15.7 18.2 2.5 16.2 15.3 -0.9

Diarrhea 14.3 9.5 -4.8 15.5 4.4 -11.1** 14.9 7.2 -7.7**

Skin diseases and ulcers 7.2 6.0 -1.2 11.7 5.7 -5.9 9.3 5.9 -3.4

Acute malnutrition n.a. 5.8 n.a. n.a. 4.9 n.a. n.a. 5.3 n.a.

Upper respiratory tract infection 4.3 4.5 0.2 2.8 6.2 3.4 3.6 5.3 1.7

Diabetes n.a. 2.9 n.a. n.a. 1.2 n.a. n.a. 2.1 n.a.

Stroke 0.0 2.7 2.7** 2.7 0.0 -2.7 1.2 1.4 0.2

Pneumonia 4.6 2.0 -2.6 5.0 3.9 -1.1 4.8 2.9 -1.9

Cholera 2.4 0.8 -1.6 1.8 0.0 -1.8 2.1 0.4 -1.7

Ear infection 2.2 0.8 -1.4 2.5 2.5 -0.0 2.3 1.6 -0.8

Rheumatism 0.0 0.6 0.6 0.0 0.0 0.0 0.0 0.3 0.3

Typhoid 0.8 0.0 -0.8 1.8 1.8 0.0 1.3 0.8 -0.4

Intestinal worms 0.0 0.0 0.0 1.6 0.0 -1.6 0.7 0.0 -0.7

Sample sizec 119--164 55--84 174--248



*** Statistically significant at the 1 percent level; ** statistically significant at the 5 percent level; * statistically significant at the 10 percent level. a Because multiple responses were possible, percentages sum to more than 100. b The “Other” category is not strictly comparable between baseline and midline because the former included “acute malnutrition” and “diabetes” and the latter had them as

separate categories. Therefore, the statistical significance of their difference was not assessed. c Sample sizes are reported as ranges because variables have different response rates.


TABLE 5.4. COMMON REASONS FOR REFERRALS AMONG HCS (PERCENTAGE, AMONG HCS CONDUCTING

REFERRALS)



Common reasons for referrals out of the facility in the previous two months, as documented among facilities conducting referrals:a

Malaria or severe malaria 54.0 47.0 -7.1 53.0 69.7 16.8** 53.5 59.4 5.9

Pregnancy-related complications 44.1 64.4 20.3*** 60.8 56.1 -4.7 53.2 59.9 6.7

Something else n.a. 51.2 n.a. n.a. 64.1 n.a. n.a. 58.3 n.a.

Anemia 56.4 38.5 -18.0*** 40.9 57.5 16.6** 48.0 48.8 0.8

Hypertension 22.9 21.2 -1.7 35.9 43.2 7.4 30.0 33.2 3.2





bites, burns, and cuts 28.2

8.9 -19.3*** 33.9 51.4 17.5*** 31.3 32.0 0.7

Diarrhea 8.0 4.8 -3.1 10.0 6.2 -3.7 9.1 5.6 -3.5

Skin diseases and ulcers 3.1 3.0 -0.1 16.1 9.0 -7.1 10.2 6.3 -3.9


Upper respiratory tract infection 7.6 3.8 -3.8 13.4 10.1 -3.3 10.8 7.2 -3.6


Stroke 0.0 4.4 4.4** 7.1 12.3 5.2 3.9 8.7 4.8*

Pneumonia 8.7 7.6 -1.1 17.2 17.3 0.1 13.3 12.9 -0.4

Cholera 2.0 1.0 -1.0 1.5 3.9 2.4 1.7 2.6 0.9

Ear infection 3.7 1.0 -2.7 3.0 2.2 -0.9 3.3 1.6 -1.7

Rheumatism 0.0 0.0 0.0 5.0 3.5 -1.5 2.7 1.9 -0.8

Typhoid 2.1 1.0 -1.1 9.7 2.2 -7.5 6.2 1.6 -4.6

Intestinal worms 0.0 0.0 0.0 0.0 4.1 4.1 0.0 2.2 2.2

Sample sizec 72--79 47--54 119--133

Common reasons for referrals into the facility in the previous two months, among facilities receiving referrals:a

Malaria or severe malaria 35.1 49.8 14.7 48.8 59.9 11.1 44.2 56.6 12.3

Pregnancy-related complications 31.6 31.6 -0.0 46.1 35.3 -10.8 41.3 34.0 -7.2

Other 44.3 51.9 7.6 b 40.1 36.4 -3.6 b 41.5 41.6 0.1 b

Anemia 37.0 33.3 -3.7 6.2 29.7 23.5 16.5 30.9 14.4

Hypertension 0.0 14.9 14.9 22.0 13.8 -8.2 14.7 14.2 -0.5


bites, burns, and cuts 18.6

35.1 16.6 16.6 35.4 18.8* 17.2 35.3 18.0**

Diarrhea 12.8 14.9 2.0 10.9 0.0 -10.9 11.6 5.0 -6.6

Skin diseases and ulcers 0.0 0.0 0.0 15.1 0.0 -15.1 10.1 0.0 -10.1


Upper respiratory tract infection 0.0 9.3 9.3 6.9 12.4 5.5 4.6 11.3 6.7


Stroke n.a. 5.2 n.a. n.a. 0.0 n.a. n.a. 1.9 n.a.

Pneumonia 0.0 7.4 7.4 13.9 5.5 -8.5 9.3 6.1 -3.2

Cholera 13.0 14.9 1.9 15.1 19.3 4.2 14.4 17.8 3.4

Ear infection 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

Rheumatism 0.0 0.0 0.0 0.0 5.5 5.5 0.0 3.6 3.6

Typhoid 7.4 7.4 0.0 5.5 0.0 -5.5 6.1 2.5 -3.6

Intestinal worms 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0




Sample sizec 13--26 15--26 28--52



*** Statistically significant at the 1 percent level; ** statistically significant at the 5 percent level; * statistically significant at the 10 percent level. a Because multiple responses were possible, percentages sum to more than 100. b The “Other” category is not strictly comparable between baseline and midline because the former included “acute malnutrition” and “diabetes” and the latter had them as

separate categories. Therefore, the statistical significance of their difference was not assessed. c Sample sizes are reported as ranges because variables have different response rates.


B. Availability of Services

TABLE 6.1. AVAILABILITY OF MALARIA SERVICES AMONG CHPS (PERCENTAGE OF FACILITIES)



Malaria testing

Facility reported that all suspected cases of malaria

were tested using RDT and/or microscopy and the

results were recorded in the register

n.a. 52.7 n.a. n.a. 50.8 n.a. n.a. 51.6 n.a.


Facility provided these reasons for not testing for malaria for every client with a provisional diagnosis of malaria, among facilities that did not test and record results for all

clients with a provisional diagnosis:a

Insufficient supply of RDT n.a. 87.5 n.a. n.a. 89.9 n.a. n.a. 88.6 n.a.

RDT/lab is not available at all times of the day

and night

n.a. 29.6 n.a. n.a. 26.2 n.a. n.a. 28.0 n.a.

Lack of skill in conducting RDT/microscopy n.a. 0.0 n.a. n.a. 0.0 n.a. n.a. 0.0 n.a.

Other reasons n.a. 2.4 n.a. n.a. 11.9 n.a. n.a. 6.8 n.a.


Malaria treatment


Facility has at least one staff member providing treatment for malaria

86.2 85.3 -0.9 75.5 74.0 -1.5 80.4 79.1 -1.2

Facility adhered to GHS protocol for malaria

treatment in two previous monthsb

n.a. 46.0 n.a. n.a. 49.0 n.a. n.a. 47.7 n.a.

Sample sizec 270--279 168--171 438--450


Note: Percentages are weighted to adjust for sampling probabilities. *** Statistically significant at the 1 percent level; ** statistically significant at the 5 percent level; *

statistically significant at the 10 percent level. a Because multiple responses were possible, percentages may sum to more than 100. b Defined as testing all cases with provisional diagnosis of malaria and recording the treatment for all positive cases. c Sample sizes are reported as ranges because variables have different response rates and because some variables apply to different subsets of respondents.


TABLE 6.2. AVAILABILITY OF MALARIA SERVICES AMONG HCS (PERCENTAGE OF HCS)



Malaria testing

Facility reported that all suspected cases of malaria

were tested using RDT and/or microscopy and the

results were recorded in the register

n.a. 44.5 n.a. n.a. 40.0 n.a. n.a. 42.1 n.a.


Facility provided these reasons for not testing for malaria for every client with a provisional diagnosis of malaria, among facilities that did not test and record results for all

clients with a provisional diagnosis:a

Insufficient supply of RDT n.a. 89.3 n.a. n.a. 89.4 n.a. n.a. 89.3 n.a.

RDT/lab is not available at all times of the day

and night

n.a. 28.7 n.a. n.a. 21.7 n.a. n.a. 24.7 n.a.

Lack of skill in conducting RDT/microscopy n.a. 0.0 n.a. n.a. 1.9 n.a. n.a. 1.1 n.a.

Other reasons n.a. 10.6 n.a. n.a. 14.6 n.a. n.a. 12.9 n.a.


Malaria treatment

Facility has at least one staff member providing

treatment for malaria

100.0 100.0 0.0 100.0 98.6 -1.4 100.0 99.2 -0.8

Facility adhered to GHS protocol for malaria

treatment in two previous monthsb

n.a. 42.2 n.a. n.a. 34.3 n.a. n.a. 38.1 n.a.

Sample sizec 86--88 52--56 138--144




*** Statistically significant at the 1 percent level; ** statistically significant at the 5 percent level; * statistically significant at the 10 percent level. a Because multiple responses were possible, percentages may sum to more than 100. b Defined as testing all cases with provisional diagnosis of malaria and recording the treatment for all positive cases. c Sample sizes are reported as ranges because variables have different response rates and because some variables apply to different subsets of respondents.


TABLE 7A. AVAILABILITY OF FAMILY PLANNING SERVICES AMONG CHPS (PERCENTAGE OF CHPS, UNLESS




Family planning services offered:

Family planning counseling only 15.0 1.6 -13.4*** 5.7 9.8 4.0 10.0 6.1 -3.9*

Contraceptives only 2.6 0.3 -2.3** 0.9 0.0 -0.9 1.7 0.2 -1.5**

Both 79.3 94.2 15.0*** 88.0 86.3 -1.7 84.0 89.9 5.9**

Neither 3.1 3.8 0.7 5.4 3.9 -1.4 4.3 3.9 -0.5


Facility can provide long-acting methods

of contraception on day of interview,

among those with control cards for

those methods

n.a. 100.0 n.a. n.a. 100.0 n.a. n.a. 100.0 n.a.

Facility can provide at least 4 modern

methods of family planning on day of

interview, among facilities with control

cards for those methods)

n.a. 69.3 n.a. n.a. 60.3 n.a. n.a. 65.9 n.a.

Number of clients receiving

contraceptives for the first time from

facility in previous two months (mean)

n.a. 19.4 n.a. n.a. 11.0 n.a. n.a. 14.9 n.a.



facility in previous two months

(median)

n.a. 12 n.a. n.a. 6 n.a. n.a. 8 n.a.

Sample sizea 110--279 33--171 143--450


Note: Percentages, means, and medians are weighted using weights that adjust for sampling probabilities. *** Statistically significant at the 1 percent level; **

statistically significant at the 5 percent level; * statistically significant at the 10 percent level. a Sample sizes are reported as ranges because variables have different response rates.


TABLE 7B. AVAILABILITY OF FAMILY PLANNING SERVICES AMONG HCS

(PERCENTAGE OF HCS, UNLESS OTHERWISE INDICATED)



Family planning services offered:

Family planning counseling only 8.3 0.0 -8.3*** 3.7 0.0 -3.7 5.8 0.0 -5.8***

Contraceptives only 0.0 0.0 0.0 1.2 0.0 -1.2 0.6 0.0 -0.6

Both 90.6 98.9 8.3*** 90.7 98.1 7.5** 90.6 98.5 7.9***

Neither 1.1 1.1 0.0 4.4 1.9 -2.6 2.9 1.5 -1.4


Facility can provide long-acting methods

of contraception on day of interview,

among those with control cards for

those methods

n.a. 98.9 n.a. n.a. 100.0 n.a. n.a. 99.5 n.a.

Facility can provide at least 4 modern methods of family planning on day of

interview, among facilities with control

cards for those methods)

n.a. 72.3 n.a. n.a. 75.0 n.a. n.a. 73.6 n.a.



facility in previous two months (mean)

n.a. 46.8 n.a. n.a. 55.3 n.a. n.a. 51.4 n.a.



facility in previous two months

(median)

n.a. 24 n.a. n.a. 28 n.a. n.a. 27 n.a.

Sample sizea 65--89 32--56 97--145


Note: Percentages, means, and medians are weighted using weights that adjust for sampling probabilities.

*** Statistically significant at the 1 percent level; ** statistically significant at the 5 percent level; * statistically significant at the 10 percent level. a Sample sizes are reported as ranges because variables have different response rates.


TABLE 8A. AVAILABILITY OF DELIVERY AND ANTENATAL CARE SERVICES AMONG CHPS

(PERCENTAGE OF CHPS, UNLESS OTHERWISE INDICATED)



Delivery care

Facility conducts deliveries 26.3 48.5 22.2*** 22.6 36.6 14.0*** 24.3 42.1 17.8***


Delivery care in the previous two months, among facilities conducting deliveries:

Average (mean) number of deliveries in the

facility 6.2 7.9 1.7** 7.2 5.9 -1.3 6.7 7.0 0.3

Average percentage of deliveries in which

mother received at least two doses of

sulfadoxine-pyrimethamine

86.6 89.8 3.2 86.1 94.6 8.5 86.3 92.2 5.9*

Percentage of attended births that were

registered at the facility n.a. 98.3 n.a. n.a. 98.5 n.a. n.a. 98.4 n.a.

Facility registered any home births n.a. 49.3 n.a. n.a. 35.8 n.a. n.a. 41.9 n.a.

Average percentage of births in the facility that

were emergency deliveries 2.6 5.0 2.4* 1.7 1.0 -0.8 2.2 2.9 0.8

Facility recorded reasons for all maternal deaths

(among facilities with any maternal deaths) n.a. --a n.a. n.a. --a n.a. n.a. --a n.a.

Facility recorded reasons for all neonatal deaths

(among facilities with any neonatal deaths) n.a. --a n.a. n.a. --a n.a. n.a. --a n.a.

Sample sizeb 45--277 26--170 71--447

Antenatal care (ANC)

Facility provides ANC 66.2 71.0 4.7* 57.4 61.8 4.4 61.5 66.0 4.5**


Availability of ANC registers, among facilities providing ANC:

Register exists and seen 94.6 98.3 3.8** 95.1 95.7 0.6 94.9 97.0 2.2

Register exists, but not seen 4.4 0.0 -4.4** 1.5 0.0 -1.5 3.0 0.0 -3.0***

No register 1.0 1.7 0.7 3.4 4.3 0.9 2.2 3.0 0.8



Note: Percentages and means are weighted using weights that adjust for sampling probabilities. *** Statistically significant at the 1 percent level; ** statistically

significant at the 5 percent level; * statistically significant at the 10 percent level. a Not reported because of small sample sizes (fewer than 10). b Sample sizes are reported as ranges because variables have different response rates and because some variables apply to different subsets of respondents.



TABLE 8B. AVAILABILITY OF DELIVERY AND ANTENATAL CARE SERVICES AMONG HCS




Delivery care

Facility conducts deliveries 85.8 91.4 5.6*** 91.2 93.2 2.0 88.7 92.4 3.7*


Delivery care in the previous two months, among facilities conducting deliveries:

Average (mean) number of deliveries in the

facility 28.3 28.6 0.3 25.0 23.7 -1.3 26.5 25.9 -0.6

Average percentage of deliveries in which

mother received at least two doses of

sulfadoxine-pyrimethamine

79.3 85.7 6.4* 80.5 88.7 8.3* 79.9 87.4 7.4***

Percentage of attended births that were

registered at the facility n.a. 100.0 n.a. n.a. 99.6 n.a. n.a. 99.8 n.a.

Facility registered any home births n.a. 45.9 n.a. n.a. 48.9 n.a. n.a. 47.5 n.a.

Average percentage of births in the facility that

were emergency deliveries 2.3 4.3 2.0 4.6 2.5 -2.0 3.5 3.4 -0.2

Facility recorded reasons for all maternal deaths

(among facilities with any maternal deaths) n.a. --a n.a. n.a. --a n.a. n.a. --a n.a.

Facility recorded reasons for all neonatal deaths

(among facilities with any neonatal deaths) n.a. --a n.a. n.a. --a n.a. n.a. --a n.a.

Sample sizeb 71--88 46--56 117--144

Antenatal care (ANC)

Facility provides ANC 92.7 96.4 3.6** 94.4 94.8 0.4 93.6 95.5 1.9


Availability of ANC registers, among facilities providing ANC:

Register exists and seen 90.2 100.0 9.8*** 97.2 100.0 2.8 93.9 100.0 6.1***

Register exists, but not seen 9.8 0.0 -9.8*** 2.8 0.0 -2.8 6.1 0.0 -6.1***

No register 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0



Note: Percentages and means are weighted using weights that adjust for sampling probabilities.



a Not reported because of small sample sizes (fewer than 10). b Sample sizes are reported as ranges because variables have different response rates and because some variables apply to different subsets of respondents.


TABLE 9A. AVAILABILITY OF NUTRITION SERVICES AMONG CHPS (PERCENTAGE OF FACILITIES)



Availability of nutrition register: Register exists and seen 85.5 82.9 -2.5 86.2 81.4 -4.8 85.9 82.1 -3.8

Register exists, but not seen 5.3 6.9 1.7 2.4 0.5 -1.9 3.7 3.4 -0.3

No register 9.3 10.1 0.9 11.5 18.1 6.7 10.5 14.5 4.0


Data entered in the past two months among facilities with a nutrition register available:

Data exist and seen 67.3 79.9 12.6*** 72.5 76.3 3.8 70.2 78.0 7.8**

Data exist, but not seen 10.9 6.5 -4.5** 11.6 0.3 -11.3*** 11.3 3.1 -8.2***

No data entered 21.7 13.6 -8.1*** 15.9 23.3 7.5 18.5 18.9 0.4


Specific types of data entered in the register, among facilities with data observed:

Child’s weight data 98.6 97.3 -1.3 100.0 100.0 0.0 99.4 98.8 -0.6

Child’s age data 98.5 96.3 -2.2 100.0 98.5 -1.5 99.3 97.5 -1.9**

Child’s height data 19.4 12.1 -7.3** 24.4 10.8 -13.6*** 22.1 11.4 -10.7***

Underweight, or weight-for-age data 77.6 60.2 -17.4*** 87.4 62.9 -24.5*** 83.0 61.7 -21.3***

Infant and Young Child Feeding (IYCF)

counseling data

n.a. 43.3 n.a. n.a. 54.1 n.a. n.a. 49.1 n.a.

Sample sizeb 174--218 110--131 284--349

Facility has nutrition register with entry

within previous 30 days, among facilities

that showed their nutrition register data

74.6 85.9 11.2** 77.7 73.7 -4.0 76.2 79.5 3.2

Availability of nutritional counseling materials:a

Materials exist and seen 58.9 80.0 21.1** 67.5 86.3 18.8** 64.9 84.4 19.5***

Materials exist but not seen 22.2 16.2 -5.9 7.9 8.7 0.8 12.2 11.0 -1.3

No materials 18.9 3.8 -15.1* 24.5 5.0 -19.5** 22.8 4.7 -18.2***

Sample sizeb 48--150 45--84 93--234



statistically significant at the 10 percent level. a Asked only for facilities in the Northern, Upper East, and Upper West regions. These indicators were not considered for the sample size ranges at the bottom of the table.


b Sample sizes are reported as ranges because variables have different response rates and because some variables apply to different subsets of respondents.

n.a. = not applicable (question not asked at baseline, or not comparable)

TABLE 9B. AVAILABILITY OF NUTRITION SERVICES AMONG HCS (PERCENTAGE OF HCS)



Availability of nutrition register: Register exists and seen 91.3 90.5 -0.8 83.9 93.6 9.7 87.3 92.2 4.9

Register exists, but not seen 7.6 1.1 -6.5** 4.4 1.2 -3.2 5.8 1.2 -4.7**

No register 1.1 8.4 7.3*** 11.8 5.2 -6.6 6.9 6.7 -0.2


Data entered in the past two months among facilities with a nutrition register available:

Data exist and seen 70.4 88.7 18.3*** 78.9 91.1 12.2* 75.0 90.0 15.0***

Data exist, but not seen 23.1 1.1 -21.9*** 8.1 1.2 -6.9* 14.9 1.2 -13.8***

No data entered 6.5 10.2 3.7 13.0 7.7 -5.3 10.0 8.9 -1.2


Specific types of data entered in the register, among facilities with data observed:

Child’s weight data 98.0 99.0 1.0 100.0 100.0 0.0 99.0 99.5 0.5

Child’s age data 99.0 97.7 -1.3 100.0 97.7 -2.3 99.5 97.7 -1.8

Child’s height data 35.6 14.8 -20.8*** 31.3 18.1 -13.2*** 33.4 16.5 -16.8***

Underweight, or weight-for-age data 82.2 62.3 -19.9*** 87.4 68.2 -19.2** 85.0 65.4 -19.6***

Infant and Young Child Feeding (IYCF)

counseling data

n.a. 64.1 n.a. n.a. 55.0 n.a. n.a. 59.1 n.a.

Sample sizeb 70--79 44--51 114--130

Facility has nutrition register with entry

within previous 30 days, among facilities

that showed their nutrition register data

67.9 94.0 26.0*** 79.3 90.8 11.4 74.1 92.2 18.1***

Availability of nutritional counseling materials:a

Materials exist and seen 75.0 90.6 15.6* 91.3 95.1 3.8 85.6 93.5 7.9

Materials exist but not seen 18.8 9.4 -9.4 8.7 4.9 -3.8 12.2 6.5 -5.7

No materials 6.3 0.0 -6.3 0.0 0.0 0.0 2.2 0.0 -2.2

Sample sizeb 16--53 14--34 30--87



*** Statistically significant at the 1 percent level; ** statistically significant at the 5 percent level; * statistically significant at the 10 percent level. a Asked only for facilities in the Northern, Upper East, and Upper West regions. These indicators were not considered for the sample size ranges at the bottom of the table. b Sample sizes are reported as ranges because variables have different response rates and because some variables apply to different subsets of respondents.



TABLE 10A. AVAILABILITY OF COMMUNITY-BASED SERVICES AMONG CHPS




Home visits

Facility staff (including community health officers, or

CHOs) conducted at least one visit in the previous two

months

97.3 100.0 2.7*** 98.4 100.0 1.6* 97.9 100.0 2.1***

Facility staff (including CHO) conducted at least one

follow-up home visit in the previous two months

79.9 76.6 -3.3 77.1 82.2 5.1 78.3 79.8 1.5


follow-up home visit within the previous two months

that was recorded in the register

40.2 47.2 7.0 59.6 55.1 -4.4 51.2 51.7 0.5

Facility staff (including CHO) or other paid staff

conducted at least 10 follow-up home visits in the

previous two months

32.4 37.0 4.5 31.8 33.6 1.8 32.1 35.0 3.0



previous two months

11.3 9.7 -1.6 11.5 6.9 -4.6 11.4 8.1 -3.3*

Sample sized 190--270 129--169 319--439

Average (mean) number of home and school visits by Facility staff (including CHO) in the previous two months: Routine home visits conducted 26.1 58.4 32.3*** 27.6 30.8 3.2 26.9 43.3 16.3***

Follow-up home visits 10.7 10.9 0.2 9.8 9.6 -0.2 10.2 10.1 -0.1

Clients needing special visits 4.9 8.7 3.8*** 4.3 5.8 1.5* 4.6 7.1 2.6***

Postnatal home visits conducted 6.8 6.6 -0.3 4.0 4.7 0.6 5.3 5.5 0.3

School visits conducted 5.7 2.7 -3.0 2.8 2.6 -0.2 4.1 2.7 -1.5

Sample sized 245--274 168--170 413--443

Median number of home and school visits by facility staff (including CHO) in the previous two months:

Routine home visits conducted 10 22 12a 14 17 3 a 11 20 9 a

Follow-up home visits 4 5 1 a 5 6 1 a 5 5 0 a

Clients needing special visits 2 3 1 a 2 4 2 a 2 4 2 a

Postnatal home visits conducted 4 4 0 a 3 3 0 a 3 3 0 a

School visits conducted 2 2 0 a 2 2 0 a 2 2 0 a

Sample sized 245--274 168--170 413--443

Community health volunteers (CHVs)




Facility has at least one CHV 90.4 92.7 2.3 98.1 98.9 0.9 94.6 96.1 1.5


Services offered by CHVs in the past 12 months:b

Home visits — assess, advise and educate on health 49.4 54.4 5.0 50.8 65.9 15.1* 50.2 61.0 10.9**

Disease surveillance, identify cases, or report 39.6 51.8 12.2*** 54.8 78.7 23.9*** 48.4 67.3 19.0***

Mobilize and sensitize community for health

management action

32.1 38.6 6.5 54.8 51.8 -3.0 45.2 46.2 1.1

Provide first aid and treatment of minor ailments 31.5 32.8 1.3 48.1 44.0 -4.1 41.1 39.2 -1.8

Disseminate health promotion materials or

information

28.0 35.6 7.5* 44.2 46.7 2.5 37.3 42.0 4.6

Communicate between CHO and community on

health status of community

23.7 35.1 11.4*** 47.3 48.5 1.2 37.3 42.8 5.5

Assist CHO with home visits, outreach or work at

the CHPS

29.9 46.3 16.4*** 33.5 59.8 26.2*** 32.0 54.0 22.0***

Support the organization of community health

meetings (durbars)

19.3 46.5 27.2*** 40.5 54.5 14.0** 31.5 51.1 19.6***

Home visits — follow-up on defaulters 22.3 40.5 18.2*** 36.0 57.2 21.2** 30.2 50.1 19.9***

Refer clients to CHO for disease treatment, family

planning or nutrition

26.4 34.9 8.6** 28.2 52.2 24.0*** 27.5 44.9 17.4***

Support antenatal, postnatal or infant care 20.5 21.5 1.1 28.4 36.8 8.4 25.0 30.3 5.3

Collaborate with CHO or support CHPS service

delivery

15.9 22.8 6.9** 22.6 31.3 8.6** 19.8 27.7 7.9***

Assist in compiling and updating community register

or profile

6.9 12.3 5.4** 16.2 23.2 7.0 12.3 18.6 6.3

Provide condoms or family planning information 9.2 23.3 14.0*** 12.2 19.6 7.4* 10.9 21.2 10.2***

Facilitate support group sessions n.a. 9.6 n.a. n.a. 13.7 n.a. n.a. 11.9 n.a.


Sample sized 240--260 166--169 406--429

Number of CHVs working with facility:

Number of CHVs (mean) 7.0 5.9 -1.0** 4.6 4.3 -0.3 5.7 5.1 -0.6***

Number of CHVs (median) 4 4 0a 4 4 0a 4 4 0a


Community health meetings

At least one community health meeting (durbar) was

held in last complete quarter

n.a. 88.1 n.a. n.a. 82.2 n.a. n.a. 84.8 n.a.




Number of community health meetings (durbars) held

in the last complete quarter (mean)

n.a. 1.7 n.a. n.a. 2.0 n.a. n.a. 1.9 n.a.

Sample sized 257--268 163--165 420--433

Key persons planning and organizing the last community health meeting, among facilities holding a community health meeting in the previous quarter:b

Community health officer (CHO) 55.3 70.2 15.0*** 64.9 54.0 -10.9 60.9 60.7 -0.3

Community health volunteers (CHVs) 23.8 13.7 -10.2** 12.8 10.0 -2.8 17.4 11.5 -5.8

Community leaders not part of Community health

committee (CHC)

28.1 18.6 -9.5 7.4 17.9 10.6 15.9 18.2 2.3

CHC 20.2 34.3 14.1*** 8.1 53.7 45.6*** 13.1 45.7 32.6***

Someone else 42.2 24.2 -18.0*** 48.5 28.4 -20.1*** 45.9 26.7 -19.2***


Key topics of discussion during last community health meeting, among facilities holding a community health meeting in the previous two months: b

Family planning 20.5 23.2 2.7 30.9 50.4 19.5* 26.6 39.1 12.5*

Malaria (any topic) 25.3 33.9 8.6 21.2 50.2 29.0*** 22.9 43.5 20.5***

Cholera 22.7 19.8 -2.9 23.3 23.2 -0.1 23.1 21.8 -1.3

Maternal and child health 14.0 30.3 16.2** 23.7 41.2 17.5 19.7 36.7 17.0**

Antenatal care attendance 21.9 15.7 -6.2 16.4 43.7 27.3*** 18.7 32.1 13.4***

Newborn health 9.3 19.1 9.8** 12.4 19.0 6.5 11.1 19.0 7.9**

WASH (water and sanitation hygiene) 18.0 21.6 3.5 11.6 20.0 8.4 14.3 20.7 6.4*

Expanded Programme on Immunizations 10.0 15.8 5.8 9.8 28.7 18.9** 9.9 23.4 13.5***

Postnatal Care Attendance 6.9 8.0 1.1 14.1 21.3 7.2 11.1 15.8 4.7

Administration of the health facility 9.5 21.5 11.9** 13.9 19.3 5.4 12.1 20.2 8.1

Health Insurance 7.7 15.4 7.7 6.9 20.5 13.6* 7.2 18.4 11.2**

Injuries such as snake bites, burns, and so on 3.7 4.5 0.8 7.5 10.1 2.7 5.9 7.8 1.9

Nutrition n.a. 15.4 n.a. n.a. 21.1 n.a. n.a. 18.5 n.a.

Goodlife, Live it Well Campaign n.a. 5.5 n.a. n.a. 14.3 n.a. n.a. 10.2 n.a.

HIV/AIDS 0.8 12.9 12.2*** 2.3 20.5 18.2** 1.7 17.4 15.7***

Something else n.a. c 58.8 n.a. c n.a. c 53.7 n.a.c n.a. c 56.0 n.a. c

Sample sized 92--221 60--132 152--353



Note: Percentages, means, and medians are weighted using weights that adjust for sampling probabilities. *** Statistically significant at the 1 percent level; ** statistically

significant at the 5 percent level; * statistically significant at the 10 percent level.

a Statistical significance for the change in medians was not calculated.

b Because multiple responses were possible, percentages sum to more than 100. c The “Something else” category is not strictly comparable between baseline and midline because the former included “Nutrition” and “Goodlife, Live it Well Campaign”, and

the latter had them as separate categories. Therefore, the statistical significance of their difference was not assessed. d Sample sizes are reported as ranges because variables have different response rates and because some variables apply to different subsets of respondents.

n.a. = not applicable (not measured at baseline, or not comparable).

TABLE 10B. AVAILABILITY OF COMMUNITY-BASED SERVICES AMONG HCS




Home visits

Facility staff (including community health officers, or

CHOs) conducted at least one visit in the previous two

months

97.3 100.0 2.7* 95.7 100.0 4.3 96.4 100.0 3.6**


follow-up home visit in the previous two months

84.0 72.9 -11.1* 77.4 79.9 2.5 80.3 76.8 -3.6


follow-up home visit within the previous two months

that was recorded in the register

43.6 56.7 13.1 67.2 64.2 -3.0 56.3 60.7 4.4



previous two months

50.7 37.4 -13.3 45.1 33.6 -11.5 47.6 35.3 -12.3**



previous two months

15.9 14.2 -1.7 17.2 19.9 2.7 16.6 17.4 0.8

Sample sizeb 61--79 39--55 100--134

Average (mean) number of home and school visits by facility staff (including CHO) in the previous two months:

Routine home visits conducted 67.1 113.8 46.7* 39.6 50.5 11.0 51.9 78.9 27.0*

Follow-up home visits 12.9 17.7 4.9 13.5 21.7 8.2 13.2 19.9 6.7*

Postnatal home visits conducted 17.1 16.9 -0.2 12.5 9.2 -3.3 14.6 12.6 -1.9

School visits conducted 9.5 4.6 -4.8 30.1 5.0 -25.1 20.9 4.9 -16.0

Sample sizeb 73--82 51--56 124--138

Median number of home and school visits by facility staff (including CHO) in the previous two months:




Routine home visits conductedc 18 25 7 16 16 0 16 18 2

Follow-up home visitsc 10 6 -4 7 5 -2 8 6 -2

Postnatal home visits conductedc 8 7 -1 6 7 1 6 7 1

School visits conductedc 3 3 0 4 4 0 3 3 0

Sample sizeb 73--82 51--56 124--138

Community health volunteers (CHVs)

Facility has at least one CHV 87.4 82.2 -5.2 95.1 94.5 -0.6 91.6 89.0 -2.7


Services offered by Community Health Volunteers (CHVs) in the past 12 months:a

Home visits — assess, advise and educate on health 43.4 47.6 4.2 63.3 69.4 6.1 54.7 60.0 5.3

Disease surveillance, identify cases, or report 57.4 64.3 6.8 72.6 79.7 7.1 66.1 73.0 7.0

Mobilize and sensitize community for health

management action 42.8 38.1 -4.7 50.5 54.2 3.7 47.2 47.2 0.0

Provide first aid and treatment of minor ailments 44.8 35.8 -9.0 62.3 54.1 -8.2 54.8 46.2 -8.6

Disseminate health promotion materials or

information 38.6 46.5 7.9 61.0 50.0 -11.1 51.4 48.5 -2.9

Communicate between CHO and community on

health status of community 29.1 39.3 10.2 57.3 41.2 -16.2* 45.2 40.4 -4.8

Assist CHO with home visits, outreach or work at

the CHPS 35.9 52.5 16.7* 46.1 57.5 11.4 41.7 55.4 13.7**

Support the organization of community health

meetings (durbars) 28.1 44.4 16.3** 58.0 54.6 -3.4 45.1 50.2 5.1

Home visits — follow-up on defaulters 30.9 40.5 9.6 36.1 51.6 15.5 33.9 46.8 12.9*

Refer clients to CHO for disease treatment, family

planning or nutrition 23.0 42.6 19.5*** 43.3 58.7 15.4 34.6 51.8 17.2**

Support antenatal, postnatal or infant care 30.9 19.9 -11.0 40.7 55.5 14.8 36.5 40.2 3.7

Collaborate with CHO or support CHPS service

delivery 24.1 20.3 -3.8 33.0 27.6 -5.4 29.2 24.4 -4.7

Assist in compiling and updating community register

or profile 15.5 17.4 1.9 36.0 15.6 -20.4** 27.2 16.4 -10.8**

Provide condoms or family planning information 13.1 28.1 14.9** 14.9 25.6 10.7* 14.1 26.7 12.5***

Facilitate support group sessions n.a. 13.6 n.a. n.a. 6.8 n.a. n.a. 9.7 n.a.


Sample sizeb 70--74 50--53 120--127

Number of CHVs working with facility:




Number of CHVs (mean) 12.7 10.3 -2.4* 13.2 10.8 -2.4 13.0 10.6 -2.4**

Number of CHVs (median) c 6 5 -1a 10 8 -2a 7 5 -2a



Note: Percentages, means, and medians are weighted using weights that adjust for sampling probabilities.

*** Statistically significant at the 1 percent level; ** statistically significant at the 5 percent level; * statistically significant at the 10 percent level. a Because multiple responses were possible, percentages sum to more than 100. b Sample sizes are reported as ranges because variables have different response rates and because some variables apply to different subsets of respondents.

c Statistical significance for the change in medians was not calculated.

n.a. = not applicable (not measured at baseline, or not comparable).

C. Staff Training

TABLE 11A. STAFF TRAINING FOR MALARIA CAREGIVING AMONG CHPS




Facility had at least one staff member trained in the following key aspects of malaria care in the previous 12 months:

Malaria case management 79.5 78.6 -0.9 64.6 68.1 3.5 71.3 72.9 1.5

Malaria RDTs (including refresher training) 72.0 75.0 3.1 56.7 68.9 12.2*** 63.6 71.7 8.1***

Malaria in pregnancy 62.8 67.6 4.9 42.9 49.0 6.1 51.7 57.3 5.6**

Other trainings 82.5 100.0 17.5*** 69.6 100.0 30.4** 76.2 100.0 23.8***

Sample sizec 265--273 168--170 435--443

Facilities receiving at least 2 clinical supervisory visits in the previous 12 months on

Malaria case management n.a. 48.8 n.a. n.a. 53.9 n.a. n.a. 51.6 n.a.

Malaria RDTs (including refresher training) n.a. 40.8 n.a. n.a. 51.2 n.a. n.a. 46.5 n.a.

Malaria data collating and reporting n.a. 47.4 n.a. n.a. 54.4 n.a. n.a. 51.2 n.a.

Supply chain management n.a. 36.7 n.a. n.a. 39.8 n.a. n.a. 38.4 n.a.


Facility had at least one staff member trained in

each of the three key aspects of malaria care in the

previous 12 monthsa

53.1 59.9 6.8** 34.0 45.4 11.4*** 42.5 51.8 9.4***





any of the three key aspects of malaria care in the

previous 12 monthsa

85.1 86.0 0.9 69.0 74.0 5.0 76.3 79.4 3.1


any aspect of malaria care and received supportive

supervision in the previous 12 monthsb

58.5 42.8 -15.7*** 56.8 45.2 -11.6* 57.5 44.1 -13.4***

Facility with at least one staff member receiving

“training plus” in malaria treatmentd

n.a. 29.5 n.a. n.a. 32.4 n.a. n.a. 31.0 n.a.

Facility had at least one CHV trained in malaria-

related topics in the previous 12 monthsb

43.0 34.1 -8.9** 61.6 54.4 -7.2 53.6 45.6 -8.0***

Facility had at least one CHV trained in malaria-related topics and received coaching by

supervisors to address documented errors in the

previous 12 monthsb

25.9 25.1 -0.7 44.7 36.2 -8.5* 36.7 31.5 -5.2*

Sample size 238--274 147--170 386--444


Note: Percentages and means are weighted using weights that adjust for sampling probabilities. *** Statistically significant at the 1 percent level; ** statistically significant at

the 5 percent level; * statistically significant at the 10 percent level. a Key aspects of malaria care are malaria case management, malaria RDTs, and malaria in pregnancy. b Includes malaria-related topics in general, and not specific topics.

c Sample sizes are reported as ranges because variables have different response rates. d Training complemented by supportive supervision in all three key aspects of malaria care (malaria in pregnancy, malaria case management, and RDTs)


TABLE 11B. STAFF TRAINING FOR MALARIA CAREGIVING AMONG HCS




Facility had at least one staff member trained in the following aspects of malaria care in the previous 12 months:

Malaria case management 85.6 79.6 -6.1 76.9 90.5 13.6** 80.8 85.6 4.7

Malaria RDTs (including refresher training) 72.2 73.5 1.3 64.7 98.6 33.8*** 68.1 87.3 19.1***

Malaria in pregnancy 69.5 67.5 -2.0 62.6 85.9 23.3*** 65.7 77.6 11.9**

Malaria microscopy 29.0 29.1 0.1 31.2 33.0 1.9 30.1 31.2 1.1

Other trainings 21.1 25.7 4.5 29.8 24.3 -5.5 25.9 24.9 -1.0


Sample sizec 85--87 55--56 141--142

Facilities receiving at least 2 clinical supervisory visits in the last year on:

Malaria case management n.a. 59.8 n.a. n.a. 83.6 n.a. n.a. 72.6 n.a.

Malaria RDTs (including refresher training) n.a. 53.7 n.a. n.a. 81.8 n.a. n.a. 68.8 n.a.

Malaria data collating and reporting n.a. 60.7 n.a. n.a. 82.8 n.a. n.a. 72.6 n.a.

Supply chain management n.a. 53.8 n.a. n.a. 64.7 n.a. n.a. 59.6 n.a.



each of the three key aspects of malaria care in

the previous 12 monthsa

57.3 62.3 5.0 41.3 82.2 40.9*** 48.3 73.4 25.1***


“training plus” in malaria treatmentd

n.a. 40.6 n.a. n.a. 72.2 n.a. n.a. 57.9 n.a.


any of the three key aspects of malaria care in

the previous 12 monthsa

87.5 83.4 -4.2 84.8 98.6 13.8** 86.1 91.6 5.5*


any aspect of malaria care and received

supportive supervision in the previous 12

monthsb

66.5 34.6 -31.9*** 67.3 63.9 -3.5 66.9 50.6 -16.3***

Sample sizec 80--88 53--56 133--144


Note: Percentages and means are weighted using weights that adjust for sampling probabilities.

*** Statistically significant at the 1 percent level; ** statistically significant at the 5 percent level; * statistically significant at the 10 percent level. a Key aspects of malaria care are malaria case management, malaria RDTs, and malaria in pregnancy. b Includes malaria-related topics in general, and not specific topics.

c Sample sizes are reported as ranges because variables have different response rates. d Training complemented by supportive supervision in all three key aspects of malaria care (malaria in pregnancy, malaria case management, and RDTs)


TABLE 12A. STAFF TRAINING FOR NUTRITION AND OTHER KEY CAREGIVING SERVICES AMONG CHPS

(PERCENTAGE OF FACILITIES)



Facility had at least one staff member trained in the following in the previous 12 months:

Infant and young child feeding (IYCF) 41.4 48.9 7.4* 52.8 49.6 -3.2 47.7 49.3 1.6

Community management of acute malnutrition

(CMAM)

29.6 48.0 18.4*** 38.1 52.6 14.5** 34.3 50.5 16.2***


Management of acute malnutrition 31.0 47.3 16.3*** 28.8 50.3 21.5*** 29.8 48.9 19.2***

Essential newborn care (ENC) 24.2 29.4 5.3* 21.4 31.3 9.9 22.6 30.4 7.8*

Active management of third stage of labor (AMTSL) 12.9 17.1 4.3* 19.0 16.9 -2.1 16.2 17.0 0.8

Anemia prevention control n.a. 29.5 n.a. n.a. 28.7 n.a. n.a. 29.1 n.a.

Maternal, Neonatal and Child Health (MNCH) life

saving skills

n.a. 27.7 n.a. n.a. 33.4 n.a. n.a. 30.8 n.a.

Integrated Management of Neonatal Childhood

Illness (IMNCI)

n.a. 37.7 n.a. n.a. 30.3 n.a. n.a. 33.7 n.a.

Other trainings n.a. a 55.0 n.a.a n.a. a 52.1 n.a..a n.a. a 53.4 n.a..a

Sample sizeb 267--276 168--170 435--445

Facility had at least one trained staff member receive

supportive supervision in the previous 12 months:

Infant and young child feeding (IYCF) 27.9 34.3 6.4* 38.4 42.8 4.5 33.8 39.1 5.3


(CMAM) or other undernutrition management

practices

19.5 33.5 14.0*** 30.0 44.5 14.5** 25.3 39.6 14.3***

Management of acute malnutrition 18.8 32.4 13.6*** 22.5 42.4 19.9*** 20.8 37.9 17.1***

Essential newborn care (ENC) 13.0 17.3 4.3** 14.5 17.7 3.2 13.8 17.5 3.7

Active management of third stage of labor (AMTSL) 6.5 6.4 -0.2 11.4 8.8 -2.6 9.2 7.7 -1.5



saving skills

n.a. 11.2 n.a. n.a. 23.1 n.a. n.a. 17.7 n.a.


Illness (IMNCI)

n.a. 22.7 n.a. n.a. 23.2 n.a. n.a. 23.0 n.a.


“training plus” in nutritionc

n.a. 19.5 n.a. n.a. 89.8 n.a. n.a. 26 n.a.


“training plus” in maternal and neonatal cared

n.a. 4.2 n.a. n.a. 4.7 n.a. n.a. 4.5 n.a.

Sample sizeb 86--280 54--171 140--451



statistically significant at the 10 percent level. a The “Other trainings” category is not strictly comparable between baseline and midline. Therefore, the statistical significance of their difference was not assessed. b Sample sizes are reported as ranges because variables have different response rates. c Training complemented by supportive supervision in critical skill areas in nutrition (infant and young child feeding, management of acute malnutrition, and community

management of acute malnutrition). d Training complemented by supportive supervision in critical skill areas in maternal & neonatal care (active management of third stage of labor, essential newborn care, and

anemia prevention control).



TABLE 12B. STAFF TRAINING FOR NUTRITION AND OTHER KEY CAREGIVING SERVICES AMONG HCS

(PERCENTAGE OF HCS)




Infant and young child feeding (IYCF) 55.9 62.9 7.0 54.6 63.0 8.3 55.2 62.9 7.7


(CMAM)

40.3 52.2 11.9* 39.1 61.3 22.2** 39.7 57.2 17.6***

Management of acute malnutrition 37.5 56.8 19.3*** 38.9 59.6 20.8* 38.3 58.3 20.1***

Essential newborn care (ENC) 60.2 58.8 -1.4 38.8 66.0 27.1*** 48.8 62.6 13.8***

Active management of third stage of labor (AMTSL) 46.0 43.9 -2.1 45.4 66.1 20.7** 45.7 56.0 10.3*



saving skills

n.a. 57.1 n.a. n.a. 67.1 n.a. n.a. 62.4 n.a.


Illness (IMNCI)

n.a. 44.9 n.a. n.a. 41.5 n.a. n.a. 43.1 n.a.

Other trainings n.a. a 58.3 n.a.a n.a. a 72.1 n.a..a n.a. a 65.8 n.a..a

Sample sizeb 83--88 52--56 135--143

Facility had at least one trained staff member receive supportive supervision in the previous 12 months:

Infant and young child feeding (IYCF) 41.6 44.2 2.6 48.2 53.3 5.1 45.3 49.2 4.0


(CMAM) or other undernutrition management

practices

33.6 37.2 3.6 32.2 52.7 20.4** 32.8 45.7 12.9**

Management of acute malnutrition 32.3 42.6 10.4* 35.4 53.3 17.9 34.0 48.5 14.5**

Essential newborn care (ENC) 41.9 39.5 -2.3 29.8 52.3 22.6*** 35.4 46.4 11.1**

Active management of third stage of labor (AMTSL) 25.9 21.7 -4.3 33.2 45.8 12.5 29.9 34.9 5.0



saving skills

n.a. 30.8 n.a. n.a. 51.1 n.a. n.a. 41.9 n.a.


Illness (IMNCI)

n.a. 32.7 n.a. n.a. 34.0 n.a. n.a. 33.4 n.a.


“training plus” in nutritionc

n.a. 25.8 n.a. n.a. 81.0 n.a. n.a. 33.3 n.a.

Facility with at least one staff member receiving “training plus” in maternal and neonatal cared

n.a. 10.7 n.a. n.a. 20.7 n.a. n.a. 16.1 n.a.

Sample sizeb 33--89 25--56 58--145




*** Statistically significant at the 1 percent level; ** statistically significant at the 5 percent level; * statistically significant at the 10 percent level. a The “Other trainings” category is not strictly comparable between baseline and midline. Therefore, the statistical significance of their difference was not assessed. b Sample sizes are reported as ranges because variables have different response rates. c Training complemented by supportive supervision in critical skill areas in nutrition (infant and young child feeding, management of acute malnutrition, and community

management of acute malnutrition). d Training complemented by supportive supervision in critical skill areas in maternal & neonatal care (active management of third stage of labor, essential newborn care, and

anemia prevention control).


TABLE 13A. STAFF TRAINING FOR DATA TRACKING AND MANAGEMENT AMONG CHPS

(PERCENTAGE OF CHPS)



Training in malaria data tracking

Facility had at least one nurse or CHO

trained in malaria data collating and

reporting in the previous 12 months

70.5 64.0 -6.5 69.8 62.7 -7.0 70.1 63.3 -6.8*

Facility had at least one staff member trained

in malaria data capture and reporting in the

previous 12 months

78.6 66.6 -12.0*** 74.3 66.4 -7.9 76.3 66.5 -9.8***

Facility has a person in charge of records

with training on malaria data reporting and

tools in the previous 12 months

--a --a --a -- a -- a -- a -- a -- a -- a

Sample sized 241--269 143--152 384--421

Training in other tracking and management topics


Supply chain and logistics management 33.6 35.1 1.5 27.9 36.7 8.9 30.4 36.0 5.6

Supervision skills 21.0 32.5 11.5*** 17.5 36.3 18.7*** 19.1 34.6 15.5***

Other training n.a. 55.0 n.a. n.a. 52.1 n.a. n.a. 53.4 n.a.

Sample sized 266--276 169--170 436--445


Supply chain and logistics management 23.7 22.5 -1.2 22.1 30.9 8.8** 22.8 27.2 4.4

Supervision skills 11.7 15.8 4.0* 13.2 27.9 14.8*** 12.5 22.5 10.0***

Sample sized 259--265 170 429--435


Facility maintains a list of when refresher trainings, new skills trainings, or professional

development trainings are due and

conducted

n.a. 4.6 n.a. n.a. 6.7 n.a. n.a. 5.7 n.a.

Facility with at least one staff member

receiving “training plus” in supply chain

managementb

n.a. 53.9 n.a. n.a. 48.0 n.a. n.a. 50.8 n.a.


receiving “training plus”c

n.a. 4.0 n.a. n.a. 0.4 n.a. n.a. 2.0 n.a.

Sample sized 258--279 149--171 407--450



statistically significant at the 10 percent level. a Not reported because of small sample sizes (fewer than 10). b Training complemented by supportive supervision in critical skill areas in supply chain management (including supervision skills). c Training complemented by supportive supervision in critical skill areas in malaria treatment (malaria in pregnancy, malaria case management, and RDTs), nutrition (infant and

young child feeding, management of acute malnutrition, and community management of acute malnutrition) supply chain management (including supervision skills), and maternal

& neonatal care (active management of third stage of labor, essential newborn care, and anemia prevention control). d Sample sizes are reported as ranges because variables have different response rates.


TABLE 13B. STAFF TRAINING FOR DATA TRACKING AND MANAGEMENT AMONG HCS (PERCENTAGE OF HCS)



Training in malaria data tracking

Facility had at least one staff member trained in malaria data collating and reporting in the previous 12 months:

Nurses or CHOs 81.0 67.5 -13.6*** 73.9 84.9 11.0 77.1 77.0 -0.1

Outpatient department in-charges 55.3 65.0 9.6 39.5 76.3 36.9*** 46.6 71.3 24.7***

Records staff members 34.1 37.9 3.8 33.8 39.7 5.9 33.9 38.9 4.9

Lab staff members 28.8 33.2 4.4 30.9 46.0 15.1 30.0 40.4 10.4*

Other staff members 16.0 28.5 12.5** 37.2 37.2 0.0 28.3 33.6 5.3

Sample sizec 55--82 38--54 93--136

Facility had at least one staff member trained

in malaria data capture and reporting in the

previous 12 months

87.2 74.9 -12.3** 89.0 88.8 -0.2 88.2 82.6 -5.6

Facility has a person in charge of records

with training on malaria data reporting and

tools in the previous 12 months

53.6 45.6 -8.0 47.8 54.0 6.2 50.5 50.2 -0.3




Sample sizec 78--84 53--54 131--138

Training in other tracking and management topics


Supply chain and logistics management 46.4 53.5 7.2 42.7 41.5 -1.2 44.3 46.8 2.4

Supervision skills 29.0 32.4 3.5 31.3 49.5 18.2** 30.2 41.7 11.4**

Other training n.a. 58.3 n.a. n.a. 72.1 n.a. n.a. 65.8 n.a.

Sample sizec 80--86 54--56 136--141


Supply chain and logistics management 29.7 38.9 9.2 34.4 37.6 3.3 32.3 38.2 5.9

Supervision skills 20.8 19.0 -1.9 27.5 40.2 12.7 24.5 30.7 6.2

Sample sizec 55--89 38--56 93--145

Facility maintains a list of when refresher

trainings, new skills trainings, or professional

development trainings are due and

conducted

n.a. 15.2 n.a. n.a. 21.4 n.a. n.a. 18.5 n.a.


receiving “training plus” in supply chain

managementa

n.a. 71.5 n.a. n.a. 83.7 n.a. n.a. 78.1 n.a.


receiving “training plus”b

n.a. 7.7 n.a. n.a. 15.9 n.a. n.a. 12.1 n.a.




*** Statistically significant at the 1 percent level; ** statistically significant at the 5 percent level; * statistically significant at the 10 percent level. a Training complemented by supportive supervision in critical skill areas in supply chain management (including supervision skills). b Training complemented by supportive supervision in critical skill areas in malaria treatment (malaria in pregnancy, malaria case management, and RDTs), nutrition (infant and

young child feeding, management of acute malnutrition, and community management of acute malnutrition) supply chain management (including supervision skills), and maternal

& neonatal care (active management of third stage of labor, essential newborn care, and anemia prevention control). c Sample sizes are reported as ranges because variables have different response rates.



D. Treatment Protocols and Sanitation and Infection Prevention

TABLE 14A. AVAILABILITY OF TREATMENT PROTOCOLS AMONG CHPS (PERCENTAGE OF CHPS)



Availability of written protocols for managing maternal and newborn care:

Protocols exist and seen 18.9 24.2 5.3 27.0 33.4 6.5* 23.3 29.2 6.0**

Protocols exist, but not seen 8.4 7.1 -1.3 4.5 4.8 0.3 6.3 5.8 -0.4

No protocols 72.8 68.7 -4.1 68.5 61.8 -6.7 70.4 64.9 -5.5*


Availability of written protocols for managing acute undernutrition:

Protocols exist and seen 28.1 37.9 9.9*** 33.4 34.4 1.1 30.9 36.0 5.1

Protocols exist, but not seen 9.7 7.5 -2.2 8.0 5.9 -2.1 8.8 6.7 -2.2

No protocols 62.2 54.5 -7.7*** 58.6 59.7 1.1 60.2 57.3 -2.9





TABLE 14B. AVAILABILITY OF TREATMENT PROTOCOLS AMONG HCS (PERCENTAGE OF HCS)



Availability of written protocols for managing maternal and newborn care:

Protocols exist and seen 62.0 74.1 12.1* 70.3 80.3 9.9* 66.5 77.5 10.9**

Protocols exist, but not seen 18.6 5.7 -12.9*** 12.3 8.4 -3.9 15.2 7.2 -8.0***

No protocols 19.4 20.2 0.8 17.4 11.3 -6.0 18.3 15.4 -2.9


Availability of written protocols for managing acute undernutrition:

Protocols exist and seen 43.4 48.6 5.2 32.7 51.9 19.2** 37.6 50.4 12.7**

Protocols exist, but not seen 24.7 5.3 -19.4*** 12.0 2.6 -9.4* 17.8 3.8 -14.0***

No protocols 31.9 46.2 14.2** 55.3 45.5 -9.8 44.5 45.8 1.3



Source: Health, Population, and Nutrition Office Health Systems baseline and midline survey data Note: Percentages are weighted to adjust for sampling probabilities.


TABLE 15A. SANITATION AND INFECTION PREVENTION AMONG CHPS (PERCENTAGE OF CHPS)



Facility has access to water supply through

piped water or bore holes n.a. 32.2 n.a. n.a. 28.1 n.a. n.a. 30.0 n.a.

Facility has a functional latrine or toilet n.a. 50.8 n.a. n.a. 41.6 n.a. n.a. 45.8 n.a.

Sample sizeb 279--280 171 450--451

Key sanitation measures in place for prevention and control of infections:a

Hand-washing station/Veronica bucket 73.4 73.7 0.3 69.3 59.1 -10.2*** 71.2 65.8 -5.4**

Staff consistently wear gloves 68.0 78.5 10.5*** 57.8 72.8 15.0*** 62.5 75.4 12.9***


Key sterilization measures in place for prevention and control of infections:a

Availability of disinfectants 45.3 70.8 25.5*** 33.6 58.0 24.3*** 39.0 63.8 24.9***

Protocol for mixing chlorine for

disinfection 33.9 46.0 12.1*** 30.0 21.9 -8.0** 31.8 32.9 1.2

Staff disinfects instruments 27.4 73.6 46.2*** 22.0 58.3 36.3*** 24.4 65.2 40.8***

Staff sterilizes equipment 10.5 52.8 42.3*** 8.7 34.6 26.0*** 9.5 42.9 33.4***

Availability of functioning sterilizing

equipment such as boilers or autoclaves 10.8 10.9 0.1 4.7 7.8 3.1 7.5 9.2 1.8

Sample sizeb 278--279 170 448--449

Key disposal measures in place for prevention and control of infections:a

Staff uses a sharps container 75.7 96.4 20.7*** 68.1 79.8 11.8*** 71.5 87.4 15.8***

Separation of waste disposal 44.6 75.3 30.7*** 41.9 63.4 21.5*** 43.1 68.8 25.7***

Availability of polythene bags for waste n.a. 50.1 n.a. n.a. 38.8 n.a. n.a. 43.9 n.a.

Availability of a functioning incinerator 2.5 3.5 1.0 3.3 3.4 0.2 2.9 3.5 0.6

Sample sizeb 279--280 171 450--451

Key measures in place for dealing with contagious clients for prevention and control of infections:a

Separating clients with contagious

diseases from healthy clients 35.2 30.9 -4.3 37.5 37.3 -0.1 36.5 34.4 -2.0

Separating sick newborns from healthy

newborns 6.7 19.6 12.9*** 8.0 23.2 15.3*** 7.4 21.6 14.2***




Sample sizeb 264--269 167--168 432--436


Note: Percentages are weighted to adjust for sampling probabilities. Sample size varies across rows because of item nonresponse a Because multiple responses were possible (except for none), percentages sum to more than 100. b Sample sizes are reported as ranges because variables have different response rates.

TABLE 15B. SANITATION AND INFECTION PREVENTION AMONG HCS (PERCENTAGE OF HCS)



Key sanitation measures in place for prevention and control of infections:a

Hand-washing station/Veronica

bucket

97.5 96.4 -1.1 100.0 98.6 -1.4 98.8 97.6 -1.3

Staff consistently wear gloves 87.2 87.8 0.6 98.8 97.2 -1.6 93.4 92.8 -0.6


Key sterilization measures in place for prevention and control of infections:a

Disinfectants 53.7 91.9 38.2*** 66.7 100.0 33.3*** 60.7 96.2 35.6***

Protocol for mixing chlorine for

disinfection

55.3 73.5 18.2*** 66.7 87.5 20.8** 61.4 81.0 19.6***

Staff disinfects instruments 49.2 98.3 49.2*** 54.3 100.0 45.7*** 51.9 99.2 47.3***

Staff sterilizes equipment 34.9 88.9 54.0*** 56.1 97.5 41.4*** 46.3 93.5 47.2***

Functioning sterilizing equipment

such as boilers or autoclaves

40.8 59.2 18.4*** 55.3 79.9 24.6*** 48.6 70.3 21.7***


Key disposal measures in place for prevention and control of infections:a

Staff uses a sharps container 80.7 98.0 17.3*** 86.3 100.0 13.7*** 83.7 99.1 15.4***

Separation of waste disposal 55.9 87.2 31.4*** 65.2 98.1 33.0*** 60.8 93.1 32.2***

Availability of polythene bags for

waste

n.a. 59.5 n.a. n.a. 67.8 n.a. n.a. 63.9 n.a.

Availability of a functioning

incinerator

11.4 18.3 6.9* 19.8 23.0 3.2 15.9 20.8 4.9


Key measures in place for dealing with contagious clients for prevention and control of infections:a


Separating clients with contagious

diseases from healthy clients

57.2 60.3 3.1 70.6 63.1 -7.5 64.4 61.8 -2.6

Separating sick newborns from

healthy newborns

19.2 50.8 31.6*** 26.5 47.6 21.1*** 23.1 49.1 25.9***

Sample sizeb 87--88 56 143--144


Note: Percentages are weighted to adjust for sampling probabilities. Sample size varies across rows because of item nonresponse a Because multiple responses were possible (except for none), percentages sum to more than 100. b Sample sizes are reported as ranges because variables have different response rates.

E. Access to Supplies and Equipment

TABLE 16A. AVAILABILITY AND USE OF TOOLS AND MECHANISMS FOR SUPPLY CHAIN MANAGEMENT AMONG

CHPS (PERCENTAGE OF CHPS)



Facility has dedicated person responsible for

ordering supplies

68.3 81.1 12.7*** 60.4 71.6 11.2* 64.0 75.9 11.9***


Standard operating procedures (SOP) manual:

Exists and seen 28.2 34.7 6.5** 7.3 20.5 13.3*** 16.6 26.8 10.2***

Exists, but not seen 7.7 7.5 -0.2 5.2 4.6 -0.6 6.3 5.9 -0.4

No SOP manual 64.1 57.7 -6.3* 87.6 74.9 -12.7** 77.1 67.3 -9.8***

Facility has utilized RRIRV (Report Requisition

Issue and Receipt Voucher) to reorder

commodities based on consumption

n.a. 54.8 n.a. n.a. 47.7 n.a. n.a. 50.9 n.a.

Sample sizeb 261--275 167--171 428--446

Frequency with which facility cannot supply clients’ needs due to a stock-out:

Once or more per week 10.8 7.1 -3.7** 5.9 9.7 3.9 8.2 8.4 0.2

Once every two weeks 3.7 4.6 0.9 3.0 4.8 1.8 3.4 4.7 1.4

Once every three weeks 4.1 4.8 0.7 1.3 2.5 1.2 2.7 3.6 0.9

Once per month 31.3 47.4 16.1*** 34.5 53.4 18.9*** 32.9 50.5 17.5***

Less often than once per month 50.1 27.1 -23.0*** 55.3 23.0 -32.3*** 52.8 25.0 -27.8***


Key sources of information for forecasting supply needs for malaria RDTs in the previous 12 months, among facilities that treat malaria:a

Number of malaria cases given a final

diagnosis of malaria

34.7 38.9 4.3 26.9 25.3 -1.6 30.8 32.2 1.4


Number of malaria cases given a

provisional diagnosis of malaria

64.3 52.5 -11.8*** 63.8 65.0 1.2 64.0 58.7 -5.4

Outpatient department attendance 33.8 34.1 0.3 48.2 54.9 6.6 41.0 44.4 3.4

Number of RDTs and microscopy tests

performed

23.4 29.3 5.9* 11.3 21.2 9.9*** 17.4 25.3 7.9***

Some other data or method 15.2 12.5 -2.7 7.5 9.3 1.8 11.4 10.9 -0.4






TABLE 16B. AVAILABILITY AND USE OF TOOLS AND MECHANISMS FOR SUPPLY CHAIN MANAGEMENT AMONG

HCS (PERCENTAGE OF HCS)



Facility has dedicated person

responsible for ordering supplies 81.4 89.8 8.4* 80.3 96.2 16.0** 80.8 93.3 12.5***


Standard operating procedures (SOP) manual: Exists and seen 45.5 54.1 8.6 26.0 46.5 20.5* 34.7 49.9 15.2**

Exists, but not seen 23.0 10.0 -12.9*** 24.6 4.7 -19.9*** 23.9 7.1 -16.8***

No SOP manual 31.6 35.8 4.3 49.4 48.8 -0.6 41.4 43.0 1.6

Facility has utilized RRIRV (Report

Requisition Issue and Receipt Voucher)

to reorder commodities based on

consumption

n.a. 73.2 n.a. n.a. 90.7 n.a. n.a. 82.7 n.a.

Sample sizeb 79--84 53--55 132--139

Frequency with which facility cannot supply clients’ needs due to a stock-out: Once or more per week 6.2 7.9 1.7 4.3 2.9 -1.3 5.2 5.2 0.1

Once every two weeks 4.3 1.7 -2.6 3.8 2.5 -1.2 4.0 2.2 -1.8

Once every three weeks 8.6 8.3 -0.3 1.9 1.4 -0.4 5.0 4.6 -0.4

Once per month 28.7 55.3 26.7*** 34.9 53.7 18.8** 32.0 54.4 22.4***

Less often than once per month 52.2 22.2 -30.0*** 55.2 32.9 -22.3*** 53.8 28.0 -25.9***


Key sources of information for forecasting supply needs for malaria RDTs in the previous 12 months, among facilities that treat malaria:a


Number of malaria cases given a final

diagnosis of malaria 35.1 41.4 6.2 41.2 60.7 19.5* 38.3 51.6 13.2**

Number of malaria cases given a

provisional diagnosis of malaria 63.8 51.6 -12.1* 56.0 71.2 15.2 59.7 62.0 2.3

Outpatient department attendance 45.5 41.0 -4.6 36.3 45.4 9.1 40.7 43.3 2.6

Number of RDTs and microscopy

tests performed 29.5 28.1 -1.5 20.9 33.1 12.2 25.0 30.7 5.7

Some other data or method 8.9 12.6 3.7 8.7 7.8 -0.8 8.8 10.1 1.3






TABLE 17A. MANAGEMENT OF ESSENTIAL SUPPLIES AMONG CHPS (PERCENTAGE OF CHPS)



Availability of control cards for specific commodities

Facility has control card for the following commodities related to nutrition, diarrhea, and infectious diseases:

Albendazole for deworming 45.7 69.6 23.9*** 37.1 51.2 14.1*** 41.0 59.6 18.6***

First-line antibiotic treatment for

severe acute malnutrition

n.a. 54.9 n.a. n.a. 15.9 n.a. n.a. 33.6 n.a.

Iron and folic acid tablets 43.8 59.7 15.9*** 29.5 35.1 5.7 36.0 46.4 10.4***

Oral rehydration salts and zinc

tablets

58.6 73.8 15.2*** 40.6 49.1 8.5*** 48.8 60.4 11.6***

Vitamin A 20.1 59.4 39.3*** 24.4 48.0 23.5*** 22.5 53.2 30.7***

Sample sizea 276--278 167--171 443--449

Facility has control card for the following immunization commodities:

Polio 32.4 50.2 17.7*** 31.5 43.2 11.8** 31.9 46.4 14.5***

Yellow fever 32.8 48.7 15.9*** 31.5 40.7 9.3* 32.1 44.4 12.3***

Measles 32.5 50.0 17.5*** 32.0 42.8 10.8** 32.2 46.1 13.9***

Rotarix 33.0 51.1 18.1*** 30.9 42.7 11.8** 31.9 46.5 14.7***

Tetanus toxoid 30.8 46.4 15.6*** 29.1 38.7 9.6** 29.9 42.2 12.3***

Pentavalent 32.6 53.0 20.4*** 33.2 39.6 6.3 32.9 45.8 12.8***

Pneumo 32.9 53.4 20.5*** 29.4 42.5 13.0** 31.0 47.5 16.5***

Bacillus Calmette-Guerin 32.8 53.5 20.7*** 26.8 41.9 15.1** 29.6 47.2 17.6***





Sample sizea 274--276 164--166 438--442

Facility has control card for the following malaria commodities:

Pediatric syrup paracetamol 65.8 76.9 11.1*** 47.6 52.4 4.8 56.0 63.6 7.7***

Adult paracetamol 66.8 77.4 10.6*** 48.8 55.0 6.2*** 57.1 65.3 8.2***

Artesunate and amodiaquine 61.2 66.5 5.3** 47.4 50.0 2.6 53.7 57.6 3.9*

Artemether and lumenfantrine 61.5 73.9 12.4*** 39.6 54.1 14.5*** 49.6 63.2 13.6***

Malaria RDTs 48.3 72.1 23.9*** 40.1 49.2 9.1*** 43.9 59.7 15.8***

Sulfadoxine pyrimethamine (SP) n.a. 57.0 n.a. n.a. 33.5 n.a. n.a. 44.2 n.a.

Sample sizea 276--279 166--170 443--449

Facility has control card for the following family planning commodities, among facilities providing contraception:

An injectable contraceptive 68.6 76.8 8.2*** 57.1 67.7 10.7 62.5 72.0 9.5*

Condoms 53.6 60.3 6.7 50.7 38.5 -12.2* 52.1 48.8 -3.3

A hormonal implant such as

Implanon, Jadelle, Sino Implant II, or

Norplant

34.9 50.4 15.5*** 20.0 40.6 20.6*** 27.1 45.2 18.2***

Combined oral contraceptive pills 56.7 54.1 -2.6 36.1 27.7 -8.3 45.8 40.1 -5.6*

Progestogen-only pill 17.1 25.7 8.6*** 4.8 11.2 6.4** 10.5 18.0 7.5***

An intrauterine device 2.4 3.1 0.7 5.5 0.5 -5.1** 4.1 1.7 -2.4*

Uterotonic drugs n.a. 17.5 n.a. n.a. 15.3 n.a. n.a. 16.3 n.a.

Sample sizea 210--280 119--171 329--451

Availability of updated control cards for specific commodities

Facility has control card for the following nutrition commodities that was updated in the previous 30 days:

Albendazole for deworming 16.3 46.9 30.6*** 12.8 32.1 19.3*** 14.4 39.0 24.5***

Iron and folic acid tablets 15.4 44.6 29.2*** 10.2 21.1 10.9*** 12.6 32.2 19.5***


tablets

19.2 52.0 32.8*** 13.8 30.8 17.0*** 16.3 40.8 24.4***

Vitamin A 10.4 49.7 39.3*** 13.2 39.5 26.3*** 11.9 44.2 32.2***



n.a. 39.0 n.a. n.a. 9.9 n.a. n.a. 23.1 n.a.

Sample sizea 272--277 156--171 429--448

Facility has control card for the following immunization commodities that was updated in the previous 30 days:

Polio 24.9 46.2 21.3*** 21.9 30.6 8.7 23.3 37.8 14.5***

Yellow fever 24.6 37.7 13.1*** 21.5 26.5 5.0 22.9 31.7 8.8**





Measles 22.9 42.5 19.6*** 22.3 28.9 6.6 22.6 35.2 12.6***

Rotarix 25.3 44.8 19.5*** 21.4 31.2 9.7* 23.2 37.5 14.3***

Tetanus toxoid 22.3 38.8 16.5*** 21.7 26.4 4.7 22.0 32.1 10.1***

Pentavalent 23.4 45.1 21.6*** 22.7 26.8 4.1 23.1 35.4 12.3***

Pneumo 24.8 49.5 24.7*** 21.9 32.5 10.6* 23.2 40.4 17.2***

Bacillus Calmette-Guerin 23.2 45.2 22.0*** 15.0 25.6 10.7* 18.8 34.8 16.0***

Sample sizea 271--275 157--162 428--435

Facility has control card for the following malaria commodities that was updated in the previous 30 days:

Pediatric syrup paracetamol n.a. 56.4 n.a. n.a. 32.8 n.a. n.a. 43.5 n.a.

Adult paracetamol n.a. 57.7 n.a. n.a. 35.8 n.a. n.a. 45.8 n.a.

Artesunate and amodiaquine n.a. 46.8 n.a. n.a. 32.5 n.a. n.a. 39.0 n.a.

Artemether and lumenfantrine n.a. 55.9 n.a. n.a. 33.8 n.a. n.a. 43.9 n.a.

Malaria RDTs n.a. 62.5 n.a. n.a. 37.6 n.a. n.a. 48.9 n.a.


Sample sizea 278--279 170--171 448--450


An injectable contraceptive n.a. 67.1 n.a. n.a. 50.4 n.a. n.a. 58.4 n.a.

Condoms n.a. 45.1 n.a. n.a. 22.7 n.a. n.a. 33.4 n.a.



Norplant

n.a. 42.3 n.a. n.a. 27.7 n.a. n.a. 34.6 n.a.

Combined oral contraceptive pills n.a. 37.2 n.a. n.a. 17.0 n.a. n.a. 26.6 n.a.

Progestogen-only pill n.a. 16.8 n.a. n.a. 5.6 n.a. n.a. 10.9 n.a.

An intrauterine device n.a. 3.1 n.a. n.a. 0.4 n.a. n.a. 1.7 n.a.


Sample sizea 258--280 147--171 405--451






TABLE 17B. MANAGEMENT OF ESSENTIAL SUPPLIES AMONG HCS (PERCENTAGE OF HCS)




Facility has control card for the following commodities related to nutrition, diarrhea, and infectious diseases:

Albendazole for deworming 78.6 83.4 4.8 86.7 92.3 5.6 83.1 88.3 5.2



n.a. 82.7 n.a. n.a. 54.5 n.a. n.a. 67.4 n.a.

Iron and folic acid tablets 70.1 81.8 11.7** 82.0 86.5 4.5 76.5 84.4 7.8*


tablets

88.3 90.0 1.7 82.5 96.7 14.2** 85.2 93.6 8.4**

Vitamin A 44.3 73.5 29.1*** 38.0 81.3 43.2*** 41.0 77.6 36.6***

Sample sizea 83--87 54--56 139--143

Facility has control card for the following immunization commodities: Polio 58.8 86.1 27.3*** 64.3 91.4 27.1*** 61.8 89.0 27.2***

Yellow fever 59.4 83.9 24.5*** 62.5 89.6 27.1*** 61.1 87.1 25.9***

Measles 58.8 85.0 26.2*** 64.1 91.4 27.3*** 61.7 88.5 26.8***

Rotarix 59.6 85.0 25.4*** 60.6 90.0 29.4*** 60.2 87.7 27.6***

Tetanus toxoid 56.5 80.9 24.4*** 61.3 83.3 22.0*** 59.1 82.2 23.1***

Pentavalent 57.2 86.2 29.1*** 62.1 89.6 27.4*** 59.9 88.1 28.2***

Pneumo 58.5 84.3 25.7*** 61.4 91.3 29.9*** 60.1 88.1 28.0***

Bacillus Calmette-Guerin 58.3 84.3 26.0*** 58.2 91.4 33.2*** 58.2 88.2 29.9***

Sample sizea 84--86 55--56 140--142

Facility has control card for the following malaria commodities: Pediatric syrup paracetamol 89.7 95.2 5.4 90.6 94.3 3.7 90.2 94.7 4.5

Adult paracetamol 90.6 91.7 1.1 86.9 100.0 13.1** 88.6 96.2 7.7**

Artesunate and amodiaquine 87.2 81.8 -5.4 86.7 94.8 8.1 86.9 88.8 1.9

Artemether and lumenfantrine 86.2 93.0 6.8* 86.6 98.6 12.0** 86.4 96.0 9.6***

Malaria RDTs 75.1 84.3 9.2 75.8 93.3 17.5*** 75.5 89.1 13.7***


Sample sizea 85--88 54--56 139--144

Facility has control card for the following family planning commodities, among facilities providing contraception:

An injectable contraceptive 79.9 93.2 13.3** 61.2 90.1 29.0*** 69.8 91.5 21.7***





Condoms 75.8 85.1 9.3 56.0 62.1 6.1 65.2 72.8 7.6



Norplant

67.3 84.9 17.6** 58.5 76.3 17.9** 62.6 80.3 17.7***

Combined oral contraceptive pills 71.0 75.3 4.4 48.2 70.2 21.9** 58.8 72.6 13.8**

Progestogen-only pill 40.5 45.1 4.6 18.7 27.0 8.3 28.6 35.2 6.6

An intrauterine device 36.4 31.1 -5.3 16.1 11.0 -5.1 25.4 20.3 -5.2*


Sample sizea 65--87 44--55 110--142

Facility has control card for the following BEmONC commodities, among Health Centers:

Parenteral antibiotics n.a. 46.2 n.a. n.a. 54.9 n.a. n.a. 51.0 n.a.

Magnesium sulfate for preclampsia

and eclampsia

n.a. 46.8 n.a. n.a. 55.2 n.a. n.a. 51.3 n.a.

Sample sizea 79--81 51--52 131--132

Availability of updated control cards for specific commoditiesa

Facility has control card for the following nutrition commodities that was updated in the previous 30 days: Albendazole for deworming 41.5 67.6 26.2*** 34.7 65.2 30.6*** 37.8 66.4 28.5***

Iron and folic acid tablets 38.6 69.7 31.1*** 52.2 61.8 9.6 45.9 65.5 19.6***


tablets

45.5 65.6 20.1*** 48.4 79.0 30.6*** 47.0 72.7 25.7***

Vitamin A 25.5 61.8 36.3*** 16.5 64.8 48.4*** 20.8 63.4 42.6***



n.a. 58.0 n.a. n.a. 45.5 n.a. n.a. 51.2 n.a.

Sample sizea 79--87 50--56 129--143

Facility has control card for the following immunization commodities that was updated in the previous 30 days:

Polio 48.1 81.6 33.5*** 44.8 80.6 35.8*** 46.3 81.0 34.7***

Yellow fever 46.7 68.6 21.9*** 40.3 63.6 23.3** 43.3 65.9 22.6***

Measles 48.6 78.6 30.0*** 45.2 70.4 25.2*** 46.8 74.2 27.4***

Rotarix 49.5 78.6 29.2*** 43.4 68.8 25.4*** 46.2 73.4 27.2***

Tetanus toxoid 45.0 72.8 27.9*** 37.5 65.3 27.7** 41.1 68.9 27.8***

Pentavalent 46.0 76.7 30.7*** 43.3 65.7 22.4*** 44.6 70.8 26.2***

Pneumo 46.6 80.4 33.8*** 44.1 77.1 33.0*** 45.3 78.6 33.4***





Bacillus Calmette-Guerin 46.3 77.0 30.7*** 38.8 64.4 25.6*** 42.3 70.3 28.0***

Sample sizea 81--83 49--52 131--135

Facility has control card for the following malaria commodities that was updated in the previous 30 days:

Pediatric syrup paracetamol n.a. 76.4 n.a. n.a. 82.0 n.a. n.a. 79.4 n.a.

Adult paracetamol n.a. 71.9 n.a. n.a. 84.9 n.a. n.a. 78.9 n.a.

Artesunate and amodiaquine n.a. 57.7 n.a. n.a. 80.5 n.a. n.a. 70.1 n.a.

Artemether and lumenfantrine n.a. 76.7 n.a. n.a. 82.0 n.a. n.a. 79.5 n.a.

Malaria RDTs n.a. 71.2 n.a. n.a. 86.2 n.a. n.a. 79.3 n.a.


Sample sizea 87--89 55--56 142--145


An injectable contraceptive n.a. 73.4 n.a. n.a. 71.3 n.a. n.a. 72.3 n.a.

Condoms n.a. 55.9 n.a. n.a. 47.6 n.a. n.a. 51.5 n.a.



Norplant

n.a. 65.2 n.a. n.a. 57.9 n.a. n.a. 61.3 n.a.

Combined oral contraceptive pills n.a. 50.7 n.a. n.a. 53.1 n.a. n.a. 52.0 n.a.

Progestogen-only pill n.a. 32.4 n.a. n.a. 23.5 n.a. n.a. 27.6 n.a.

An intrauterine device n.a. 23.0 n.a. n.a. 5.4 n.a. n.a. 13.7 n.a.


Sample sizea 86--88 54--55 141--143

Facility has control card for the following BEmONC commodities that was updated in the previous 30 days, among Health Centers:



and eclampsia

n.a. 37.6 n.a. n.a. 34.2 n.a. n.a. 35.8 n.a.

Sample sizea 78--80 51--52 130--131






TABLE 18A. STOCK-OUTS FOR SPECIFIC COMMODITIES IN PREVIOUS TWO MONTHS, AMONG CHPS WITH

RELEVANT CONTROL CARDS (PERCENTAGE OF CHPS)



Facility experienced stock-out of the following nutrition commodities, among facilities with relevant control cards:

Albendazole for deworming 33.1 47.2 14.1** 9.6 17.6 7.9 22.8 34.1 11.4**

Iron and folic acid tablets 28.7 27.1 -1.6 20.2 15.7 -4.5 25.3 22.6 -2.7

Oral rehydration salts (ORS) and zinc

tablets

33.1 35.0 1.9 24.8 12.8 -12.0* 29.6 25.6 -4.0

Vitamin A 17.6 9.7 -7.9 24.2 4.0 -20.2 20.9 6.8 -14.1**



n.a. 30.3 n.a. n.a. 23.9 n.a. n.a. 28.6 n.a.

Facility experienced stock out of any of 4

nutrition commodities measured at

baseline and endline (Albendazole, Iron

and Folic Acid tablets, ORS and zinc

tablets, Vitamin A)

69.4 68.0 -1.4 51.2 39.3 -11.9 62.1 56.5 -5.6

Sample sizeb 40--152 22--58 62--210

Facility experienced stock-out of the following immunization commodities, among facilities with relevant control cards:

Polio 11.6 7.3 -4.3 19.4 2.5 -16.9** 16.0 4.6 -11.4**

Yellow fever 9.6 13.8 4.3 29.7 25.6 -4.2 20.2 20.0 -0.2

Measles 10.6 1.7 -8.9*** 27.6 11.6 -16.0 20.1 7.3 -12.9**

Rotarix 2.5 1.6 -0.8 15.7 7.6 -8.1 9.7 4.9 -4.8

Tetanus toxoid 6.2 5.3 -0.9 22.9 9.5 -13.3 14.7 7.4 -7.2

Pentavalent 18.5 6.4 -12.1** 27.0 0.0 -27.0*** 23.0 3.0 -20.0***

Pneumo 4.1 4.6 0.4 19.2 0.0 -19.2 12.1 2.1 -10.0**

Bacillus Calmette-Guerin 25.4 6.2 -19.2** 48.2 5.7 -42.5*** 36.9 6.0 -31.0***


immunization commodities

44.1 39.2 -4.9 55.5 37.0 -18.6* 50.5 38.0 -12.5**

Sample sizeb 58--66 30--37 88--99

Facility experienced stock-out of the following malaria commodities, among facilities with relevant control cards:

Pediatric syrup paracetamol 31.3 35.5 4.2 27.1 22.3 -4.9 29.5 29.8 0.3

Adult paracetamol 30.0 27.0 -3.0 14.1 13.1 -1.0 22.9 20.8 -2.1

Artesunate and amodiaquine 25.4 31.0 5.6 13.0 27.7 14.7* 19.7 29.5 9.7*




Artemether and lumenfantrine 24.4 24.1 -0.3 24.2 16.0 -8.3 24.3 20.6 -3.7

Malaria RDTs 24.3 15.8 -8.5* 23.4 13.5 -9.9 23.9 14.7 -9.2**



malaria commodities measured at

baseline and endline (Pediatric syrup

paracetamol, Adult paracetamol,

Artesunate and amodiaquine, Artemether

and lumenfantrine, Malaria RDTs)

66.2 61.8 -4.4 59.6 52.5 -7.1 63.3 57.6 -5.6

Sample sizeb 123--179 57--74 180--253

Facility experienced stock-out of the following family planning commodities, among facilities with relevant control cards:

An injectable contraceptive 18.8 6.5 -12.3*** 8.4 8.3 -0.1 13.9 7.3 -6.5**

Condoms 12.8 18.0 5.2 18.3 4.6 -13.6 15.3 11.7 -3.6



Norplant

18.3 9.8 -8.5 7.0 43.8 36.8 14.8 20.5 5.7

Combined oral contraceptive pills 15.3 34.0 18.7*** 11.2 21.5 10.4 14.1 30.4 16.3**

Progestogen-only pill 8.9 41.1 32.2*** --a --a -- a 8.1 37.5 29.4***

An intrauterine device -- a -- a -- a -- a -- a -- a -- a -- a -- a



family planning commodities measured at baseline and endline

73.6 79.0 5.3 -- -- -- 74.8 83.2 8.4

Sample sizeb 18--121 12--53 19--174



*** Statistically significant at the 1 percent level; ** statistically significant at the 5 percent level; * statistically significant at the 10 percent level. a Not reported because of small sample sizes (fewer than 10).

b Sample sizes are reported as ranges because variables have different response rates and because some variables apply to different subsets of respondents.



TABLE 18B. STOCK-OUTS FOR SPECIFIC COMMODITIES IN PREVIOUS TWO MONTHS, AMONG HCS WITH

RELEVANT CONTROL CARDS (PERCENTAGE OF HCS)



Facility experienced stock-out of the following nutrition commodities, among facilities with relevant control cards:

Albendazole for deworming 26.0 18.1 -7.9 11.1 17.4 6.3 17.3 17.7 0.4

Iron and folic acid tablets 37.8 27.4 -10.4 10.0 16.4 6.4 21.3 20.9 -0.4

Oral rehydration salts (ORS) and zinc

tablets 37.4 32.0 -5.4 10.7 20.9 10.2 23.0 26.0 3.0

Vitamin A 31.4 0.0 -31.4** 14.5 5.6 -8.9 22.0 3.1 -18.9*


severe acute malnutrition n.a. 22.4 n.a. n.a. 14.1 n.a. n.a. 18.8 n.a.


nutrition commodities measured at

baseline and endline (Albendazole, Iron

and Folic Acid tablets, ORS and zinc

tablets, Vitamin A)

70.6 53.2 -17.4** 31.2 48.3 17.1 49.3 50.6 1.3

Sample sizea 24--72 17--44 41--113

Facility experienced stock-out of the following immunization commodities, among facilities with relevant control cards:

Polio 7.4 0.0 -7.4 3.0 5.9 3.0 4.7 3.6 -1.2

Yellow fever 8.6 27.1 18.5** 0.0 31.1 31.1*** 3.5 29.4 25.9***

Measles 12.1 0.0 -12.1* 0.0 1.9 1.9 4.8 1.2 -3.7

Rotarix 6.8 0.0 -6.8 0.0 0.0 0.0 2.8 0.0 -2.8

Tetanus toxoid 6.9 3.7 -3.2 2.2 4.5 2.3 4.1 4.2 0.1

Pentavalent 17.8 14.0 -3.8 9.0 3.1 -6.0* 12.6 7.5 -5.1

Pneumo 3.3 0.0 -3.3 2.4 0.0 -2.4 2.8 0.0 -2.8

Bacillus Calmette-Guerin 27.5 3.0 -24.5** 18.8 6.0 -12.8 22.4 4.8 -17.7**


immunization commodities acillus

Calmette-Guerin)

45.4 40.8 -4.6 29.7 46.2 16.5 36.2 43.9 7.7

Sample sizea 37--42 31--35 68--76

Facility experienced stock-out of the following malaria commodities measured at baseline and endline, among facilities with relevant control cards: Pediatric syrup paracetamol 39.8 32.1 -7.6 14.7 10.5 -4.2 26.3 20.5 -5.8

Adult paracetamol 44.8 25.8 -19.0** 8.0 13.0 4.9 24.3 18.6 -5.7

Artesunate and amodiaquine 23.5 47.8 24.3** 0.0 25.6 25.6*** 10.1 35.1 25.0***

Artemether and lumenfantrine 32.2 23.0 -9.1 19.0 10.0 -9.0 24.9 15.9 -9.1**




Malaria RDTs 29.4 28.6 -0.8 18.3 25.6 7.3 23.0 26.9 3.9



malaria commodities (Pediatric syrup


Artesunate and amodiaquine, Artemether

and lumenfantrine, Malaria RDTs)

78.7 72.0 -6.7 39.3 51.5 12.3 57.7 61.1 3.4

Sample sizea 52--75 40--49 92--121

Facility experienced stock-out of the following family planning commodities, among facilities with relevant control cards: An injectable contraceptive 19.6 9.8 -9.8 10.5 11.0 0.5 15.2 10.4 -4.8

Condoms 23.1 7.1 -16.0* 14.0 10.3 -3.7 19.3 8.5 -10.9

A hormonal implant such as Implanon,

Jadelle, Sino Implant II, or Norplant 22.1 14.9 -7.2 16.5 15.8 -0.7 19.3 15.4 -4.0

Combined oral contraceptive pills 4.8 29.2 24.3*** 25.8 0.0 -25.8** 13.5 17.1 3.7

Progestogen-only pill -- b -- b -- b -- b -- b -- b 15.1 0.0 -15.1*

An intrauterine device 17.8 16.3 -1.5 -- b -- b -- b 19.9 10.3 -9.6



family planning commodities measured at

baseline and endline

60.5 67.1 6.6 -- -- -- 65.0 65.2 0.2

Sample sizea 10--57 14--34 14--91

Facility experienced stock-out of the following BEmONC commodities, among Health Centers with relevant control cards: Parenteral antibiotics n.a. 15.3 n.a. n.a. 10.2 n.a. n.a. 12.3 n.a.

Magnesium sulfate for preclampsia and

eclampsia n.a. 12.1 n.a. n.a. 12.1 n.a. n.a. 12.1 n.a.

Sample sizea 38--39 28--30 66--69



*** Statistically significant at the 1 percent level; ** statistically significant at the 5 percent level; * statistically significant at the 10 percent level. a Sample sizes are reported as ranges because variables have different response rates and because some variables apply to different subsets of respondents. b Not reported because of small sample sizes (fewer than 10).



TABLE 19A. AVAILABILITY OF ESSENTIAL SUPPLIES AMONG CHPS (PERCENTAGE OF CHPS)



Among facilities with relevant control cards

Facility has the following nutrition commodities available: Albendazole for deworming 72.4 63.4 -8.9 90.5 78.6 -11.9* 80.4 70.2 -10.2**

Iron and folic acid tablets 82.1 79.4 -2.6 88.2 91.4 3.2 84.5 84.1 -0.3


tablets

68.3 69.4 1.1 83.9 90.6 6.8 74.9 78.4 3.5

Vitamin A 86.3 97.6 11.3** 90.1 82.1 -8.1 88.2 89.9 1.6

First-line antibiotic treatment

for severe acute malnutrition

n.a. 71.5 n.a. n.a. 72.8 n.a. n.a. 71.8 n.a.

Facility has the following 4 nutrition

commodities available

(Albendazole, Iron and Folic Acid

tablets, ORS and zinc tablets, Vitamin A)

0.0 27.6 27.6*** 0.0 29.9 29.9*** 0.0 28.5 28.5***

Sample sizec 41--196 22--77 63--273

Facility has the following immunization commodities available:

Measles 89.0 92.3 3.3 79.0 92.7 13.6 83.5 92.5 9.0*

Polio 86.6 85.1 -1.5 72.7 76.4 3.8 79.3 80.5 1.2

Pneumo 90.9 93.8 2.9 78.1 85.9 7.8 83.8 89.4 5.6

Rotarix 97.2 95.6 -1.6 86.8 94.9 8.1 91.6 95.2 3.6

Pentavalent 91.7 93.4 1.8 78.2 93.6 15.5 84.8 93.5 8.7*

Tetanus toxoid 87.8 89.7 1.9 83.3 84.4 1.1 85.5 86.9 1.5

Yellow fever 93.4 91.8 -1.6 85.7 92.3 6.6 89.3 92.1 2.7

Bacillus Calmette-Guerin 81.4 90.0 8.6 68.4 89.2 20.8* 74.9 89.6 14.7**

Facility has all of the above

immunization commodities

available

54.8 57.6 2.9 33.6 51.1 17.5 45.0 54.6 9.7

Sample sizec 59--136 30--60 89--196

Facility has the following malaria commodities available:

Pediatric syrup paracetamol 75.7 63.9 -11.8** 78.7 80.1 1.4 77.0 70.9 -6.1

Adult paracetamol 74.0 77.9 3.9 90.6 89.6 -1.0 81.4 83.1 1.7

Artesunate and amodiaquine 83.2 67.4 -15.8** 88.4 78.2 -10.2* 85.6 72.3 -13.2***

Artemether and lumenfantrine 81.5 77.9 -3.5 88.5 90.5 2.0 84.5 83.4 -1.1




Malaria RDTs 85.2 96.3 11.1*** 96.9 96.1 -0.8 90.7 96.2 5.5**


Facility has the following 5 malaria

commodities available (Pediatric

syrup paracetamol, Adult

paracetamol, Artesunate and

amodiaquine, Artemether and

lumenfantrine, Malaria RDTs)

45.3 37.4 -8.0 62.8 54.7 -8.1 52.8 44.8 -8.0

Sample sizec 93--178 36--74 129--252

Facility has the following family planning commodities available: An injectable contraceptive 94.3 94.8 0.6 92.6 98.3 5.7 93.5 96.5 3.0

Condoms 88.4 86.8 -1.5 79.8 87.6 7.8 84.3 87.2 2.9


Implanon, Jadelle, Sino Implant

II, or Norplant

80.5 89.5 9.0 100.0 80.5 -19.5 86.6 86.7 0.1

Combined oral contraceptive

pills

91.1 80.3 -10.8 89.0 90.0 1.0 90.5 83.1 -7.4

Progestogen-only pill 89.4 59.9 -29.5** --a -- a -- a 90.4 54.5 -35.9**

An intrauterine device -- a -- a -- a -- a -- a -- a -- a -- a -- a

Uterotinic drugs n.a. 79.8 n.a. n.a. 91.9 n.a. n.a. 86.0 n.a.

Facility has all of the above family

planning commodities available

-- -- -- -- -- -- -- -- --

Facility has no expired commodities

(among vitamin A, Pentavalent,

uterotonic drugs such as Oxytocin

or ergometrine, malaria RDTs,

Artesunate + amodiaquine, and

injectable contraceptives),

according to control cardsb

n.a. 7.7 n.a. n.a. 3.4 n.a. n.a. 5.6 n.a.

Sample sizec 17--229 12--109 18--338


Note: Percentages are weighted to adjust for sampling probabilities. *** Statistically significant at the 1 percent level; ** statistically significant at the 5 percent level; * statistically significant at the 10 percent level. a Not reported because of small sample sizes (fewer than 10). b Sample includes all facilities with a control card for at least one of these commodities. c Sample sizes are reported as ranges because variables have different response rates.



TABLE 19B. AVAILABILITY OF ESSENTIAL SUPPLIES AMONG HCS (PERCENTAGE OF HCS)



Among facilities with relevant control cards

Facility has the following nutrition commodities available: Albendazole for deworming 77.7 89.4 11.7 91.2 85.8 -5.4 85.6 87.3 1.7

Iron and folic acid tablets 83.0 80.0 -3.0 90.1 88.9 -1.2 87.2 85.3 -1.9


tablets

72.0 66.2 -5.8 95.4 72.4 -23.1** 84.6 69.5 -15.1**

Vitamin A 77.4 100.0 22.6* 94.4 100.0 5.6 87.1 100.0 12.9*



n.a. 73.9 n.a. n.a. 87.3 n.a. n.a. 79.7 n.a.

Facility has the following 4 nutrition

commodities available (Albendazole,

Iron and Folic Acid tablets, ORS and

zinc tablets, Vitamin A)

1.7 32.6 30.9*** 0.0 35.6 35.6*** 0.8 34.2 33.5***

Sample sizea 23--72 17--44 40--113

Facility has the following immunization commodities available:

Measles 95.4 98.2 2.9 100.0 97.0 -3.0 98.2 97.5 -0.6

Polio 86.6 85.0 -1.6 93.9 86.5 -7.5 90.9 85.9 -5.0

Pneumo 96.4 98.2 1.8 100.0 97.0 -3.0 98.6 97.5 -1.1

Rotarix 100.0 98.3 -1.7 97.3 100.0 2.7 98.4 99.3 0.9

Pentavalent 92.9 98.1 5.2 94.6 91.7 -3.0 93.9 94.2 0.3

Tetanus toxoid 90.1 97.7 7.5 100.0 90.7 -9.3 96.0 93.5 -2.4

Yellow fever 98.3 98.3 -0.0 100.0 100.0 0.0 99.3 99.3 -0.0

Bacillus Calmette-Guerin 90.8 98.2 7.5 94.2 96.8 2.6 92.8 97.4 4.7

Facility has all of the above

immunization commodities available

74.4 75.3 0.9 62.7 68.3 5.6 68.0 71.5 3.4

Sample sizea 37--69 31--44 68--113

Facility has the following malaria commodities available: Pediatric syrup paracetamol 71.2 76.1 4.8 88.0 86.5 -1.5 80.3 81.7 1.4

Adult paracetamol 59.4 86.0 26.6*** 96.2 96.5 0.2 79.7 91.8 12.0**

Artesunate and amodiaquine 81.7 79.3 -2.5 95.2 92.8 -2.4 89.4 87.0 -2.4

Artemether and lumenfantrine 86.8 83.7 -3.1 86.3 96.5 10.2* 86.5 90.7 4.2

Malaria RDTs 78.1 95.3 17.2*** 86.5 85.9 -0.6 83.0 89.8 6.8





Facility has the following 5 malaria

commodities available (Pediatric syrup


Artesunate and amodiaquine,

Artemether and lumenfantrine, Malaria

RDTs)

41.1 44.7 3.6 65.8 61.6 -4.2 54.5 53.9 -0.7

Sample sizea 38--74 25--49 63--120

Facility has the following family planning commodities available:

An injectable contraceptive 80.5 91.6 11.1 92.5 92.0 -0.5 86.6 91.8 5.2

Condoms 75.8 98.2 22.4*** 94.2 79.3 -14.9** 83.8 90.0 6.3



Norplant

85.0 90.1 5.2 93.5 95.4 1.9 89.6 92.9 3.4

Combined oral contraceptive pills 97.0 72.3 -24.7** 66.6 92.4 25.8** 83.7 81.1 -2.7

Progestogen-only pill -- b -- b -- b -- b -- b -- b 83.5 89.7 6.2

An intrauterine device 82.2 77.6 -4.6 -- b -- b -- b 80.1 85.8 5.7

Uterotinic drugs n.a. 83.5 n.a. n.a. 86.2 n.a. n.a. 84.8 n.a.

Facility has all of the above family

planning commodities available

-- -- -- -- -- -- -- -- --

Sample sizea 11--57 14--34 13--91

Facility has the following BEmONC commodities available (among Health Centers):



and eclampsia

n.a. 73.9 n.a. n.a. 80.7 n.a. n.a. 77.9 n.a.

Facilities with one or more expired

commodities (among vitamin A,

Pentavalent, uterotonic drugs such as

Oxytocin or ergometrine, malaria

RDTs, Artesunate + amodiaquine, and

injectable contraceptives) according to

control cardsb

n.a. 8.7 n.a. n.a. 3.3 n.a. n.a. 5.7 n.a.

Sample sizea 37--85 28--56 65--141





a Sample includes all facilities with a control card for at least one of these commodities. b Not reported because of small sample sizes (fewer than 10). c Sample sizes are reported as ranges because variables have different response rates.


TABLE 20A. AVAILABILITY OF ESSENTIAL EQUIPMENT AMONG CHPS (PERCENTAGE OF CHPS)



Facility has the following items for childbirth/delivery available and in working order, among facilities that conduct deliveries:

Domiciliary midwifery kit n.a. 46.1 n.a. n.a. 57.3 n.a. n.a. 51.4 n.a.

Sterile Delivery Kit n.a. 64.7 n.a. n.a. 66.5 n.a. n.a. 65.6 n.a.

Suturing set n.a. 50.3 n.a. n.a. 59.0 n.a. n.a. 54.4 n.a.

Hand held vacuum extractor 23.1 13.6 -9.5** 23.5 28.0 4.5 23.3 20.3 -3.0

An examination light 11.8 14.6 2.8 22.3 8.2 -14.1 16.7 11.7 -5.0

An examination couch 58.3 55.8 -2.5 84.1 65.9 -18.2 70.3 60.5 -9.8

Postpartum hemorrhage, or PPH, pack

for post-partum management

18.5 24.5 6.0 55.0 55.2 0.1 35.6 38.9 3.3

Pre-eclampsia and eclampsia pack for


8.3 18.6 10.3* 33.4 37.3 3.8 20.0 27.3 7.3

Resuscitation kits for resuscitating

babies

46.0 48.7 2.7 59.4 80.3 20.9*** 52.2 63.4 11.2**

Sample sizeb 69--136 33--64 102--200

Facility has the following items for nutrition assessment and counselling available and in working order:

A mid-upper arm circumference

measuring tape, also known as a MUAC

tape

57.2 64.9 7.7** 40.6 71.6 31.0*** 48.2 68.5 20.4***

A tape measure 71.7 79.5 7.8** 67.3 67.0 -0.4 69.3 72.7 3.3

A hanging scale or Salter weighting scale 95.6 82.1 -13.5*** 84.6 75.6 -9.0** 89.6 78.6 -11.1***

An adult weighing scale or bathroom

scale

84.4 73.8 -10.6*** 80.5 71.5 -9.1** 82.3 72.5 -9.8***

A baby-weighing scale or a newborn- or

infant-weighing scale

46.8 38.7 -8.1** 51.3 39.5 -11.8** 49.3 39.1 -10.1***

An infantometer 13.4 7.2 -6.2** 8.6 5.3 -3.3 10.7 6.1 -4.6***

A weighing pant 67.8 60.6 -7.2** 63.8 56.1 -7.7* 65.6 58.2 -7.4***

An Integrated Management of Neonatal

and Childhood Illnesses chart booklet

48.9 48.2 -0.7 24.5 27.0 2.5 35.6 36.7 1.0

An infant and young child feeding

register

34.4 45.0 10.5** 29.7 46.8 17.1** 31.9 46.0 14.1***




HemoCue Hb device and testing strips

or coulter counter and testing strips

n.a. 16.0 n.a. n.a. 16.8 n.a. n.a. 16.4 n.a.

Sample sizeb 269--280 163--170 432--449

Facility has the following storage equipment available for use:

A vaccine refrigerator 34.9 34.4 -0.6 24.8 15.1 -9.7** 29.4 23.9 -5.6**

A vaccine fridge thermometer 40.8 31.2 -9.5*** 24.2 12.1 -12.1*** 31.8 20.8 -10.9***

An up-to-date temperature-monitoring

sheet

33.6 25.8 -7.8*** 17.6 10.2 -7.4** 24.9 17.3 -7.5***

Ice packs 70.5 65.7 -4.8 47.2 46.7 -0.5 57.8 55.4 -2.5

A cold box 35.6 29.1 -6.5** 28.0 17.3 -10.7** 31.5 22.7 -8.8***

An emergency storage plan 22.2 15.9 -6.3** 20.7 10.8 -9.9** 21.4 13.1 -8.2***

A vaccine carrier 89.2 81.3 -7.9** 69.9 65.2 -4.7 78.7 72.5 -6.2**

Clock or watch with second hand n.a. 25.8 n.a. n.a. 24.4 n.a. n.a. 25.0 n.a.

Sample sizeb 278--280 170--171 448--451

Facility has the following basic supplies available for use:

A generator 26.7 4.6 -22.1*** 21.9 4.1 -17.8*** 24.1 4.4 -19.7***

A fire extinguisher 2.3 2.8 0.5 0.8 4.4 3.6 1.5 3.7 2.2*


Facility meets minimum competency criteria

for delivery of infant and young child feeding

(IYCF)a

n.a. 0.3 n.a. n.a. 0.0 n.a. n.a. 0.2 n.a.




*** Statistically significant at the 1 percent level; ** statistically significant at the 5 percent level; * statistically significant at the 10 percent level. a Includes quality service provision in the following areas: (1) Availability of all essential equipment in working order (6 items): Mid-upper-arm circumference tape (MUAC),

hanging scale, bathroom weighing scale, infantometers, hemoglobin (HB) test kit; (2) Existence of at least one staff trained in the last 12 months in infant and young child feeding

(IYCF); (3) Quality record keeping - completeness of infant records based on spot check of three records randomly pulled; (4) Availability of all nutrition commodities and

supplies (5 items): Vitamin A capsules, Oral rehydration salts (ORS), Iron and Folic Acid tablets (IFAs), Infant and Young Child Feeding (IYCF) registers, and nutrition counseling

materials (any of counseling cards, key messages leaflets, nutrition pamphlets, or other nutrition materials). b Sample sizes are reported as ranges because variables have different response rates.


TABLE 22. CONTINUED


TABLE 20B. AVAILABILITY OF ESSENTIAL EQUIPMENT AMONG HCS (PERCENTAGE OF HCS)



Facility has the following items for childbirth/delivery available and in working order:

Domiciliary midwifery kit n.a. 63.2 n.a. n.a. 81.6 n.a. n.a. 73.2 n.a.

Sterile Delivery Kit n.a. 92.7 n.a. n.a. 98.5 n.a. n.a. 95.8 n.a.

Suturing set n.a. 87.8 n.a. n.a. 91.8 n.a. n.a. 90.0 n.a.

Hand held vacuum extractor 43.1 38.5 -4.6 43.2 57.0 13.8 43.2 48.5 5.4

An examination light 48.6 44.7 -3.9 56.4 49.6 -6.8 52.8 47.3 -5.5

An examination couch 82.9 86.7 3.7 86.5 94.7 8.2 84.9 91.0 6.1

Postpartum hemorrhage, or PPH, pack

for post-partum management

53.4 74.0 20.5*** 76.9 88.9 12.0* 66.2 82.1 15.9***

Pre-eclampsia and eclampsia pack for


44.2 63.1 18.9** 74.8 84.0 9.2* 60.8 74.5 13.6***

Resuscitation kits for resuscitating

babies

79.5 94.4 14.9*** 83.1 88.4 5.3 81.4 91.1 9.7**

A large postpartum curette 20.0 42.9 22.9*** 31.6 32.2 0.6 26.5 36.9 10.5*

Sample sizeb 74--81 48--52 122--133

Facility has the following items for nutrition assessment and counselling available and in working order:

A mid-upper arm circumference

measuring tape, also known as a

MUAC tape

72.3 86.2 13.9*** 49.3 78.8 29.5** 60.2 82.3 22.1***

A tape measure 99.2 95.3 -3.9* 92.3 97.5 5.2 95.5 96.5 1.0

A hanging scale or Salter weighting

scale

98.9 96.7 -2.2 91.4 96.4 5.0 94.9 96.5 1.6

An adult weighing scale or bathroom

scale

98.1 97.8 -0.3 98.6 98.6 0.0 98.4 98.2 -0.1

A baby-weighing scale or a newborn-

or infant-weighing scale

86.1 89.2 3.1 93.1 90.5 -2.6 89.9 89.9 0.0

An infantometer 30.1 26.2 -3.9 34.4 20.3 -14.1* 32.5 23.0 -9.5**

A weighing pant 75.4 81.4 6.0 78.4 81.4 3.1 77.0 81.4 4.4

An Integrated Management of

Neonatal and Childhood Illnesses

chart booklet

71.7 70.9 -0.8 56.3 37.2 -19.1*** 63.3 52.5 -10.8**

An infant and young child feeding

register

59.9 62.3 2.4 41.2 49.2 8.0 49.6 55.1 5.5

HemoCue Hb device and testing strips

or coulter counter and testing strips

n.a. 49.5 n.a. n.a. 44.3 n.a. n.a. 46.7 n.a.




Sample sizeb 82--89 54--56 137--145

Facility has the following storage equipment available for use:

A vaccine refrigerator 90.1 84.5 -5.6 76.6 82.7 6.1 82.8 83.5 0.7

A vaccine fridge thermometer 88.1 81.4 -6.7* 85.2 78.1 -7.1 86.6 79.6 -6.9**

An up-to-date temperature-

monitoring sheet

87.8 77.5 -10.3** 76.5 74.7 -1.8 81.7 76.0 -5.7

Ice packs 97.5 96.4 -1.1 91.9 100.0 8.1* 94.5 98.3 3.8

A cold box 69.1 65.2 -3.9 78.5 76.5 -2.0 74.1 71.3 -2.9

An emergency storage plan 53.1 62.1 9.0 80.0 53.9 -26.1** 67.7 57.6 -10.1

A vaccine carrier 98.9 97.2 -1.7 93.7 100.0 6.3* 96.1 98.7 2.6

Clock or watch with second hand n.a. 72.0 n.a. n.a. 83.5 n.a. n.a. 78.1 n.a.

Sample sizeb 87--89 56 143--145

Facility has the following basic supplies available for use:

A generator 42.6 29.8 -12.9*** 54.9 24.1 -30.8*** 49.2 26.7 -22.5***

A fire extinguisher 19.7 26.2 6.5 29.7 36.7 7.0 25.1 31.8 6.8*


Facilities meeting minimum competency

criteria for delivery of infant and young

child feeding (IYCF)a

n.a. 0.0 n.a. n.a. 0.0 n.a. n.a. 0.0 n.a.




*** Statistically significant at the 1 percent level; ** statistically significant at the 5 percent level; * statistically significant at the 10 percent level. a Includes quality service provision in the following areas: 1) Availability of all essential equipment in working order: 6 items - Mid-upper-arm circumference tape (MUAC),

hanging scale, bathroom weighing scale, infantometers, hemoglobin (HB) test kit; 2) Existence of at least one staff trained in the last 12 months in infant and young child feeding

(IYCF); 3) Quality record keeping - completeness of infant records based on spot check of three records randomly pulled; 4) Availability of all nutrition commodities and

supplies (5 items): Vitamin A capsules; Oral rehydration salts (ORS), Iron and Folic Acid tablets (IFAs); Infant and Young Child Feeding (IYCF) registers; and nutrition counseling

materials (any of counseling cards, key messages leaflets, nutrition pamphlets, or other nutrition materials). We looked at commodities available the day of visit and commodities

with bin card. b Sample sizes are reported as ranges because variables have different response rates.


TABLE 22. CONTINUED


TABLE 20D. AVAILABILITY OF COMMUNICATION TECHNOLOGY AMONG CHPS (PERCENTAGE OF CHPS)



Facility has working cell phone 13.4 16.6 3.2 20.9 18.3 -2.6 17.4 17.5 0.0

Facility has working cell phone with

short message service (SMS)

12.9 16.2 3.4 20.1 16.3 -3.9 16.8 16.2 -0.5


multimedia service (MMS)

7.2 9.6 2.4 8.0 10.0 2.0 7.6 9.8 2.2


Internet access

6.2 8.7 2.5 8.3 7.3 -1.0 7.3 7.9 0.6


camera

9.1 12.3 3.1 10.2 9.1 -1.2 9.7 10.5 0.8

Facility has a working smart phone 6.2 6.4 0.2 7.2 7.3 0.1 6.7 6.9 0.2

Facility has a working computer or

tablet

8.4 18.5 10.1** 6.6 22.8 16.2*** 7.4 20.8 13.4***


tablet with Internet access

2.5 7.6 5.1** 2.7 11.7 9.0 2.6 9.8 7.2**

Sample sizea 278-279 168-170 447-449




TABLE 20D.1. AVAILABILITY OF COMMUNICATION TECHNOLOGY AMONG HCS (PERCENTAGE OF HCS)



Facility has working cell phone 19.2 20.6 1.4 25.5 42.6 17.1** 22.6 32.5 9.9*


short message service (SMS) 17.0 20.6 3.7 25.5 42.6 17.1** 21.6 32.5 10.9**


multimedia service (MMS) 10.8 13.8 3.0 13.9 19.9 6.1 12.4 17.1 4.6


Internet access 11.1 10.1 -1.0 11.3 21.1 9.7 11.2 16.1 4.8


camera 12.4 12.2 -0.1 16.5 35.8 19.3** 14.6 25.0 10.4*


Facility has a working smart phone 9.7 9.6 -0.1 7.4 19.6 12.2* 8.5 15.0 6.5


tablet 66.4 69.2 2.8 78.6 75.4 -3.2 73.0 72.5 -0.5


tablet with Internet access 50.4 45.6 -4.8 54.9 32.6 -22.3*** 52.8 38.6 -14.3***

Sample sizea 86--89 55--56 142--145




TABLE 21A. HEALTH PROMOTION USING CAMPAIGN MATERIALS AMONG CHPS (PERCENTAGE OF CHPS)



Facility displays GoodLife, Live it Well campaign

materials

n.a. 61.9 n.a. n.a. 56.9 n.a. n.a. 59.2 n.a.

Facility uses GoodLife, Live it Well campaign

materials during health promotion activities

n.a. 77.3 n.a. n.a. 68.1 n.a. n.a. 72.3 n.a.

Sample sizea 279 170--171 449--450

Source: Health, Population, and Nutrition Office Health Systems midline survey data

Note: Percentages are weighted to adjust for sampling probabilities. *** Statistically significant at the 1 percent level; ** statistically significant at the 5 percent level; * statistically significant at the 10 percent level. a Sample sizes are reported as ranges because variables have different response rates.


TABLE 21B. HEALTH PROMOTION USING CAMPAIGN MATERIALS AMONG HCS (PERCENTAGE OF HCS)



Facility displays GoodLife, Live it Well campaign

materials

n.a. 83.3 n.a. n.a. 80.5 n.a. n.a. 81.8 n.a.

Facility uses GoodLife, Live it Well campaign

materials during health promotion activities

n.a. 77.2 n.a. n.a. 81.3 n.a. n.a. 79.4 n.a.


Sample sizea 87--89 56 143--145

Source: Health, Population, and Nutrition Office Health Systems Midline Survey Data Note: Percentages are weighted to adjust for sampling probabilities.



IV. CULTURE OF QUALITY ASSURANCE AND QUALITY IMPROVEMENT

TABLE 22A. EXISTENCE OF QA/QI TEAMS AND PLANS AMONG CHPS (PERCENTAGE OF CHPS)



Facility has a QA/QI action plan in place:

Plan exists and seen 29.5 38.5 9.0*** 37.4 48.1 10.7* 33.8 43.7 9.9***

Plan exists, but not seen 17.1 13.0 -4.0 12.4 9.5 -3.0 14.5 11.1 -3.5*

No plan 53.4 48.5 -4.9 50.2 42.4 -7.8 51.7 45.2 -6.5*


Facility had used QA/QI nutritional information to improve services in the previous two

months, among facilities with nutrition included

as a topic in their action plan

41.5 80.9 39.4** 26.8 74.1 47.3*** 31.5 76.3 44.8***

Facility has implemented a malaria QI action

plan in the previous two months, among

facilities with malaria included as a topic in

their action plan

n.a. 81.0 n.a. n.a. 81.1 n.a. n.a. 81.1 n.a.

Sample sizea 24--74 22--60 46--134




TABLE 22B. EXISTENCE OF QA/QI TEAMS AND PLANS AMONG HCS (PERCENTAGE OF HCS)




Facility has an active QA/QI team 44.4 47.8 3.4 43.8 59.5 15.7 44.1 54.3 10.2

Facility has an active QA/QI team that met at

least once in the previous three months 29.1 34.1 5.0 39.7 52.7 13.0 35.0 44.5 9.5*

Sample sizea 78--81 53 131--134

Facility has a QA/QI action plan in place:

Plan exists and seen 24.5 36.6 12.1** 28.1 46.0 17.9 26.5 41.7 15.3**

Plan exists, but not seen 23.7 18.6 -5.2 26.2 15.6 -10.7* 25.1 16.9 -8.2**

No plan 51.8 44.9 -6.9 45.6 38.5 -7.2 48.4 41.3 -7.1


Facility has an active QA/QI planc 23.4 31.5 8.1 32.2 37.6 5.5 28.2 34.9 6.6

Facility had used QA/QI nutritional

information to improve services in the

previous two months, among facilities with

nutrition included as a topic in their action

plan

-- b -- b -- b -- b -- b -- b 40.4 93.6 53.2**

Facility has implemented a malaria QI action

plan in the previous two months, among

facilities with malaria included as a topic in

their action plan

n.a. 81.4 n.a. n.a. 100.0 n.a. n.a. 92.4 n.a.

Sample sizea 29--83 22--54 13--137



*** Statistically significant at the 1 percent level; ** statistically significant at the 5 percent level; * statistically significant at the 10 percent level. a Sample sizes are reported as ranges because variables have different response rates. b Not reported because of small sample sizes (fewer than 10). c Defined as having an active QA/QI team that met at least once in the previous three months and a QA/QI action plan in place.


TABLE 23A. DATA VALIDATION AMONG CHPS (PERCENTAGE OF CHPS)



Facility validated the DHIMS2

reports using source documents

n.a. 88.1 n.a. n.a. 89.4 n.a. n.a. 88.8 n.a.






TABLE 23B. DATA VALIDATION AMONG HCS (PERCENTAGE OF HCS)



Facility validated the DHIMS2

reports using source documents

n.a. 93.6 n.a. n.a. 96.1 n.a. n.a. 95.0 n.a.





TABLE 23.1. DATA USE AMONG CHPS (PERCENTAGE OF CHPS)



Facility used data generated for monthly reports for the following purposes in the previous 12 months:a

Plan community outreach 65.5 59.6 -5.9 58.8 53.9 -4.9 61.9 56.5 -5.4

Help allocate resources 61.7 54.4 -7.4* 58.0 50.6 -7.4 59.7 52.3 -7.4*

Improve supply chain and

logistics 56.1 55.2 -0.9 49.2 52.1 2.9 52.3 53.5

1.2

Help develop action plans 51.8 53.4 1.5 52.6 51.4 -1.2 52.2 52.3 0.1

Identify training needs 43.3 43.8 0.5 47.4 40.3 -7.1 45.5 41.9 -3.7

Plan or decide anything

else 17.7 24.6 6.9** 14.9 18.2 3.2 16.1 21.0

4.9*

Sample sizeb 256--278 166--171 422--449



*** Statistically significant at the 1 percent level; ** statistically significant at the 5 percent level; * statistically significant at the 10 percent level. a Because multiple responses were possible, percentages sum to more than 100. b Sample sizes are reported as ranges because variables have different response rates.


TABLE 23.2. DATA USE AMONG HCS (PERCENTAGE OF HCS)



Facility used data generated for monthly reports for the following purposes in the previous 12 months:a

Plan community outreach 79.4 83.3 3.9 72.7 84.5 11.9 75.7 84.0 8.3*

Help allocate resources 81.2 78.8 -2.4 78.1 79.3 1.1 79.5 79.1 -0.5

Improve supply chain and

logistics 78.3 83.4 5.1 66.8 87.4 20.6** 71.9 85.6 13.6**

Help develop action plans 70.3 67.7 -2.6 65.9 80.1 14.2 67.9 74.4 6.5

Identify training needs 69.2 61.3 -8.0 64.4 66.3 1.9 66.6 64.0 -2.5

Plan or decide anything

else 30.8 30.2 -0.6 17.6 41.2 23.5** 23.5 36.3 12.8**

Sample sizeb 79--83 53--56 132--138




TABLE 24A. DISPLAY OF DATA AND INFORMATION AMONG CHPS (PERCENTAGE OF CHPS)



Facility has the following graphs or tables displayed:a

Maternal and child health or reproductive

and child health

15.3 28.3 13.0*** 14.9 26.0 11.1** 15.1 27.1 12.0***

Expanded Program on Immunization 47.4 54.1 6.7** 48.5 51.1 2.6 48.0 52.5 4.6

Malaria or insecticide-treated net

distribution

n.a. 16.9 n.a. n.a. 15.9 n.a. n.a. 16.4 n.a.

Sample sizeb 275--277 156--171 431--448

Facility has at least one graph, or table with

data from past month

22.4 18.9 -3.5 25.7 16.7 -9.0 24.2 17.8 -6.4*







TABLE 24B. DISPLAY OF DATA AND INFORMATION AMONG HCS (PERCENTAGE OF HCS)



Facility has the following graphs or tables displayed:a Maternal and child health or reproductive

and child health

37.6 49.2 11.5* 34.8 47.1 12.3 36.1 48.1 12.0**

Expanded Program on Immunization 80.9 73.3 -7.5 78.8 90.5 11.7* 79.8 82.5 2.7

Malaria or insecticide-treated net

distribution

n.a. 22.3 n.a. n.a. 32.8 n.a. n.a. 27.9 n.a.

Sample sizeb 86--88 54--55 140--143

Facility has at least one graph, or table with

data from past month

39.6 40.6 1.0 40.0 32.7 -7.3 39.8 36.3 -3.5






V. COMMUNITY AND GOVERNMENTAL SUPPORT FOR CHPS

TABLE 25A. COMMUNITY SUPPORT FOR CHPS (PERCENTAGE OF CHPS)



CHPS has CHCs 53.8 90.9 37.1*** 69.2 96.4 27.1*** 62.3 93.9 31.6***

CHCs played a leading role in the previous

12 months in developing a community health

action plan, among CHPSs with a CHC

49.3 22.4 -26.9*** 47.3 33.8 -13.5* 48.1 29.7 -18.4***

Sample sizea 122--268 106--165 228--433

Rating of CHCs’ effectiveness at mobilizing resources for the CHPS to provide services to the community, among CHPSs with CHCs:


Excellent 5.1 3.2 -1.9 5.6 3.9 -1.7 5.4 3.6 -1.8

Very good 7.9 9.7 1.7 8.3 14.8 6.5 8.2 12.8 4.6*

Good 34.4 39.9 5.5 26.6 47.1 20.5*** 29.6 44.3 14.6***

Fair 25.0 28.2 3.2 24.3 15.7 -8.6 24.6 20.5 -4.1

Poor 26.3 16.8 -9.5** 32.4 17.8 -14.6*** 30.0 17.4 -12.6***

CHCs do not do this at all 1.2 2.3 1.1 2.8 0.7 -2.0 2.2 1.3 -0.8


Rating of CHCs’ effectiveness at sensitizing and mobilizing the community for health action, among CHPSs with CHCs:

Excellent 3.0 1.4 -1.6 3.4 2.9 -0.5 3.2 2.3 -0.9

Very good 11.7 19.4 7.7* 14.1 18.9 4.8 13.2 19.1 5.9*

Good 41.5 46.5 5.1 41.5 53.8 12.3** 41.5 51.0 9.5**

Fair 23.4 19.2 -4.2 20.0 17.3 -2.7 21.3 18.0 -3.3

Poor 17.8 10.2 -7.6** 18.3 7.1 -11.2** 18.1 8.3 -9.8***

CHCs do not do this at all 2.8 3.3 0.6 2.7 0.0 -2.7* 2.8 1.3 -1.5



Note: Percentages are weighted to adjust for sampling probabilities. *** Statistically significant at the 1 percent level; ** statistically significant at the 5 percent level; * statistically significant at the 10 percent level. a Sample sizes are reported as ranges because variables have different response rates.

VI. HEALTH INSURANCE

TABLE 26A. HEALTH INSURANCE AMONG CHPS (PERCENTAGE OF CHPS)



Facility submitted at least one National Health

Insurance Scheme (NHIS) claim in previous two months

76.1 72.3 -3.8*** 72.7 62.0 -10.7*** 74.3 66.7 -7.5***


Change in number of clients who are part of NHIS in previous two months:

Increase 62.2 45.0 -17.2*** 70.2 32.8 -37.4*** 66.5 38.6 -27.9***

Decrease 26.4 38.5 12.1*** 23.2 42.2 19.0** 24.7 40.4 15.8***

No change 11.4 16.5 5.1** 6.6 25.0 18.4*** 8.8 21.0 12.2***

Facility’s respondent is aware of at least some health

services not covered by NHIS

51.2 66.4 15.2*** 57.6 62.2 4.6 54.8 64.1 9.3**


Sample sizea 216--226 129--139 355




TABLE 26B. HEALTH INSURANCE AMONG HCS (PERCENTAGE OF HCS)



Facility submitted at least one National Health

Insurance Scheme (NHIS) claim in previous two months

95.6 91.5 -4.1 96.5 93.7 -2.8 96.1 92.7 -3.4*


Change in number of clients who are part of NHIS in previous two months:

Increase 70.2 49.5 -20.7*** 68.1 36.7 -31.4** 69.1 42.6 -26.4***

Decrease 18.7 37.5 18.7*** 30.2 48.1 17.9 24.9 43.2 18.3***

No change 11.0 13.0 2.0 1.7 15.2 13.5** 6.0 14.2 8.2**

Facility’s respondent is aware of at least some health

services not covered by NHIS

62.7 59.4 -3.2 70.2 75.3 5.1 66.8 68.1 1.3

Sample sizea 80--82 51--52 131--134



*** Statistically significant at the 1 percent level; ** statistically significant at the 5 percent level; * statistically significant at the 10 percent level. a Sample sizes are reported as ranges because variables have different response rates, or because some questions were asked to different sub-sets of respondents.


Appendix E: Quantitative Instrument

2-5-2017

HPNO Midline Draft Survey

PART I: BASIC INFORMATION

I.1. Facility Section

ALL;

PROGRAMMER: ALL INFORMATION IN THESE GRAY BOXES IS FOR YOU, AND DOES NOT NEED TO

APPEAR IN THE SURVEY.

MOST OF THE INFORMATION IN THIS SECTION WILL BE KNOWN BEFOREHAND. IT’S POSSIBLE SOME

WILL HAVE TO BE UPDATED IN THE FIELD.

I1. FACILITY INFORMATION SECTION

INSTRUCTION: FILL IN THE FIRST SET OF QUESTIONS THAT START WITH I FROM THE SAMPLE

LIST BEFORE THE VISIT.

In what region is the facility?

Select one only

CENTRAL ......................................................................................................1

GREATER ACCRA ......................................................................................2

NORTHERN .................................................................................................3

VOLTA ...........................................................................................................4

WESTERN .....................................................................................................5

UPPER EAST .................................................................................................6

UPPER WEST ................................................................................................7

ASHANTI .......................................................................................................8

BRONG AHAFO .........................................................................................9

EASTERN .................................................................................................... 10

ALL;

A DROP DOWN WITH THE RELEVANT DISTRICT NAMES BASED ON REGION CHOSEN. CODES

SHOULD BE CONTINUOUS FOR ALL DISTRICTS, NOT DUPLICATED.

I ASSUME YOU CANNOT HAVE A “SPECIFY” WITHIN THIS QUESTION IF “OTHER DISTRICT” IS

SELECTED, BUT NEED A FOLLOW-UP QUESTION LIKE I2O. IS THAT CORRECT?

I.2. In what district is the facility?

Select one only

DISTRICT 1 ...................................................................................................1

DISTRICT 2 ...................................................................................................2

DISTRICT 3 ...................................................................................................3

DISTRICT 4… ..............................................................................................4

OTHER DISTRICT .................................................................................. 99


IF I2=99

I.2.o. If other, what is the name of district?

NAME OF DISTRICT

(STRING 100)

I.2. Interviewer Section

ALL; ADD NAME OF INTERVIEWERS.

I7. What is the interviewer’s name?

INTERVIEWER 1 ................................................................................................................................. 1

INTERVIEWER 2 ................................................................................................................................. 2

INTERVIEWER 3 ................................................................................................................................. 3

INTERVIEWER 4 ................................................................................................................................. 4

INTERVIEWER 5 ................................................................................................................................. 5

INTERVIEWER 6 ................................................................................................................................. 6

INTERVIEWER 7 ................................................................................................................................. 7

INTERVIEWER 8 ................................................................................................................................. 8

OTHER .................................................................................................................................................. 99

IF I7=99

I7o. What is the interviewer’s name?

INSTRUCTION: TYPE FIRST AND LAST NAMES.

FIRST NAME AND LAST NAME

(STRING 100)

IF I7=99

I7n. What is the interviewer’s ID number?

INTERVIEWER’S ID NUMBER

ALL; PLEASE ADD A DATE PICKER.

I8. What is the date of the visit?

DATE PICKER

ALL

I8b. Is this a return visit to the facility to complete the interview?


INSTRUCTION: IF YOU MUST RETURN TO A FACILITY, ALWAYS START THE INTERVIEW HERE.

YES ............................................................................................................................................. 1

NO .............................................................................................................................................. 0

IF I8b = 1

I8bi. Why did you have to return?

INSTRUCTION: IF YOU MUST RETURN TO THE FACILITY TO CONDUCT OR FINISH THE INTERVIEW,

ADD A NOTE REGARDING THE WHY YOU HAD TO RETURN, NUMBER OF TIMES YOU HAD TO

RETURN, AND SO ON.

REASON FOR RETURN

(STRING 500)

IF I8b = 1

I8bii. What is the date of the return visit?

INSTRUCTION: IF YOU MUST RETURN TO THE FACILITY TO CONDUCT OR FINISH THE INTERVIEW,

ENTER THE NEW DATE HERE.

DATE PICKER

ALL;

CAN WE DISPLAY WHAT WE COLLECTED IN THE BASELINE TO HELP LOCATE FACILITIES?

THIS SHOULD NOT BE A REQUIRED QUESTION.

I9. What are the GPS Coordinates of the facility?

INSTRUCTIONS: TAP TO RECORD GPS.

THE GPS COORDINATES SHOULD BE GENERATED AT THE FACILITY CLOSE TO THE POINT OF DATA

CAPTURE. GPS COORDINATES ARE NOT REQUIRED IF YOU CANNOT GET THEM EASILY. LEAVE A

NOTE AT THE END OF THE SURVEY IF YOU CANNOT GET THE GPS COORDINATE.

ALL

I10. Describe the facility location using landmarks and describe the appearance of the facility so that

it can easily be located.

(STRING 500)


PART 2: STAFF MEMBER INTERVIEW

A. INTERVIEW WITH PRIMARY FACILITY RESPONDENT: CONSENT AND BASIC INFORMATION

ALL

A1. CONSENT AND BASIC INFORMATION

INSTRUCTIONS:

- GREET THE PEOPLE OF THE FACILITY.

- EXPLAIN THE PURPOSE OF YOUR VISIT.

- LOCATE THE DESIRED RESPONDENT.

o IN A CHPS COMPOUND, THAT WILL LIKELY BE THE COMMUNITY HEALTH OFFICER

(CHO), COMMUNITY HEALTH NURSE, ENROLLED NURSE OR MIDWIFE.

o IN A HEALTH CENTER, THAT WILL LIKELY BE THE MEDICAL ASSISTANT OR PHYSICIAN

ASSISTANT IN CHARGE OF THE FULL FACILITY, AND/OR THE MIDWIFE IN CHARGE OF

THE MATERNITY.

ALL

A2. Is there an appropriate person at the facility to interview?

INSTRUCTION: THIS IS A QUESTION FOR THE INTERVIEWER. DO NOT READ THIS QUESTION

OUT LOUD. IF THE APPROPRIATE RESPONDENT IS NOT AVAILABLE, PLEASE LEAVE A COMMENT

INCLUDING DATE, WHAT HAPPENED, AND THE NEW APPOINTMENT FOR THE INTERVIEW, IF

OBTAINED. EXIT THE SURVEY.

YES ............................................................................................................................................. 1 GO TO A3

NO .............................................................................................................................................. 0 GO TO K3

A2b. If appropriate person is not available leave comment

COMMENT SHOULD INCLUDE DATE, WHAT HAPPENED, AND THE NEW

APPOINTMENT FOR INTERVIEW, IF OBTAINED. EXIT SURVEY,


IF A2=1;

CAN A “START TIME” FOR THE INTERVIEW BE RECORDED WHEN A2. IS CODED? INCLUDE DATE IN

START TIME STAMP. IF NOT, WE CAN ADD A QUESTION HERE TO RECORD THE START TIME.

A3. Thank you for taking the time for this interview today. My name is …, and I am working for

DevtPlan in support of the USAID Evaluate for Health Project.

We are conducting a midline study of health services in Ghana. The goal of this study is to

help inform decision-makers about the integration of health services, availability of

community-based resources, the strength of health systems, and health sector governance

and accountability. This midline study is being funded by USAID Ghana, and was designed in

close cooperation with the Ghana Health Service.

The purpose of this interview is to gather information from health facility staff on health

care and services in CHPS zones and health centers. Specifically we will be asking about the

resources available to you and the work you do. Your responses will be confidential, that is,

none of your responses will be identified as yours with anyone outside of the study team and

study sponsors.

HAND CONSENT FORM. This is our study consent form, which was approved by GHS. Did

you receive this consent form from us? Can you please read it and sign it if you are in

agreement with it?

Ok. Please continue

A3b. Did the respondent sign the consent form?

YES .......................................................................................................................................................... 1 GO TO A3i

NO .......................................................................................................................................................... 2 GO TO K2

INSTRUCTIONS: THIS IS THE FIRST TEXT TO BE READ ALOUD TO THE RESPONDENT. READ

ALL WORD-FOR-WORD.

HAVE THE ETHICS REVIEW COMMITTEE APPROVED INFORMED CONSENT FORM IN HAND. READ

THE TEXT BELOW AND THEN WAIT FOR SIGNED CONSENT FORM BEFORE BEGINNING THE

INTERVIEW WITH EACH STUDY PARTICIPANT.

IF A3B = 1

A3i. What is the start date and time of the interview?

INSTRUCTION: DO NOT READ THIS QUESTION ALOUD. IN ORDER TO DOCUMENT THE START TIME,

WE MUST MARK THE DATE AGAIN.

DATE PICKER


IF A3=1

A4. Do you have any questions about the interview?

INSTRUCTION: ANSWER ANY QUESTIONS THE RESPONDENT MIGHT HAVE AND THEN CONTINUE.

To start with, could you tell me your name?

IF THE RESPONDENT DOES NOT KNOW, ENTER “DK.” IF THE RESPONDENT REFUSES TO ANSWER,

ENTER “R.”

(STRING 200)

ALL

A5. We will need a number of records, registers and reports for this interview. It might be

easiest to collect them all before we begin, to make things go more quickly. Here are the

ones we will need.

INSTRUCTION: HAND RESPONDENT LIST OF REGISTERS AND BOOKS NEEDED.

1. Home visits register

2. School visits register

3. Insurance records

4. Referral records or book

5. Birth records or delivery book or child welfare cards (CWC) records

6. Child welfare clinic register

7. Maternal / newborn records

8. Antenatal care services (ANC) register

9. Nutrition register

10. Written protocols for maternal and newborn care, family planning counseling and other areas

11. Family planning register

12. Malaria records

13. Facility action plan or master action plan

14. Quality Improvement (QI) action plan and indicators

15. Progress activity charts and tables for Maternal and Child Health (MCH) or Reproductive and

Child Health (RCH) and other areas

16. Bin, tally or inventory control cards

17. Consulting room register

18. Monthly reports

19. Morbidity forms, records and reports

20. Standard operating procedures or SOP

21. Ledger book

22. Health promotion register

INSTRUCTION: HAND RESPONDENT LIST OF REGISTERS AND BOOKS NEEDED


ALL;

A DROP DOWN WITH THE RELEVANT SUB-DISTRICT NAMES BASED ON DISTRICT CHOSEN. CODES

SHOULD BE CONTINUOUS FOR ALL SUB-DISTRICTS, NOT DUPLICATED.

I3. In what sub-district is this facility?

SUB-DISTRICT 1..................................................................................................................... 1

SUB-DISTRICT 2..................................................................................................................... 2

SUB-DISTRICT 3..................................................................................................................... 3

SUB-DISTRICT 4..................................................................................................................... 4

OTHER ...................................................................................................................................... 99

IF I3=99

I3o. If other specify?

NAME OF SUB-DISTRICT

(STRING 100)

ALL

I3c. In the last two years, has there been a change in sub-district name in which this facility is

located?

INSTRUCTION: THIS SHOULD BE MARKED ‘YES” IF THERE WAS A RE-DRAWING OF SUB-DISTRICT

LINES AND/OR RENAMING OF THE SUB-DISTRICT. IF THE FACILITY ITSELF HAS PHYSICALLY MOVED

TO A NEW SUB-DISTRICT, THE ANSWER HERE SHOULD BE “NO.”

YES ............................................................................................................................................. 1

NO .............................................................................................................................................. 0

DON’T KNOW ...................................................................................................................... 96

REFUSED ................................................................................................................................... 97

IF I3c=1

I3ca. What was the previous name of the sub-district?

INSTRUCTION: IF THE RESPONDENT DOES NOT KNOW, ENTER “DK.”

IF THE RESPONDENT REFUSES TO ANSWER, ENTER “R.”

OLD NAME OF SUB-DISTRICT

(STRING 100)


ALL;

CAN THIS BE A DROP DOWN WITH THE RELEVANT FACILITIES’ NAMES AND CODES BASED ON SUB-

DISTRICT AND FACILITY TYPE CHOSEN? “OTHER” OPTIONS SHOULD ALSO BE SUPPLIED, WITH

CODES AND A PLACE TO SPECIFY. PLEASE ALLOW CAPS ONLY.

I6. What is the name of the facility?

Select one only

FACILITY NAME 1 ............................................................................................................................. 1

FACILITY NAME 2 ............................................................................................................................. 2

FACILITY NAME 3 ............................................................................................................................. 3

FACILITY NAME 4 ............................................................................................................................. 4

OTHER FACILITY NAME ................................................................................................................ 99

IF I6=99

I6o. If other, specify:

NAME OF FACILITY

(STRING 100)

ALL

I6.2. In the past two years, has the name of this facility changed?

YES .......................................................................................................................................................... 1

NO .......................................................................................................................................................... 2

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97

IF I6.2=1

I6FCb. What was the name of the facility before it changed?

INSTRUCTION: IF THE RESPONDENT DOES NOT KNOW, ENTER “DK.”

IF THE RESPONDENT REFUSES TO ANSWER, ENTER “R.”

NAME OF FACILITY

(STRING 100)


ALL

I4. Is this a CHPS zone with a compound, a CHPS zone without a compound, a Health Center,

or something else?

INSTRUCTION: NOTE THAT IN THE CHPS SYSTEM, THE “CHPS COMPOUND” IS THE FACILITY AND THE

“CHPS ZONE” IS THE CATCHMENT AREA FOR SERVICE DELIVERY. IF A CHPS CATCHMENT AREA DOES

NOT HAVE A “COMPOUND” BUT DOES HAVE A COMMUNITY HEALTH OFFICER (CHO), THE CHO WILL

STILL BE INTERVIEWED AND THE “FACILITY” WILL BE CONSIDERED A CHPS ZONE.

Select one only

CHPS ZONE WITH A COMPOUND .......................................................................................... 1

CHPS ZONE WITHOUT A COMPOUND ................................................................................ 2

HEALTH CENTER .............................................................................................................................. 3

SOMETHING ELSE ............................................................................................................................. 4

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97

IF I4 = 4

I5. In the past two years, has this facility been a CHPS, health center, or neither?

CHPS ...................................................................................................................................................... 1

HEALTH CENTER .............................................................................................................................. 2

NEITHER ............................................................................................................................................... 0 GO TO K2

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97

IF I5 ≠ 0.

[“ALL” THROUGHOUT THIS SURVEY SHOULD BE UNDERSTOOD TO MEAN ALL EXCEPT IF I5 = 0.]

A6. Now I would like to ask, what is your job title here?

Select all that apply

COMMUNITY HEALTH OFFICER (CHO) ................................................................................. 1

MEDICAL OR PHYSICIAN ASSISTANT IN CHARGE OF THE FULL FACILITY ............ 2

MIDWIFE OR PUBLIC HEALTH NURSE MIDWIFE ................................................................ 3

COMMUNITY HEALTH NURSE OR ENROLLED NURSE .................................................... 4

HEALTH CARE ASSISTANT CLINICAL ...................................................................................... 5

OTHER ................................................................................................................................................. 99

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97

IF A6=99

A6o. What is your job title here?


INSTRUCTION: IF THE RESPONDENT DOES NOT KNOW, ENTER DK;

IF THE RESPONDENT REFUSES TO ANSWER, ENTER R.

JOB TITLE/S (STRING 300)

ALL

A7. How long have you been in this role here?

IF THEY HAVE MORE THAN ONE JOB TITLE, TAKE THE ONE THAT IS LISTED HIGHEST ON THE LIST IN

A6.

IF THE RESPONDENT DOES NOT KNOW, ENTER DK;


NUMBER OF DAYS, WEEKS, MONTHS OR YEARS

(RANGE 1-52)

A7u. Unit of duration

DAYS ...................................................................................................................................................... 1

WEEKS ................................................................................................................................................... 2

MONTHS .............................................................................................................................................. 3

YEARS .................................................................................................................................................... 4

OTHER .................................................................................................................................................. 99

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97

IF A7u=99

A7o. How long have you been in this role here?



LENGTH OF SERVICE

(STRING 150)


ALL

A8. Are you working with community-based agents, community health volunteers, community

surveillance volunteers or other volunteers?

YES .......................................................................................................................................................... 1

NO .......................................................................................................................................................... 2 GO TO B6

DON’T KNOW .................................................................................................................................. 96 GO TO B6

REFUSED ............................................................................................................................................... 97 GO TO B6

IF A8=1

A9. How many of these volunteers work with your facility?

INSTRUCTION: IF THE RESPONDENT DOES NOT KNOW, ENTER 996;

IF THE RESPONDENT REFUSES TO ANSWER, ENTER 997.

NUMBER OF VOLUNTEERS (RANGE 0-99)

B. WORK IN COMMUNITY

A8=1

B1. WORK IN COMMUNITY

The first topic I would like to discuss is your relationship with the community and the

volume of work you do here. I note that you have Community-based agents, community

health volunteers, which are also known as CHVs, community surveillance volunteers or

other volunteers. Who recruited and organized these volunteers?


COMMUNITY HEALTH COMMITTEE, ALSO KNOWN AS CHC .................................... 1

CHO ....................................................................................................................................................... 2

COMMUNITY LEADERS NOT PART OF CHC ....................................................................... 3

SOMEONE ELSE ................................................................................................................................. 99

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97

IF B1=99

B1o. Who recruited and organized these volunteers?



RECRUITER/S AND ORGANIZER/S

(STRING 250)


A8=1

B2. For the next few questions in this section, I will refer to all the types of volunteers and

agents we are discussing as CHVs.

In the past 12 months, what types of services did the CHVs provide?

PROBE IF ONLY ONE ANSWER IS GIVEN, “Anything else?”


HOME VISITS – ASSESS, ADVISE OR EDUCATE ON HEALTH ......................................................... 1

HOME VISITS – FOLLOW-UP ON DEFAULTERS .................................................................................. 2

PROVIDE CONDOMS OR FAMILY PLANNING INFORMATION ................................................... 3

PROVIDE FIRST AID OR TREATMENT OF MINOR AILMENTS ....................................................... 4

CONDUCT DISEASE SURVEILLANCE, IDENTIFY CASES OR REPORT ........................................ 5

COMMUNICATE BETWEEN CHO & COMMUNITY ON HEALTH STATUS OF

COMMUNITY .................................................................................................................................................... 6

DISSEMINATE HEALTH PROMOTION MATERIALS OR INFORMATION ................................... 7

MOBILIZE OR SENSITIZE COMMUNITY FOR HEALTH MANAGEMENT ACTION ................. 8

SUPPORT THE ORGANIZATION OF COMMUNITY HEALTH MEETINGS OR

DURBARS ............................................................................................................................................................ 9

REFER CLIENTS TO CHO FOR DISEASE TREATMENT, FAMILY PLANNING, OR

NUTRITION ....................................................................................................................................................... 10

ASSIST CHO WITH HOME VISITS, OUTREACH OR WORK AT THE CHPS .............................. 11

COLLABORATE WITH CHO OR SUPPORT CHPS SERVICE DELIVERY ...................................... 12

ASSIST IN COMPILING OR UPDATING COMMUNITY REGISTER OR PROFILE ...................... 13

SUPPORT ANC, PNC OR INFANT CARE ............................................................................................... 14

FACILITATE SUPPORT GROUP SESSIONS .............................................................................................. 15

SOMETHING ELSE ............................................................................................................................................ 99

DON’T KNOW ................................................................................................................................................. 96

REFUSED .............................................................................................................................................................. 97

IF B2=99

B2o. In the past 12 months, what types of services did the CHVs provide?



SERVICES

(STRING 150)


A8=1

B3. In the past 12 months, what kinds of support did this facility provide CHVs?


TRAINING, REFRESHERS OR CAPACITY BUILDING .......................................................................... 1

LOGISTICAL HELP (WITH PLANNING, KITS, PAMPHLETS, OR SUPPLIES, ETC.) .................... 2

TRANSPORTATION SUPPORT ................................................................................................................... 3

PHYSICAL MOTIVATORS (T-SHIRT, HAT, ETC.) .................................................................................. 4

SOMETHING ELSE ............................................................................................................................................ 99

NO SUPPORT .................................................................................................................................................... 6

DON’T KNOW ................................................................................................................................................. 96

REFUSED .............................................................................................................................................................. 97

B3=99

B3o. In the past 12 months, what kinds of support did this facility provide CHVs?



SUPPORT

(STRING 250)

A8=1

B4a. In the past 12 months, has any CHV provided you with a report, including verbal reports or

updates to the community registers?

YES .......................................................................................................................................................... 1

NO .......................................................................................................................................................... 2 GO TO B6a1

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97


B4a=1

B4b. In the past 12 months, about how often have you received reports from CHVs, including

verbal reports and updates to the community registers from CHVs?

INSTRUCTION: TRY TO PROBE TO DETERMINE AN ANSWER IN THE TOP FIVE RESPONSES, IF

POSSIBLE.

Select one only

ONCE OR MORE PER DAY ........................................................................................................... 1

ONCE OR MORE PER WEEK, BUT NOT DAILY ................................................................... 2

ONCE OR MORE PER MONTH, BUT NOT WEEKLY .......................................................... 3

ONCE OR MORE EVERY THREE MONTHS, BUT NOT MONTHLY ............................... 4

ONCE OR MORE PER YEAR, BUT NOT QUARTERLY ........................................................ 5

IRREGULARLY .................................................................................................................................... 6

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97

B4a=1

B5. What topics do the reports cover?


DATA ON HOME VISITS ....................................................................................................................... 1

NUMBER OF PREGNANCIES ............................................................................................................... 2

BIRTHS ......................................................................................................................................................... 3

SUPPORT GROUP ACTIVITIES………………………………………………………. ......... 4

NUTRITION COUNSELING……………………………………………………………. ..... 5

OTHER TOPICS ........................................................................................................................................ 99

NO HEALTH TOPICS ............................................................................................................................. 94

DON’T KNOW ......................................................................................................................................... 96

REFUSED ...................................................................................................................................................... 97


B5=99

B5o. What topics do the reports cover?



TOPICS

(STRING 250)

ALL; PROGRAMMER, ALLOW UP TO 4 DIGITS FOR ANSWERS. ASK SUB-QUESTION B6x1 AND B6x2

RIGHT AFTER EACH OTHER EXCEPT IF B6x1 = 0, DK OR REFUSED. IF B6a-f1 = 0, DK OR REFUSED SKIP

B6a-f2 FOR THAT SUB-QUESTION.

FROM B6b1 ON, PLEASE MAKE THE INTRODUCTORY PART OF THIS QUESTION GREYED OUT, SO IT

IS LEFT AS A REFERENCE, BUT NOT READ BY THE INTERVIEWER IF NOT NEEDED.

B6. I’d like to ask you a bit about home and school visits. Would it be possible to look at your

home and school visit registers and monthly reports for the next few questions?

INSTRUCTION: THESE QUESTIONS ARE ABOUT ALL STAFF MEMBERS AT THE FACILITY, BUT DO NOT

INCLUDE VOLUNTEERS.

DOCUMENTS NEEDED: HOME VISITS REGISTER, SCHOOL VISITS REGISTER, AND MONTHLY REPORTS

In the last two complete months, can you please tell me the number of...

RECORD NUMBER

IF B6x1>0 and B6x1<9996, ASK RECORD

NUMBER

a1. routine home visits

you conducted? | | | | |

DK = 9996

REFUSED = 9997

B6a2. Is this number from an

up-to-date register or record,

or is it an estimate?

Register = 1

Estimate = 2

DK = 96

REFUSED = 97

b1. follow-up home visits

you conducted? | | | | |

DK = 9996

REFUSED = 9997

B6b2. Is this number from an



Register = 1

Estimate = 2

DK = 96

REFUSED = 97

IF I4=1 OR 2

c1. CHPS zone clients

needing special visits

that you visited?

| | | | |

DK = 9996

REFUSED = 9997

IF I4=1 OR 2

B6c2. Is this number from an



Register = 1

Estimate = 2

DK = 96

REFUSED = 97

d1. post-natal home

visits you conducted? | | | | |

DK = 9996

REFUSED = 9997

B6d2. Is this number from an



Register = 1

Estimate = 2

DK = 96

REFUSED = 97

e1. school visits you

conducted? | | | | |

DK = 9996

REFUSED = 9997

B6e2. Is this number from an



Register = 1

Estimate = 2

DK = 96

REFUSED = 97


IF I4 = 1 OR 2

B7a. Currently, how many communities are within this CHPS zone?



NUMBER OF COMMUNITIES

(RANGE 0-99)

IF I4 = 1 OR 2

B7b. Do you organize community health meetings, also called durbars, group discussions, or

other such names?

YES .......................................................................................................................................................... 1

NO .......................................................................................................................................................... 2

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97

IF B7b = 1

B7c. In the last complete quarter, how many community health meetings did you hold?



NUMBER OF MEETINGS

(RANGE 0-999)

IF B7b = 1 AND B7c >0 & < 996

B8. For the most recent community health meeting you held, who planned and organized it?


COMMUNITY HEALTH COMMITTEE, ALSO KNOWN AS CHC .................................... 1

CHO ....................................................................................................................................................... 2

COMMUNITY LEADERS NOT PART OF CHC ....................................................................... 3

COMMUNITY HEALTH VOLUNTEER/S OR CHVS ............................................................... 4

COMMUNITY HEALTH WORKER …………………………………………………..5

SOMEONE ELSE ................................................................................................................................. 99

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97


B8=99;

IF YOU CANNOT HAVE A FILL IN AND A MARKED RESPONSE TO THE SAME

QUESTION, ADD INSTRUCTION THAT READS, “IF RESPONDENT DOES NOT

KNOW, ENTER 96; IF RESPONDENT REFUSES, ENTER 97.”

B8o. For the most recent community health meeting you held, who planned and organized it?



PLANNERS AND ORGANIZERS

(STRING 250)

IF B7b = 1 AND B7c >0 & < 96

B9. In the last two complete months, what were the topics of discussion during the community

health meetings that you held?

INSTRUCTION: PROBE AND SELECT ALL THAT APPLY.


NEWBORN HEALTH ....................................................................................................................... 1

MATERNAL AND CHILD HEALTH ............................................................................................. 2

FAMILY PLANNING .......................................................................................................................... 3

HIV/AIDS ............................................................................................................................................... 4

ANC ATTENDANCE........................................................................................................................ 5

PNC ATTENDANCE ........................................................................................................................ 6

HEALTH INSURANCE ..................................................................................................................... 7

MALARIA (ANY TOPIC) .................................................................................................................. 8

WASH (WATER AND SANITATION HYGIENE) ................................................................... 9

EPI-EXPANDED PROGRAMME ON IMMUNIZATIONS ....................................................... 10

CHOLERA ............................................................................................................................................ 11

INJURIES SUCH AS SNAKE BITES, BURNS, ETC. .................................................................... 12

ADMINISTRATION OF THE HEALTH FACILITY ................................................................... 13

NUTRITION ........................................................................................................................................ 14

GOODLIFE, LIVE IT WELL CAMPAIGN ..................................................................................... 15

SOMETHING ELSE ............................................................................................................................. 99

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97


B9=99;

IF YOU CANNOT HAVE A FILL-IN AND A MARKED RESPONSE TO THE SAME

QUESTION, ADD INSTRUCTION THAT READS, “IF RESPONDENT DOES NOT

KNOW, ENTER 96; IF RESPONDENT REFUSES, ENTER 97.”

B9o. In the last two complete months, what were the topics of discussion during the community

health meetings that you held?



TOPICS

(STRING 250)

IF I4 = 1 OR 2

B10a. Now I would like to know if there are Community Health Committees that assist this CHPS

zone?

Select one only

YES .......................................................................................................................................................... 1

NO .......................................................................................................................................................... 0 GO TO C1a

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97

B10a=1

B10b. Currently, how many Community Health Committees are assisting this CHPS zone?



NUMBER OF

(RANGE 0-99)

IF I4 = 1 OR 2 AND B10a ≠ 0

B11a. Currently, do any of the communities in this CHPS zone have a Community Health Action

Plan, also known as a CHAP, in place?

Select one only

YES .......................................................................................................................................................... 1

NO .......................................................................................................................................................... 0

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97


IF [B11a=1] AND [B7a>1]

B11b. Currently, how many communities in this CHPS zone have a CHAP in place?



NUMBER OF

(RANGE 0-99)

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97

IF B11a = 1

B11c. In the past 12 months, have the Community Health Committees in your CHPS zone played

a leading part in developing their Community Health Action Plans?

Select one only

YES, AT LEAST ONE ......................................................................................................................... 1

NO .......................................................................................................................................................... 0

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97

[B11c=1] AND [B10b>1]

B11d. Currently, how many CHCs in this CHPS zone have played a leading part in developing their

CHAP?



NUMBER OF

(RANGE 0-99)


IF I4 = 1 OR 2 AND B10a ≠ 0

B12. Now I am going to ask you to rate the overall effectiveness of the Community Health

Committees in your CHPS Zone on a number of characteristics. I will ask you to rate their

work as poor, fair, good, very good, or excellent.

First, in your opinion, how effective are the Community Health Committees at mobilizing

resources for the CHPS compound to help provide services to the community - poor, fair,

good, very good, or excellent, or they don’t do it at all?

Select one only

POOR .................................................................................................................................................... 1

FAIR ........................................................................................................................................................ 2

GOOD ................................................................................................................................................... 3

VERY GOOD ....................................................................................................................................... 4

EXCELLENT ......................................................................................................................................... 5

THEY DON’T DO IT AT ALL ........................................................................................................ 95

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97

IF I4 = 1 OR 2 AND B10a ≠ 0

B13. In your opinion, how effective are the Community Health Committees at sensitizing the

community for health action, poor, fair, good, very good, or excellent, or they don’t do it at

all?

Select one only

POOR .................................................................................................................................................... 1

FAIR ........................................................................................................................................................ 2

GOOD ................................................................................................................................................... 3

VERY GOOD ....................................................................................................................................... 4

EXCELLENT ......................................................................................................................................... 5

THEY DON’T DO IT AT ALL ........................................................................................................ 95

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97


C. CLIENTS TO FACILITY

ALL

C1a. CLIENTS TO FACILITY

Now I would like to ask you about seeing clients at this facility and your referral system.

To start, in the last two complete months, how many clients were seen at the Out Patient

Department or OPD here?

DOCUMENT NEEDED: CD1 REPORT AND/OR MORBIDITY RETURNS. THE TOTAL

ATTENDANCE SHOULD BE USED, AND NOT THE REGISTRANTS.

INSTRUCTION: IF THE RESPONDENT DOES NOT KNOW, ENTER 99,996;

IF THE RESPONDENT REFUSES TO ANSWER, ENTER 99,997.

NUMBER OF CLIENTS

(RANGE 0-99,999)

ALL

C1b. In the last two complete months, how many clients were seen by the midwife, as recorded

in your Midwifery Returns form, or Form A?

DOCUMENT NEEDED: FORM A OR MIDWIFERY RETURN FORM. THE TOTAL




NUMBER OF CLIENTS

(RANGE 0-99,999)

ALL

C1c. In the last two complete months, how many clients were seen for family planning, as

recorded in your Family Planning Report, or Form B?

DOCUMENT NEEDED: FORM B OR FAMILY PLANNING REPORT. THE TOTAL




NUMBER OF CLIENTS

(RANGE 0-99,999)


ALL

C1d. In the last two complete months, how many children were seen at this facility, as recorded

in your Child Health Returns, or Form C?

DOCUMENT NEEDED: FORM C OR CHILD HEALTH RETURNS. THE TOTAL




NUMBER OF CLIENTS

(RANGE 0-99,999)

ALL

C1e. In the last two complete months, how many clients were seen at the Prevention of Mother-

to-Child Transmission of HIV and Early Infant Diagnosis unit, or the PMTCT/EID unit, as

recorded in your PMTCT/EID report form?

DOCUMENT NEEDED: PMTCT/EID REPORT FORM. THE TOTAL ATTENDANCE

SHOULD BE USED, AND NOT THE REGISTRANTS.



NUMBER OF CLIENTS

(RANGE 0-99,999)

ALL

C1f. In the last two complete months, how many clients were seen at the Adolescent Health and

Development center, or the ADHD centre, as recorded in your Adolescent Health Reports?

DOCUMENT NEEDED: ADOLESCENT HEALTH REPORTS. THE TOTAL




NUMBER OF CLIENTS

(RANGE 0-99,999)


ALL

C1g. In the last two complete months, how many clients were seen at the Nutritional

Rehabilitation Centre, if you have one?

DOCUMENT NEEDED: NUTRITION FORM. THE TOTAL ATTENDANCE SHOULD BE

USED, AND NOT THE REGISTRANTS.



NUMBER OF CLIENTS

(RANGE 0-99,999)

ALL

C2a. In the last two complete months, have any clients been referred from this facility to another

health facility?

INSTRUCTION: PLEASE DO NOT INCLUDE FOLLOW-UPS REFERRED BACK TO FACILITIES.

Select one only

YES .......................................................................................................................................................... 1

NO .......................................................................................................................................................... 0

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97

IF C2a=1

C2b. Do you have referral records for any of the clients referred from this facility to another

health facility in the last two complete months?


DOCUMENTS NEEDED: REFERRAL RECORDS OR REGISTERS AND MONTHLY REPORTS, IF AVAILABLE.

Select one only

YES, RECORDS SEEN ....................................................................................................................... 1

YES, RECORDS NOT SEEN ............................................................................................................ 2

NO .......................................................................................................................................................... 0

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97


IF C2b=1 OR 2

C3. For the most recent client referred from this facility, may I see the referral record?

INSTRUCTION: INDICATE WHETHER THE MOST RECENT REFERRAL HAS BEEN RECORDED AND IF SO,

WHETHER YOU HAVE SEEN THE RECORD.

PLEASE DO NOT INCLUDE FOLLOW-UPS REFERRED BACK TO A FACILITY.

Select one only

YES, REFERRAL WAS RECORDED, SEEN .................................................................................. 1

YES, REFERRAL WAS RECORDED, NOT SEEN ...................................................................... 2

NO, REFERRAL WAS NOT RECORDED................................................................................... 0

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97

IF C2a=1

C4. In the last two complete months, among all the clients seen at this facility, how many clients

were referred from this facility to another health facility?


DOCUMENTS NEEDED: REFERRAL RECORDS AND MONTHLY REPORTS, IF AVAILABLE.



NUMBER OF CLIENTS REFERRED

(RANGE 0-9,999)


IF C4 ≠ 0, 9,996 OR 9,997

C5. In the last two complete months, among all clients referred to other health facilities, what

types of health issues most often led to clients being referred?

DOCUMENT NEEDED: REFERRAL RECORDS, IF AVAILABLE.


MALARIA OR SEVERE MALARIA .................................................................................................. 1

PREGNANCY-RELATED COMPLICATIONS ............................................................................ 2

CHOLERA ............................................................................................................................................ 3

ACCIDENTS AND INJURIES, SUCH AS SNAKE BITES, BURNS, AND CUTS ............... 4

TYPHOID ............................................................................................................................................. 5

DIARRHEA ........................................................................................................................................... 6

UPPER RESPIRATORY TRACT INFECTION ............................................................................. 7

SKIN DISEASES AND ULCERS ...................................................................................................... 8

HYPERTENSION ................................................................................................................................ 9

PNEUMONIA ...................................................................................................................................... 10

ANEMIA ................................................................................................................................................ 11

INTESTINAL WORMS ...................................................................................................................... 12

RHEUMATISM ..................................................................................................................................... 13

EAR INFECTION ................................................................................................................................ 14

STROKE ................................................................................................................................................ 15

ACUTE MALNUTRITION……………………………………………………….. ............ 16

DIABETES………………………………………………………………………. ............... 17

SOMETHING ELSE ............................................................................................................................. 99

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97

C5=99

C5o. In the last two complete months, among all clients referred to other health facilities, what

types of health issues most often led to clients being referred?



HEALTH ISSUE/S

(STRING 250)


IF C4 ≠ 0, 9,996 OR 9,997

C6. In the last two complete months, have any decisions to refer a client to another health

facility been influenced by whether the client had health insurance coverage or not?

Select one only

YES .......................................................................................................................................................... 1

NO .......................................................................................................................................................... 0

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97

IF I4 = 1 OR 2 AND C4 ≠ 0, 9,996 OR 9,997

C7. In the last two complete months, how many referred clients returned here with feedback

notes from another health provider?

DOCUMENT NEEDED: REFERRAL RECORDS.

INSTRUCTION: FEEDBACK COULD ALSO BE COUNTED IF OBTAINED VIA PHONE OR

PERSONAL VISITS, AS LONG AS FEEDBACK IS DOCUMENTED, SUCH AS REMARKS IN A REGISTER.

IF THE RESPONDENT DOES NOT KNOW, ENTER 996;


NUMBER OF CLIENTS WITH FEEDBACK NOTES

(RANGE 0-999)

IF I4 = 3

C8. In the last two complete months, how many clients did this health center receive who were

referred from another health facility?

DOCUMENT NEEDED: REFERRAL RECORDS OR REGISTER, IF AVAILABLE.



NUMBER OF REFERRED CLIENTS RECEIVED

(RANGE 0-999)


IF I4 = 3 AND C8 ≠ 0

C9. In the last two complete months, among all clients referred to this health facility, what types

of health issues most often led to clients being referred?

DOCUMENT NEEDED: REFERRAL RECORDS, IF AVAILABLE.


MALARIA .............................................................................................................................................. 1

PREGNANCY-RELATED COMPLICATIONS ............................................................................ 2

CHOLERA ............................................................................................................................................ 3

ACCIDENTS AND INJURIES, SUCH AS SNAKE BITES, BURNS, AND CUTS ............... 4

TYPHOID ............................................................................................................................................. 5

DIARRHEA ........................................................................................................................................... 6

UPPER RESPIRATORY TRACT INFECTION ............................................................................. 7

SKIN DISEASES AND ULCERS ...................................................................................................... 8

HYPERTENSION ................................................................................................................................ 9

PNEUMONIA ...................................................................................................................................... 10

ANEMIA ................................................................................................................................................ 11

INTESTINAL WORMS ...................................................................................................................... 12

RHEUMATISM ..................................................................................................................................... 13

EAR INFECTION ................................................................................................................................ 14

STROKE ................................................................................................................................................ 15

ACUTE MALNUTRITION………………………………………………………… ......... 16

DIABETES ……………………………………………………………………… ............... 17

SOMETHING ELSE ............................................................................................................................. 99

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97

C9=99

C9o. In the last two complete months, among all clients referred to this health facility, what types

of health issues most often led to clients being referred?



HEALTH ISSUE/S

(STRING 250)


ALL

C10. Now I would like to ask you about health insurance. Has your facility been accredited by the

National Health Insurance Scheme, also known as NHIS, to provide health care?

YES .......................................................................................................................................................... 1

NO .......................................................................................................................................................... 2

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97

IF C10=1

C11. In the last two complete months, for how many claims did you record and submit National

Health Insurance claims?

DOCUMENT NEEDED: INSURANCE RECORDS



_________________________ NUMBER INSURANCE CLAIMS

(RANGE 0-99,999)

IF C10 = 1

C12. In the last 2 complete months, have you noticed an increase, decrease or no change in the

number of clients who are seen at your facility who are part of the National Health

Insurance Scheme?

INCREASE............................................................................................................................................. 1

DECREASE ........................................................................................................................................... 2

NO CHANGE ..................................................................................................................................... 3

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97

ALL

C13a. As far as you know, are there any health care services that one would need from a health

care provider that are not covered by the National Health Insurance Scheme?

Select one only

YES .......................................................................................................................................................... 1

NO .......................................................................................................................................................... 0

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97


C13a=1

C13b. As far as you know, what are the health care services that one would need from a health

care provider that are not covered by the National Health Insurance Scheme?



HEALTH SERVICE/S

(STRING 250)

D. PROGRAMS

ALL

D1a. Now I would like to ask you a few questions about health promotion, specifically the

GoodLife, Live it Well Campaign. Does this facility display GoodLife, Live it Well Campaign

Materials?

INSTRUCTION: OBSERVE AND ASK TO SEE IF THEY ARE DISPLAYING POSTERS,

BROCHURES, OR CAR STICKERS, BEFORE ACCEPTING A ‘YES’ RESPONSE.

YES .......................................................................................................................................................... 1

NO .......................................................................................................................................................... 0

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97

ALL

D1b. In the last two complete months, has this facility used GoodLife, Live it Well Campaign

materials such as posters or cue cards during health promotion activities with health clients?

YES .......................................................................................................................................................... 1

NO .......................................................................................................................................................... 0

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97

ALL

D2. Now I would like to ask you a bit about some of the health services you might provide.

Does this facility provide antenatal care services, also known as ANC services?

Select one only

YES .......................................................................................................................................................... 1

NO .......................................................................................................................................................... 0 GO TO D4

DON’T KNOW .................................................................................................................................. 96 GO TO D4

REFUSED ............................................................................................................................................... 97 GO TO D4

IF D2=1


D3. Does this facility have an antenatal care services or ANC services register?

INSTRUCTION: ASK TO SEE REGISTER.

Select one only

YES, REGISTER SEEN ........................................................................................................................ 1

YES, REGISTER NOT SEEN ............................................................................................................. 2

NO .......................................................................................................................................................... 0

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97

ALL

D4. Does this facility conduct childbirth deliveries?

INSTRUCTION: THIS INCLUDES EMERGENCY BIRTHS.

Select one only

YES .......................................................................................................................................................... 1

NO .......................................................................................................................................................... 0

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97

IF D4 ≠ 0

D5. In the last two complete months, how many births occurred at this facility?

DOCUMENTATION: MATERNITY OR DELIVERY BOOK OR DOCUMENTATION FROM THE LABOR

WARD.



______________________NUMBER OF BIRTHS AT FACILITY

(RANGE 0-9,999)

IF D5 ≠ 0

D6. In the last two complete months, of all the births that occurred at this facility, how many

were emergency deliveries?

DOCUMENTATION: BIRTH REGISTERS



___________________NUMBER OF EMERGENCY DELIVERIES

(RANGE 0-999)

IF D5 ≠ 0


D7. In the last two complete months, how many births that occurred at this facility were

registered by this facility?

DOCUMENTATION: BIRTH REGISTERS



_______________________NUMBER OF BIRTHS REGISTERED

(RANGE 0-999)

ALL

D8. In the last two complete months, did this facility register any homebirths?

YES .......................................................................................................................................................... 1

NO .......................................................................................................................................................... 2

DON’T KNOW .................................................................................................................................. 96

REFUSED……………………………………………………………………….……… 97

IF D8=1

D9. In the last two complete months, how many homebirths did this facility register?



_____________________NUMBER OF HOME DELIVERIES

(RANGE 0-999)

ALL

D10. This year, how many births should occur in this facility’s catchment area based on annual

expected deliveries for this facility?

DOCUMENTATION: ANC RECORDS



___________________________NUMBER OF PROJECTED BIRTHS IN AREA

(RANGE 0 - 9,999)


ALL

D11. In the last two complete months, has this facility had any neonatal deaths, by which I mean

deaths of babies who were 0 to 28 days old?

DOCUMENTATION: FACILITY SPREADSHEET OR REGISTER ON NEONATAL DEATHS

YES .......................................................................................................................................................... 1

NO .......................................................................................................................................................... 0

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97

D11=1

D12. In the last two complete months, how many neonatal deaths have occurred in this facility?




___________________NUMBER

(RANGE 0-999)

D11=1

D13a. In the last two complete months, has this facility recorded the cause of [all of] the neonatal

death/s that occurred in this facility?

INSTRUCTION: ASK TO SEE RECORD/S.

Select one only

YES, RECORD/S SEEN ...................................................................................................................... 1

YES, RECORD/S NOT SEEN ........................................................................................................... 2

NO .......................................................................................................................................................... 0

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97


D11=1

D13b. In the last two complete months, what were the main reasons for the neonatal deaths that

occurred in this facility?



INFECTION ......................................................................................................................................... 1

PRE-TERM BIRTH COMPLICATIONS ......................................................................................... 2

INTRA PARTUM RELATED ............................................................................................................ 3

CONGENITAL ABNORMALITIES ................................................................................................ 4

ANOTHER REASON ....................................................................................................................... 99

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97

IF D13b=99

D13bo. In the last two complete months, what were the main reasons for the neonatal deaths that




REASONS (STRING 250)

ALL

D14a. In the last two complete months, has this facility had any maternal deaths?

DOCUMENTATION: FACILITY SPREADSHEET OR REGISTER ON MATERNAL DEATHS

YES .......................................................................................................................................................... 1

NO .......................................................................................................................................................... 0

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97

IF D14a=1

D14b. In the last two complete months, how many maternal deaths have occurred in this facility?




___________________NUMBER OF MATERNAL DEATHS

(RANGE 0-99)

D14a=1


D15a. In the last two complete months, has this facility recorded the cause of [all of] the maternal

death/s that occurred in this facility?

INSTRUCTION: ASK TO SEE RECORD/S.


Select one only

YES, RECORD/S SEEN ...................................................................................................................... 1

YES, RECORD/S NOT SEEN ........................................................................................................... 2

NO .......................................................................................................................................................... 0

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97

D14b >0<96

D15b. In the last two complete months, what were the main reasons for the maternal deaths that




HEMORRHAGE .................................................................................................................................. 1

ABORTION.......................................................................................................................................... 2

HYPERTENSIVE DISORDERS ......................................................................................................... 3

ECTOPIC GESTATION .................................................................................................................... 4

UTERINE RUPTURE .......................................................................................................................... 5

PUERPERAL SEPSIS ............................................................................................................................ 6

ANOTHER REASON ....................................................................................................................... 99

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97

IF D15b=99

D15bo. In the last two complete months, what were the main reasons for the maternal deaths that




REASONS

(STRING 250)


ALL

D16. Does this facility have written protocols for managing maternal and newborn care?

INSTRUCTION: ASK TO SEE WRITTEN PROTOCOLS.

Select one only

YES, PROTOCOL SEEN ................................................................................................................... 1

YES, PROTOCOL NOT SEEN ........................................................................................................ 2

NO .......................................................................................................................................................... 3

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97

IF D4 ≠ 0 AND IF D5 ≠ 0

D17. In the last two complete months, how many women who delivered at this facility received at

least two doses of sulfadoxine-pyrimethamine, also known as SP?

INSTRUCTION: IF ONE WOMAN RECEIVED MORE THAN TWO DOSES, SHE SHOULD ONLY BE

COUNTED ONCE. REFER TO FORM A, DELIVERY SHEET.



________________________NUMBER OF WOMEN RECEIVED SP

(RANGE 0-999)

ALL

D18. Does this facility offer family planning counseling and provide contraception?

Select one only

YES, FAMILY PLANNING COUNSELING .................................................................................. 1

YES, CONTRACEPTIVES ................................................................................................................. 2

YES, BOTH ........................................................................................................................................... 3

NO .......................................................................................................................................................... 0 GO TO D20

DON’T KNOW .................................................................................................................................. 96 GO TO D20

REFUSED ............................................................................................................................................... 97 GO TO D20


IF D18 = 2 OR 3

D19a. In the last two complete months, how many clients accepted contraceptives for the first

time from this facility?

INSTRUCTION: ASK TO SEE THE FAMILY PLANNING RECORDS AND MONTHLY REPORTS.

IF THE RESPONDENT DOES NOT KNOW, ENTER 996;


__________________________NUMBER OF CLIENTS

(RANGE 0-999)

D18=2 OR 3

D19b. In the last two complete months, based on your records, what contraceptives were

accepted for the first time by these clients?

DOCUMENT NEEDED: FORM B


A HORMONAL IMPLANT: IMPLANON, IMPLANON NXT, JADELLE, SINO

INPLANT II, OR NORPLANT ........................................................................................................ 1

AN INTRAUTERINE DEVICE, ALSO KNOWN AS AN IUD ............................................... 2

AN INJECTABLE CONTRACEPTIVE: DEPO PROVERA OR NORIGYNON .................. 3

COMBINED ORAL CONTRACEPTIVE PILLS ........................................................................... 4

PROGESTOGEN-ONLY PILL, ALSO KNOWN AS POP ....................................................... 5

CONDOMS ......................................................................................................................................... 6

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97

ALL

D20. Does this facility have a nutrition register, for example a growth monitoring register,

nutrition education counseling register, child welfare clinic register or child health register?


Select one only

YES, REGISTER SEEN ........................................................................................................................ 1

YES, REGISTER NOT SEEN ............................................................................................................. 2

NO .......................................................................................................................................................... 3 GO TO D24

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97


IF D20=1

D20o. What nutrition register does this facility have that I can see?

INSTRUCTION: IF MORE THAN ONE IS SHOWN, SPECIFY ALL SEEN.



REGISTER

(STRING 150)

IF D20=2

D20o2. What nutrition register does this facility have that I have not seen?

INSTRUCTION: IF MORE THAN ONE IS MENTIONED, SPECIFY ALL MENTIONED.



REGISTER

(STRING 150)

IF D20 = 1, 2, 96 OR 97

D21. In the last two complete months, has data been entered into the nutrition register?


Select one only

YES, DATA SEEN ................................................................................................................................ 1

YES, REPORTED BY RESPONDENT ........................................................................................... 2

NO .......................................................................................................................................................... 3

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97


IF D21 = 1

D22. I am going to ask you about different kinds of child data.

In the last two complete months, has any [FILL with a-e] been entered into the nutrition

register?

Yes No D. K. Refused

a. child’s weight data

b. child’s age data

c. child’s height data

d. under-weight, or weight for age data, also known as Z

scores or SD

e. Infant and Young Child Feeding, also known as IYCF,

counseling data

IF D21 = 1;

PROGRAMMER, CAN WE ALLOW FOR DAY, MONTH, AND/OR YEAR TO BE BLANK?

D23ai. What is the date of the most recent entry in the nutrition register? Enter day here


D23ii. Enter month here

D23iii. Enter year here

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97

IF D20 = 1

D23b. Could you please show me your Child Welfare Clinic Register, if you have one?

INSTRUCTION: BE SURE TO HAVE THE CORRECT REGISTER IN HAND.

Select one only

YES .................................................................................................................................................. 1

NO .................................................................................................................................................. 0

DON’T KNOW .......................................................................................................................... 96

REFUSED ....................................................................................................................................... 97


IF D23b = 1

D23c. May I look at 3 infant or child records that I randomly choose?

INSTRUCTION: REVIEW THREE INFANT OR CHILD ENTRIES FROM THE CHILD WELFARE CLINIC

REGISTER. IF POSSIBLE, CHOOSE THE 3RD AND 10TH ENTRY ON THE SECOND TO LAST PAGE OF

THE REGISTER, AND THE FIRST ENTRY ON THE LAST PAGE.

CHECK EACH ENTRY FOR 3 ITEMS: WEIGHT (AT LEAST ONE ENTRY), VITAMIN A SUPPLEMENTATION

(AT LEAST ONE ENTRY), AND IMMUNIZATION RECORD (AT LEAST ONE ENTRY).


INFANT OR CHILD #1 HAD AN ENTRY FOR EACH OF THE 3 ITEMS................ 1



NONE OF THEM HAVE AN ENTRY FOR ALL 3 ITEMS ............................................... 4

DON’T KNOW .......................................................................................................................... 96

REFUSED ....................................................................................................................................... 97

ALL

D24. Does this facility have written protocols for managing acute under nutrition?

INSTRUCTION: ASK TO SEE WRITTEN PROTOCOLS.

Select one only

YES, PROTOCOL SEEN ................................................................................................................... 1

YES, PROTOCOL NOT SEEN ........................................................................................................ 2

NO .......................................................................................................................................................... 0

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97

ONLY IF I1 = 3, 6, OR 7 (REGION = NORTHERN, UE, OR UW)

D25. Does this facility have nutrition counseling cards, key nutrition messages leaflets, nutrition

pamphlets, or other nutrition materials?

INSTRUCTION: ASK TO SEE MATERIALS.

Select one only

YES, SEEN ............................................................................................................................................. 1

YES, NOT SEEN .................................................................................................................................. 2

NO .......................................................................................................................................................... 0

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97

ALL


D26a. Currently does this facility have a working hand washing station or veronica bucket in place?

Select one only

YES .......................................................................................................................................................... 1

NO .......................................................................................................................................................... 0

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97

ALL

D26b. In the last two complete months, did staff in this facility consistently wear gloves when

needed for prevention and control of infections?

Select one only

YES .......................................................................................................................................................... 1

NO .......................................................................................................................................................... 0

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97

ALL

D26o. Currently, what other sanitation measures does this facility have in place for prevention and

control of infections?

INSTRUCTION: IF THERE ARE NO OTHER MEASURES, ENTER ‘NONE.’



SANITATION MEASURES (STRING 350)


ALL

D27. Please tell me which of the following sterilization measures this facility currently has in place

for prevention and control of infections. Currently, does this facility … for prevention and


Yes No

D

K Refused

a. has a protocol in place for mixing chlorine for disinfection

b. have disinfectants

c. disinfect instruments

d. have functioning sterilizing equipment such as boilers or

autoclaves

e. sterilize equipment

ALL

D27o. Currently, what other sterilization measures does this facility have in place for prevention

and control of infections?




STERILIZATION MEASURES

(STRING 350)

ALL

D28. Please tell which of the following disposal measures this facility currently has in place for

prevention and control of infections?

Currently, does this facility … for prevention and control of infections?

Yes No

D

K Refused

a. Use a sharps container

b. have available a functioning incinerator

c. have separate waste disposal

d. have available polythene bags for waste


ALL

D28o. Currently, what other disposal measures does this facility have in place for prevention and





DISPOSAL MEASURES

(STRING 350)

ALL

D29. Please tell me which of the following measures this facility currently has in place for dealing

with contagious clients for prevention and control of infections at the facility.

Currently, does this facility …

Yes No

D

K Refused

a. Separate sick newborns from healthy newborns?

b. Separate clients with contagious diseases from healthy clients?

ALL

D29o. Currently, what other measures does this facility have in place for dealing with contagious

clients for prevention and control of infections at the facility?




MEASURES (STRING 350)

IF I4=1

D30. What type of water supply does this facility have?


PIPED WATER (MUST BE OBSERVED) ....................................................................................... 1

BORE HOLE (MUST BE OBSERVED) ........................................................................................... 2

WELL...................................................................................................................................................... 3

OTHER .................................................................................................................................................. 99

NONE .................................................................................................................................................... 5

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97


IF D30=99

D30o. What type of water supply does this facility have?



WATER SUPPLY

(STRING 150)

IF I4=1

D31. Does this facility have a functional toilet or latrine?

YES .......................................................................................................................................................... 1

NO .......................................................................................................................................................... 0

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97

D31=1

D32. What type of toilet or latrine does this facility have?


FLUSH TOILET.................................................................................................................................... 1

VENTILATED PIT LATRINE .......................................................................................................... 2

OTHER .................................................................................................................................................. 99

DON’T KNOW ................................................................................................................................. 96

REFUSED ............................................................................................................................................. 97

IF D32=99

D32o. What type of toilet or latrine does this facility have?



TOILET OR LATRINE

(STRING 150)


E. MALARIA

ALL

E1. MALARIA

Now I would like to focus on malaria.

Currently, how many staff members here typically provide treatment for malaria?



________________________NUMBER OF STAFF

(RANGE 0-99)

IF E1 >0

E2. Could we please look at the consulting room register?

In the last two complete months, based on the register entries, how many clients seen at

this facility had a provisional diagnosis of malaria?

DOCUMENTATION: CONSULTING ROOM REGISTER



_________________NUMBER OF CLIENTS

(RANGE 0-999)

IF E2>0

E3a. In the last two complete months, how many clients with a provisional diagnosis of malaria

and who were tested for malaria using a Rapid Diagnostic Test, also known as an RDT, or a

microscopy test had their results recorded in the consulting room register?





(RANGE 0-999)


IF E2>0

E3b. In the last two complete months, how many clients with a provisional diagnosis of malaria


microscopy test had a positive test result recorded in the consulting room register?





(RANGE 0-999)

IF E2>0

E3c. In the last two complete months, how many clients with a provisional diagnosis of malaria


microscopy test, and had a positive test result recorded in the consulting room register, had

treatment results recorded?





(RANGE 0-999)

[IF E2>0] AND [IF E2>E3a]

E4i. In the last two complete months, were there client with provisional diagnosis of malaria

who were not tested for malaria using RDT or microscopy test?

COMPARE E2 AND E3a

YES .......................................................................................................................................................... 1

NO .......................................................................................................................................................... 0

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97


IF E4i=1

E4. In the last two complete months, what were some of the reasons that not every client with

a provisional diagnosis of malaria was tested for malaria using an RDT or microscopy test?


RDT / LAB IS NOT AVAILABLE AT ALL TIMES OF THE DAY AND NIGHT ........................... 1

INSUFFICIENT SUPPLY OF RDT ............................................................................................................. 2

LACK IN SKILL IN CONDUCTING RDT / MICROSCOPY ............................................................ 3

DO NOT WANT TO WASTE CLIENT’S TIME OR DELAY CLIENT FURTHER ...................... 4

THIS FACILITY DOES NOT TREAT MALARIA ................................................................................... 5

CLIENT WAS DIAGNOSED BASED ON SYMPTOMS ...................................................................... 6

TEST WERE CONDUCTED BUT RESULTS WERE NOT RECORDED....................................... 7

NO SPECIFIC REASON ............................................................................................................................... 8

ANOTHER REASON ................................................................................................................................... 99

DON’T KNOW ............................................................................................................................................. 96

REFUSED .......................................................................................................................................................... 97

IF E4=99

E4o. What were the other reasons that not every client with a provisional diagnosis of malaria

was tested for malaria using an RDT or microscopy test?



REASONS NOT TESTED

(STRING 150)


ALL; E5.b-d ONLY IF I4=3

E5. I will now read you a short list of staff members. Please tell me whether within the past 12

months any of these types of staff members have been trained on malaria data collating and

reporting.

INSTRUCTION: MARK ‘YES’ IF ONE OR MORE STAFF WITHIN A CATEGORY HAVE BEEN TRAINED.

In the past 12 months, have one or more of the….been trained or coached on malaria data

collating and reporting?


Not

Applicable

a. Nurses or CHOs?

b. Out Patient Department or OPD in-charges?

c. Records staff members?

d. Lab staff members?

e. Other staff members?

IF E5e=YES

E5o. In the past 12 months, who were the other staff members who were trained on malaria data

collating and reporting?



OTHER STAFF MEMBERS

(STRING 150)

ALL

E6. In the past 12 months, has the person or one of the people in charge of records in this

facility been trained on or received supportive supervision visits related to malaria data

reporting and reporting tools, such as a Consulting Room or CR register, a morbidity

register, or the monthly anti-malarial returns?

Select one only

YES .......................................................................................................................................................... 1

NO .......................................................................................................................................................... 0

FACILITY DOES NOT HAVE A PERSON IN CHARGE OF RECORDS ............................ 2

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97


ALL

E7. Now I am going to ask you how many staff members have participated in at least one

training in the past 12 months on a series of topics related to malaria. Please do not include

community health volunteers in these counts.

In the past 12 months, how many, if any of current staff members have participated in at

least one training [FILL a-e]…

Number D. K. Refused

a. on Malaria in Pregnancy, also known as MIP?

b. on malaria case management?

c. or refresher training on malaria Rapid Diagnostic Tests, also

known as RDTs?

d. ONLY IF I4=3 on malaria microscopy?

PROBE: Can be either Malaria Diagnostic Refresher Training

(MDRT) or any formally organized training on parasite

detection and species identification for malaria parasites.

e. on any other topic related to malaria?

IF 0 < E7e < 96

E7o. In the past 12 months, on what other topics related to malaria have current staff members

participated in at least one training?



OTHER TOPICS

(STRING 150)

ALL

E8. In the past 12 months, how many, if any, of the current staff members who were trained in

any topic related to malaria received training that included supportive supervision?



_______________________TRAINING AND SUPPORTIVE SUPERVISION

(RANGE 0-99)


ALL

E9. In the past 12 months, how many, if any, Supportive Supervision visits has this facility

received from district level supervisors on…

Number D.K. Refuse Not Applicable

a. malaria case management?

b. malaria data collating and reporting?

c. Rapid Diagnostic Tests?

d. supply chain management?

ALL

E10. In the past 12 months, how many, if any, community health volunteers participated in at

least one training on a topic related to malaria?



__________________________VOLUNTEER TRAINED IN MALARIA

(RANGE 0-99)

IF E10>0

E11. In the past 12 months, how many of the CHVs who were trained on at least one topic

related to malaria received coaching by supervisors to address documented errors, such as

through Supportive Supervision visits?



__________________________VOLUNTEERS COACHED

(RANGE 0-99)


F. TRAINING AND SUPERVISOR RECORDS

ALL

F1. Does your facility maintain a list of when refresher trainings, new skills trainings, or

professional development trainings are due and conducted?

IF YES, ASK, Can I see it?

DOCUMENTATION: TRAINING LIST/REGISTER

INSTRUCTIONS: YOU MUST SEE THE LIST. THE LIST SHOULD INCLUDE DATES, AND WHEN

(REFRESHER) TRAININGS ARE DUE AND WERE CONDUCTED.

Select one only

YES .......................................................................................................................................................... 1

NO .......................................................................................................................................................... 0

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97


ALL;

START OF TRAINING LOOP.

PROGRAMMER: ASK F3-F6 FOR THE FIRST TRAINING TYPE / SUB-QUESTION F2[a-j] THAT IS NOT

EQUAL TO 0, 96 OR 97. ASK ALL 4 QUESTIONS FOR THAT TRAINING TYPE, AND THEN ASK F2[b-k]

ABOUT THE NEXT TRAINING TYPE. IF ELIGIBLE, ASK F3-F6 BEFORE MOVING TO F2 FOR THE NEXT

TRAINING TYPE. CONTINUE TO ASK F3-F6 FOR ALL ELIGIBLE TRAINING TYPES [a-j], BEFORE MOVING

TO THE NEXT TRAINING TYPE.

F2. Now I would like to ask you about different types of training for the staff in this facility.

In the past 12 months, how many current staff members, not including community health

volunteers, have participated in at least one training on…

a. supply chain and logistics management based on the

Logistics Management Standard Operating

Procedures Manual?

_____________STAFF TRAINED

(RANGE 0-97)

DON’T KNOW .......................... 96

REFUSED ....................................... 97

b. Infant and Young Child Feeding, also known as IYCF? _____________STAFF TRAINED

(RANGE 0-97)

DON’T KNOW .......................... 96

REFUSED ....................................... 97

c. management of acute malnutrition? _____________STAFF TRAINED

(RANGE 0-97)

DON’T KNOW .......................... 96

REFUSED ....................................... 97

d. community management of acute malnutrition, also

known as CMAM?


(RANGE 0-97)

DON’T KNOW .......................... 96

REFUSED ....................................... 97

e. anemia prevention control? _____________STAFF TRAINED

(RANGE 0-97)

DON’T KNOW .......................... 96

REFUSED ....................................... 97

f. supervision skills? _____________STAFF TRAINED

(RANGE 0-97)

DON’T KNOW .......................... 96

REFUSED ....................................... 97

g. Essential Newborn Care, also known as ENC? _____________STAFF TRAINED

(RANGE 0-97)

DON’T KNOW .......................... 96

REFUSED ....................................... 97

h. Maternal, Neonatal and Child Health life saving skills,

also known as MNCH life saving skills?


(RANGE 0-97)

DON’T KNOW .......................... 96

REFUSED ....................................... 97


i. Integrated Management of Neonatal Childhood

Illness, also known as IMNCI?


(RANGE 0-97)

DON’T KNOW .......................... 96

REFUSED ....................................... 97

j. Active Management of Third Stage of Labor, also

known as AMTSL?


(RANGE 0-97)

DON’T KNOW .......................... 96

REFUSED ....................................... 97

k. Any other topic? _____________STAFF TRAINED

(RANGE 0-97)

DON’T KNOW .......................... 96

REFUSED ....................................... 97

IF 0 < F2k < 96;

ASK THIS QUESTION AFTER F2k, IF ELIGIBLE.

DO NOT ASK F3-F6 FOR THIS TRAINING. GO TO G1.

F2ko. In the past 12 months, on what other topics have current staff members participated in at

least one training?



OTHER TOPICS

(STRING 150)

IF F2[a-j] ≠ 0, 96 OR 97.

F3[a-j]. For the training on [F2a-j], what was the title of staff members who participated in

that training?


NURSES ................................................................................................................................................. 1

COMMUNITY HEALTH OFFICER ................................................................................................ 2

PHYSICIAN ASSISTANT .................................................................................................................. 3

MEDICAL ASSISTANT ...................................................................................................................... 4

MIDWIVES ............................................................................................................................................ 5

LAB WORKERS .................................................................................................................................. 6

COMMUNITY BASED AGENTS OR VOLUNTEERS .............................................................. 7

DISEASE CONTROL OFFICERS .................................................................................................... 8

BIOSTATISTICS OR RECORD OFFICERS OR DATA MANAGERS .................................. 9

NON-CLINICAL STAFF ................................................................................................................... 10

OTHER STAFF .................................................................................................................................... 99

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97


IF F3[a-j] = 99

F3[a-j]o. What was the title of the other staff who participated in that training?



OTHER TITLES

(STRING 150)

F2[a-j] >0 AND < 96

F4[a-j]. For the

training on [F2a-j], what training approach was used - was it residential, facility-based, on

the job training, or something else?


RESIDENTIAL ...................................................................................................................................... 1

FACILITY-BASED ............................................................................................................................... 2

ON THE JOB TRAINING, ALSO KNOWN AS OJT ............................................................... 3

NON_RESIDENTIAL ........................................................................................................................ 4

SOMETHING ELSE ............................................................................................................................. 99

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97

IF F4[a-j] = 99

F4[a-j]o. What was the other training approach used for that training



OTHER TRAINING APPROACH

(STRING 150)

F2[a-j] >0 AND < 96

F5[a-j]. Was the training on [F5a-j] part of or followed by supportive supervision?

Select one only

YES .......................................................................................................................................................... 1

NO .......................................................................................................................................................... 0

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97


F2[a-j] >0 AND < 96

F6[a-j]. Who

provided the training on [F5a-j]?


SUB-DISTRICT .................................................................................................................................... 1

DISTRICT .............................................................................................................................................. 2

REGION ................................................................................................................................................ 3

NON-GHS, SUCH AS NGO OR DONOR PROJECT ............................................................ 99

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97

IF F6[a-j] = 99

F6[a-j]o. Who provided the training?



OTHER TRAINING PROVIDER

(STRING 150)

END OF TRAINING LOOP.

LOOP THROUGH EACH ELIGIBLE TRAINING IN F2[a-j], THEN PROCEED TO F2k.


G. ACTION PLANS AND QUALITY IMPROVEMENT

ALL

G1. ACTION PLANS AND QUALITY IMPROVEMENT

Now I would like to ask a bit about [(INCLUDE IF I4 = 3) quality assurance and] quality

improvement within your facility.

Does this facility have a quality improvement or QA/QI action plan in place in which

activities are scheduled for the current planning year 2016-2017?

INSTRUCTION: ASK TO SEE PLAN.

A QA/QI PLAN IS AN OVERALL MASTER PLAN TO IMPROVE QUALITY OF SERVICE DELIVERY AT A

FACILITY. AN ACTION PLAN IS THE PLAN WHICH DETAILS ACTIVITIES, SCHEDULES AND DEADLINES

AND PERSONS RESPONSIBLE FOR CARRYING OUT THE PLAN. IN CIRCUMSTANCES WHERE THE

MASTER PLAN HAS ALL THESE DETAILS BUT THERE IS NO SEPARATE ACTION PLAN-THE MASTER

PLAN IS ACCEPTABLE AS AN ACTION PLAN. PLEASE NOTE, ANY ACTION PLAN WILL DO –

COMMUNITY HEALTH ACTION PLAN, QI ACTION PLAN, ETC.

Select one only

YES, PLAN SEEN ................................................................................................................................. 1

YES, PLAN NOT SEEN ..................................................................................................................... 2

NO .......................................................................................................................................................... 0

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97


IF G1=1 OR 2

G2. What topics does the action plan include?


NUTRITION ........................................................................................................................................ 1

MALARIA .............................................................................................................................................. 2

MATERNAL HEALTH ....................................................................................................................... 3

NEONATAL, INFANT AND CHILD HEALTH ......................................................................... 4

OTHER SPECIFIC ACTION AREA ............................................................................................... 99

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97

IF G2 = 99

G2o. What other topics does the action plan include?



OTHER TOPICS

(STRING 150)

IF I4 = 3

G3. Does this facility have a quality assurance or QA/QI team?

INSTRUCTION: A QA/QI TEAM IS AT LEAST TWO PEOPLE WHO REVIEW AT LEAST QUARTERLY

IMPLEMENTATION OF THE FACILITY QA/QI ACTION PLAN ACTIVITIES AGAINST SERVICES.

Select one only

YES .......................................................................................................................................................... 1

NO .......................................................................................................................................................... 0

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97

IF G3 = 1

G4. In the last complete quarter, how many meetings has the quality assurance or QA/QI team

held?



___________________________NUMBER OF MEETINGS

(RANGE 0-99)


IF (G1 = 1 OR 2) & G2=1

G5. In the last two complete months, what steps have been taken to implement nutrition

aspects of your facility’s QA/QI action plan, if any?

INSTRUCTION: ASK TO SEE ANYTHING THEY CAN SHOW YOU TO VERIFY STEPS IN IMPLEMENTING

NUTRITION ASPECTS OF THE ACTION PLAN, SUCH AS MINUTES OF MEETINGS, DATA REVIEWED FOR

DECISION-MAKING, PHYSICAL IMPROVEMENTS OR NEW PROCEDURES AT THE FACILITY THAT

CORRESPOND TO THE PLAN (E.G. NEW REGISTER).

SELECT YES, IF AT LEAST ONE TYPE OF THE ABOVE EVIDENCE IS PROVIDED THAT SUPPORTS STEPS

TAKEN.

YES STEPS WERE TAKEN, SAW SUFFICIENT EVIDENCE ................................................... 1

SUFFICIENT STEPS NOT TAKEN OR NO EVIDENCE ......................................................... 0

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97

IF (G1 = 1 OR 2) & G2=2

G6. In the last two complete months, what steps have been taken to implement malaria aspects

of your facility’s QA/QI action plan, if any?

INSTRUCTION: ASK TO SEE ANYTHING THEY CAN SHOW YOU TO VERIFY STEPS IN IMPLEMENTING

MALARIA ASPECTS OF THE ACTION PLAN, SUCH AS MINUTES OF MEETINGS, DATA REVIEWED FOR

DECISION-MAKING, PHYSICAL IMPROVEMENTS OR NEW PROCEDURES AT THE FACILITY THAT

CORRESPOND TO THE PLAN (E.G. INCREASED COMMUNITY OUTREACH).. SELECT YES, IF AT LEAST

ONE TYPE OF THE ABOVE EVIDENCE IS PROVIDED THAT SUPPORTS STEPS TAKEN.



DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97

IF [G1 = 1 OR 2] & [G2=3, 4 OR 99]

G7. In the last two complete months, what [other] steps have been taken to implement your

facility’s QA/QI action plan, if any?

INSTRUCTION: ASK TO SEE ANYTHING THEY CAN SHOW YOU TO VERIFY STEPS, SUCH AS MINUTES

OF MEETINGS, DATA REVIEWED FOR DECISION-MAKING, PHYSICAL IMPROVEMENTS OR NEW

PROCEDURES AT THE FACILITY THAT CORRESPOND TO THE PLAN (E.G. NEW REGISTERS OR

IMPROVED STORAGE FACILITIES).

SELECT YES, IF AT LEAST ONE TYPE OF THE ABOVE EVIDENCE IS PROVIDED THAT SUPPORTS STEPS

TAKEN



DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97


ALL

G8. Can you please show me any progress activity graphs or tables you have in the facility here,

and describe what they show?

INSTRUCTION: ASK TO SEE THE GRAPHS AND/OR TABLES AND SELECT BELOW ALL YOU SEE.


MATERNAL HEALTH (ANC OR PNC) GRAPH OR TABLE ................................................ 1

CHILD HEALTH GRAPH OR TABLE........................................................................................... 2

MALARIA, OR INSECTICIDE-TREATED NET (ITN) DISTRIBUTION GRAPH

OR TABLE ............................................................................................................................................ 3

EXPANDED PROGRAM ON IMMUNIZATION OR EPI GRAPH OR TABLE ................. 4

DO NOT HAVE ANY GRAPHS OR TABLES ............................................................................ 0

OTHER TOPICS ................................................................................................................................. 99

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97

IF G8 = 99

G8o. What are the topics of the other progress activity graphs or tables you have?



OTHER TOPICS

(STRING 150)

IF G8 ≠ 0, 96 OR 97;

PROGRAMMER, ALLOW YEAR WITHOUT MONTH TO BE ENTERED, IF NEED BE.

G9m. For the graph or table that has the most up-to-date data on it, about what month does the

data come from?

____________MONTH

DON’T KNOW .......................................................................................................................... 96

REFUSED ....................................................................................................................................... 97

G9y. For the graph or table that has the most up-to-date data on it, about what year does that

data come from?

___________YEAR

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97


ALL

G10. In the last two months, before this facility’s monthly DHIMS2 reports were submitted, did

someone validate the reports using the source documents?

INSTRUCTION: DATA CAN BE VALIDATED BY A TEAM THAT IS INTERNAL OR EXTERNAL, AND AS

SMALL AS ONE PERSON. IT JUST NEEDS TO BE ONE OR MORE PEOPLE WHO CHECK NUMBERS FOR

DHIMS2 REPORTS AGAINST THE SOURCE DOCUMENTS BEFORE THE MONTHLY SUBMISSION. IN

THEORY THE SUB-DISTRICT DATA MANAGER SHOULD VERIFY FOR CHPS (THAT SEVERAL CHPS’

DATA ARE AGGREGATED CORRECTLY) AND THE HEALTH CENTER MEDICAL ASSISTANT OR DATA

MANAGER FOR HEALTH CENTERS (DATA AGGREGATED CORRECTLY FROM ALL DEPARTMENTS

WITHIN THEIR CENTER).

Select one only

YES .......................................................................................................................................................... 1

NO .......................................................................................................................................................... 0

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97

IF [G1 = 1 OR 2] OR [G8 = 1, 2, 3, 4, OR 99]

G11. Now I will ask if you have used data generated for monthly reports and the facility graphs or

tables that you prepared to do a series of planning and decision-making tasks.

In the past 12 months, have you used these data to [FILL FROM a-f BELOW]?


a. plan community outreach?

b. improve supply chain and logistics?

c. identify training needs?

d. help develop or revise action plans?

e. help allocate resources?

f. plan or decide anything else?

IF G11f = 1

G11fo. In the past 12 months, what else have you used these data to plan or decide?



OTHER PLANNING TASKS

(STRING 150)


H. SUPPLIES

ALL;

PROGRAMMER, WHERE WE HAVE “OTHER, SPECIFY,” WHAT IS THE BEST WAY TO CAPTURE ANY

DATA TO BE ADDED, SUCH AS H1.6.d?

H1. Now I would like to talk about equipment, supplies and supply chain issues.

Can we look at your inventory control, bin or tally cards or inventory records? I would like

to note for each supply on my list whether an inventory control card exists, whether there

has been a stock-out in the last two complete months, and whether the item is available

today. For six specific supplies, I would like to conduct an actual count of the quantity on

hand.

INSTRUCTION: LOOK AT THE INVENTORY CONTROL CARDS. WITH THE RESPONDENT, NOTE AND

CHECK OFF EACH SUPPLY ON THE CHECKLIST BELOW THAT HAS AN INVENTORY CONTROL CARD,

AND ANSWER THE RELEVANT QUESTIONS FOR EACH COMMODITY BEFORE MOVING ON TO THE

NEXT COMMODITY. WHERE APPLICABLE COUNT COMMODITIES

H1.1. Is there an inventory control card for the commodity?

IF H1.1 = YES, ASK

H1.2. Has there been a stock-out for the commodity in the last 2 complete months?

H1.3. Was the inventory card updated within the last 30 days?

H1.4. Is the commodity available today?

IF H1.1 = YES AND COMMODITY IS HIGHLIGHTED IN GREEN, COUNT AND RECORD THE SUPPLY ON

HAND, NOTING RESULTS IN H1.5 AND H1.6.

DOCUMENTS NEEDED: INVENTORY CONTROL, TALLY OR BIN CARDS.

Commodity H1.1.

Control

card exists

(Y/N/DK/R

)

H1.2. Stock-

out in last two

complete

months

(Y/N/DK/R)

H1.3. Card

updated in last

30 days

(Y/N/DK/R)

H1.4. Item

available

today (Y /

N / DK /

R)

IF H1.4=1

H1.5

Actual

Count-

Expired/

Unexpired,

DK / R

H1.6 For

supplies

counted,

note unit,

DK / R

NUTRITION COMMODITIES

a. Albendazole for

deworming

b. Iron and Folic Acid

tablets, also known

as IFA tablets (WE

WANT COMBINED

TABLETS. IRON OR

FOLIC ACID ALONE

DO NOT QUALIFY.

IRON 3 IS ONE

NAME)


Commodity H1.1.

Control

card exists

(Y/N/DK/R

)

H1.2. Stock-

out in last two

complete

months

(Y/N/DK/R)

H1.3. Card

updated in last

30 days

(Y/N/DK/R)

H1.4. Item

available

today (Y /

N / DK /

R)

IF H1.4=1

H1.5

Actual

Count-

Expired/

Unexpired,

DK / R

H1.6 For

supplies

counted,

note unit,

DK / R

c. Oral rehydration

Salts and Zinc

tablets

d. First-line antibiotic

treatment, or

amoxicillin for

Severe acute

malnutrition, also

known as SAM

BEmONC Commodities Health Centers Only – IF I4 = 3

e. Parenteral

antibiotics

f. Magnesium Sulfate

for preeclampsia

and eclampsia

MALARIA COMMODITIES

g. Artemether +

Iumenfantrine

(ANY KIND IS FINE)

h. Pediatric syrup

paracetamol

i. Adult paracetamol

j. Sulfadoxine

Pyrimethamine

(SP)

FAMILY PLANNING COMMODITIES: H1x-cc ONLY IF D18 = 2 OR 3

k. hormonal implant

such as Implanon,

Implanon NXT,

Jadelle, Sino

Inplant II, or

Norplant

l. An intrauterine

device, also known

as an IUD

m. combined oral

contraceptive pills

n. progestogen-only

pill, also known as

PoP


Commodity H1.1.

Control

card exists

(Y/N/DK/R

)

H1.2. Stock-

out in last two

complete

months

(Y/N/DK/R)

H1.3. Card

updated in last

30 days

(Y/N/DK/R)

H1.4. Item

available

today (Y /

N / DK /

R)

IF H1.4=1

H1.5

Actual

Count-

Expired/

Unexpired,

DK / R

H1.6 For

supplies

counted,

note unit,

DK / R

o. condoms

p. Vitamin A

1) bottles 2) boxes

3) pieces 4) sachets 5) maxi bags

6) mini bags 7) vials 8) capsules

9) other –

specify q. Uterotonic drugs,

such as Oxytocin

or ergometrine

SAME

RESPONSE

CATEGORIE

S

r. Malaria rapid

diagnostic test kits,

also known as

RDTs

SAME

RESPONSE

CATEGORIE

S

s. Artesunate +

amodiaquine (ANY

KIND IS FINE)

SAME

t. an injectable

contraceptive

SAME

u. Pentavalent

USE

RESPONSE

CATEGORIE

S FROM

ABOVE


Commodity H1.1.

Control

card exists

(Y/N/DK/R

)

H1.2. Stock-

out in last two

complete

months

(Y/N/DK/R)

H1.3. Card

updated in last

30 days

(Y/N/DK/R)

H1.4. Item

available

today (Y /

N / DK /

R)

IF H1.4=1

H1.5

Actual

Count-

Expired/

Unexpired,

DK / R

H1.6 For

supplies

counted,

note unit,

DK / R

IMMUNIZATION COMMODITIES

v. BCG, also known

as Bacillus

Calmette-Guerin

Vaccine

w. Pneumo

x. Polio vaccine

y. Rotarix

z. Measles vaccine

aa. Yellow Fever

vaccine

bb. Tetanus Toxoid


ALL FOR a; D4=1 FOR b-l

H2. Now I would like to go through a number of supplies and equipment to learn whether they

are available today. I will start by asking about the current availability of a list of equipment

required for childbirth. To start,

Currently, does your facility have in working order the following?

INSTRUCTION: THE PARTS OF EACH KIT ARE LISTED IN CASE THE PERSON DOES NOT

KNOW WHAT THE KIT IS. YOU DO NOT NEED TO CHECK FOR EACH ITEM.


a. Domiciliary midwifery kit? (INCLUDES PLASTIC SHEET,

PLASTIC APRON, BLADE, CORD LIGATURES, TABLET OF

MISOPROSTOL, COTTON WOOL OR GAUZE SWABS,

GLOVES, AND SOAP)

b. Sterile Delivery Kit? (INCLUDES GAUZE, ARTERY FORCEPS,

BOWL TO RECEIVE PLACENTA, DISPOSABLE GLOVES, CORD

CLAMP CORD LIGATURES, CORD SCISSORS, AND SPONGE-

HOLDING FORCEPS, OVUM AND/OR OBSTETRICS FORCEPS)

c. Suturing set? (INCLUDES HEAT SOURCE (PREFERABLY A

RADIANT HEATER) TO PREVENT HEAT LOSS (OR EXTRA

BLANKETS AND LINEN CAN BE USED TO COVER THE

NEWBORN), SUCTION DEVICE, SELF-INFLATING BAG OF

NEWBORN SIZE, TWO MASKS (FOR NORMAL AND SMALL

NEW-BORNS) FOR VENTILATION, STERILE GLOVES, CLEAN

COT SHEETS TO RECEIVE AND DRY BABY THOROUGHLY,

SCISSORS TO CUT CORD, STERILE CORD TIES/CLAMPS, HEAD

COVERING (CAP) FOR BABY, CLOCK, STETHOSCOPE)

d. Hand held vacuum extractor?

e. An examination light?

f. An examination couch?

g. postpartum hemorrhage, or PPH, pack for post-partum

management? (NORMAL SALINE – 1.0 LITRE, GIVING SET,

CANNULA SIZE – 16/18G – 1, DISPOSABLE GLOVES, SURGICAL

GLOVES, INJECTION OXYTOCIN – 40 UNITS, INJECTION

ERGOMETRINE (ERGOT) – 1.0 MG, SYRINGE AND NEEDLES,

COTTON SWAB, TOURNIQUET, PLASTER FOR SECURING

LINE, CATHETER, PLAIN SPECIMEN BOTTLE FOR GROUPING

AND CROSS-MATCHING, CONDOM TAMPONADE SET)

h. Pre-eclampsia & eclampsia pack for management of

eclampsia?

i. Resuscitation kits for resuscitating babies (Self-inflating bag

and mask, suction bulb)?

PROGRAMMER: j-l BELOW ARE ONLY IF I4 = 3

l. A large postpartum Curette?

ALL


H3. Now I would like to ask you about equipment required for nutrition assessment and

counseling services.

Currently, does your facility have in working order….?

Yes No

D

K Refused

a. a mid-upper arm circumference measuring tape, also known as

a MUAC tape?

b. a tape measure?

c. a Hanging scale or Salter weighing scale?

d. an Adult weighing scale or bathroom scale?

e. a Baby weighing scale or a newborn or infant weighing scale?

f. an Infantometer?

g. a weighing pant?

h. an Integrated Management of Neonatal and Childhood Illnesses

chart booklet, also known as an IMNCI chart booklet?

i. an Infant and Young Child Feeding or IYCF register?

j. HemoCue Hb device and testing strips or coulter counter and

testing strips?


ALL

H4. Now I wanted to ask you about storage conditions and equipment. Currently, do you have in

working order …?

DOCUMENT NEEDED: INVENTORY RECORDS.

Yes No

D

K

Refused

a. a vaccine refrigerator? 1 0 96 97

b. IF H4a=1: a vaccine fridge thermometer? 1 0 96 97

c. IF H4b=1: an up-to-date temperature monitoring sheet? 1 0 96 97

c.2. IF H4c = 1: What is the date of the most recent entry on the

monitoring sheet?

DD/MM/YY

YY

96 97

d. Ice packs? 1 0 96 97

e. a cold box? 1 0 96 97

f. H4a=1: an emergency storage plan? 1 0 96 97

g. a vaccine carrier? 1 0 96 97

h. Clock or watch with second hand? 1 0 96 97

ALL

H5. Finally, I have a list of other important supplies and equipment required for running a health

facility.

INSTRUCTION: RECORD WHICH OF THESE IS AVAILABLE AT THIS FACILITY.

DOCUMENT NEEDED: INVENTORY RECORDS.

Currently, does your facility have [FILL FROM a-b BELOW]…


a. a generator?

b. a fire extinguisher?

ALL

H6. Is the Standard Operating Procedures, also known as the SOP, which contains the manual

for logistics management and supply chain management available at this facility?

INSTRUCTION: ASK TO SEE THE SOP IF THE ANSWER IS YES.

YES, SEEN ............................................................................................................................................. 1

YES, NOT SEEN .................................................................................................................................. 2

NO .......................................................................................................................................................... 0

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97


ALL

H7. In the last 2 complete months, did someone in your facility use the RRIRV or Report

Requisition Issue and Receipt Voucher to record consumption of supplies for the purposes of

reordering commodities?

INSTRUCTION: ASK TO SEE THE RRIRV OR RIRV IF THE ANSWER IS YES.

YES .......................................................................................................................................................... 1

NO .......................................................................................................................................................... 0

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97

IF H7 = 1

H7o. In the last 2 complete months, who completed the RRIRV to record consumption of supplies

for the purposes of reordering commodities?



STAFF TITLE AT FACILITY

(STRING 150)

ALL

H8. Is there one or more people here who are responsible for ordering supplies?

YES .......................................................................................................................................................... 1

NO .......................................................................................................................................................... 0

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97

IF H8 = 1

H8o. Who in this facility is responsible for ordering supplies?



STAFF TITLE AT FACILITY

(STRING 150)


ALL

H9. In general, how often is this facility unable to provide a prescribed medication, vaccine or

other supply a client needs due to a stock-out – once or more per week, once every two

weeks, once every three weeks, once per month, or less often than that?

Select one only

ONCE OR MORE PER WEEK ........................................................................................................ 1

ONCE EVERY TWO WEEKS ......................................................................................................... 2

ONCE EVERY THREE WEEKS ....................................................................................................... 3

ONCE PER MONTH ......................................................................................................................... 4

LESS OFTEN THAN ONCE PER MONTH ................................................................................. 5

NEVER ................................................................................................................................................... 6

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97

ALL

H10. In general, if this facility does not have a supply or medicine a client needs, where do you

direct the client to go to find it?



(STRING 800)

ALL

H11. In the past 12 months, to forecast supply needs for malaria Rapid Diagnostic Tests, or RDTs,

what information did this facility use?


NUMBER OF MALARIA CASES GIVEN A FINAL DIAGNOSIS OF MALARIA ................ 1

NUMBER OF CASES WITH PROVISIONAL DIAGNOSIS OF MALARIA ......................... 2

OUTPATIENT DEPARTMENT OR OPD ATTENDANCE .................................................... 3

NUMBER OF RDTS AND MICROSCOPY TESTS PERFORMED ......................................... 4

SOME OTHER DATA OR METHOD ........................................................................................... 99

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97


IF H11 = 99

H11o. In the past 12 months, what other data or method was used to forecast supply needs for

malaria RDTs?



DATA OR METHOD

(STRING 150)

J. PHONE SERVICE

ALL

J1. Finally, I wanted to ask you a few questions about telephone service at the facility.

Currently, does this facility have a working cell phone?

INSTRUCTION: A PERSONAL CELL PHONE THAT CAN BE USED FOR WORK WILL COUNT.

YES .......................................................................................................................................................... 1

NO .......................................................................................................................................................... 0

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97

IF J1 = 1

J2. Does the cellphone … [FILL FROM a-d BELOW]…


a. Have SMS capability? (SHORT MESSAGE SERVICE)

b. Have MMS capability? (MULTIMEDIA SERVICE)

c. Allow you to access the internet on it?

d. Have a camera?

IF J1 = 1

J3. Is the cellphone a Smartphone or a basic phone?

SMARTPHONE ................................................................................................................................... 1

BASIC / YAM ........................................................................................................................................ 0

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97


ALL

J4. Currently, does this facility have a working computer or tablet?

YES .......................................................................................................................................................... 1

NO .......................................................................................................................................................... 0

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97

IF J4=1

J5. Currently, does this facility have internet access for the computer or tablet?

YES .......................................................................................................................................................... 1

NO .......................................................................................................................................................... 0

DON’T KNOW .................................................................................................................................. 96

REFUSED ............................................................................................................................................... 97

K. CONCLUSION

ALL

K1. That was my last question for you. Before we conclude, do you have any questions about

this interview for me?

INSTRUCTION: ANSWER QUESTIONS AS COMPLETELY AS POSSIBLE AND PROCEED TO K2.

ALL

K2. Thank you so much for your help. Your answers are very helpful to us.

PLEASE HAVE AN AUTO “END TIME” RECORDED FOR THE INTERVIEW WHENEVER K3 IS CODED. THE

DATE SHOULD BE INCLUDED IN THE END TIME, SO THAT WE CAN DISTINGUISH BETWEEN END

TIME STAMPS IF MULTIPLE VISITS ARE REQUIRED.

AFTER CODE IS ENTERED HERE, ALL CASES SHOULD GO TO K4.

THE INTERVIEWER SHOULD BE PROMPTED FOR A PHOTO AT K4 REGARDLESS OF RESULT CODE.


K3. Disposition Code:

(STRING 1)

Code:

1. INTERVIEW COMPLETE. COMPLETED ALL QUESTIONS

2. NO ONE AT FACILITY. APPROPRIATE STAFF NOT PRESENT WHEN YOU VISIT THE HEALTH

FACILITY.

3. STAFF NOT AVAILABLE. STAFF ARE PRESENT BUT DO NOT HAVE TIME TO RESPOND TO THE

SURVEY.

4. STARTED, BUT NOT COMPLETE. YOU BEGAN THE INTERVIEW WITH THE RESPONDENT, BUT

WERE UNABLE TO FINISH.

5. REFUSED. THE RESPONDENT DECLINES TO PARTICIPATE, YOU SHOULD ALWAYS TRY A REFUSAL

CONVERSION. BE SURE TO ASK THE RESPONDENT WHY THEY DO NOT WANT TO PARTICIPATE

AND TO LISTEN TO THEIR CONCERNS. IF IT IS UNSUCCESSFUL, RECORD AS MUCH DETAIL AS YOU

CAN ABOUT THE RESPONDENT’S CONCERNS.

6. FACILITY NOT ELIGIBLE. YOU FIND THE FACILITY IS NOT A CHPS ZONE OR A HEALTH CENTER

AND WAS NOT A CHPS OR HEALTH CENTER IN THE LAST TWO YEARS, THE FACILITY WILL BE

INELIGIBLE TO PARTICIPATE. THE CASE WILL BE CLOSED. THE FACILITY WILL ALSO BE INELIGIBLE IF

IT WAS NOT IN ONE OF THE SELECTED SUB-DISTRICTS AT BASELINE.

7. FACILITY NOT LOCATED. THE FACILITY IS NOT LOCATABLE – THERE IS NO WAY TO FIND ANY

MEANS OF REACHING ANYONE AT THE SITE – THE CASE WILL BE CLOSED.

8. FACILITY NOT REACHABLE. THE FACILITY IS NOT REACHABLE – IF THERE IS NO WAY TO

CONTACT ANYONE AT THE SITE - THE CASE WILL BE CLOSED.

9. OTHER. USE ONLY WHEN AN ABOVE CODE DOES NOT ADEQUATELY DESCRIBE THE

DISPOSITION OF THE CASE. IF THIS CODE IS USED, PLEASE CAREFULLY REVIEW ALL ABOVE

DISPOSITION CODES BEFORE SELECTING “9 – OTHER”.

IF K3 = 9

K3o. What is the disposition of this case?

DETAILED COMMENTS MUST BE WRITTEN TO DESCRIBE THE DISPOSITION OF THE CASE.

DISPOSITION OF CASE

(STRING 450)

IF K3 = 2, 3, 4, 9

K3b. Did you set an appointment?

YES .......................................................................................................................................................... 1

NO .......................................................................................................................................................... 0


ALL

K3bi. Record end time and date.

DATE PICKER

ALL; PROGRAMMER, PREPARE FOR PHOTO OF THE FACILITY TO BE TAKEN AND GEO-TAGGED HERE.

NO MATTER WHETHER THE INTERVIEW IS COMPLETED OR NOT, THIS PHOTO SHOULD BE

PROMPTED BEFORE THE INTERVIEWER LEAVES. HOWEVER, THE PHOTO SHOULD BE OPTIONAL.

K4. Take photo of the front of facility before leaving. Try to get the name of the facility in the

photo.

ALL

K5. If you did not get the name of the facility in the photo, would you like to take a second photo?

L. FOR INTERVIEWER

ALL

L1. Please note whether there were any unusual circumstances that occurred during the interview or if

there was anything worthy of note. Was entire interview conducted in English? Please note.

(STRING 800)


Appendix F: Qualitative Interview Guides

1. District directors of health services

IN-DEPTH INTERVIEW GUIDE

To be conducted with the District Director of Health Services (DDHS), who is the head of the District Health

Management Team (DHMT)/District Health Administration in each district. If the DDHS is not available on

the day of the interview, another district health officer may be substituted, preferably the District Health

Information Officer (DHIO) or the District Public Health Officer (DPHO).

Do not read aloud what is in italics nor in bold.

Introduction and consent for audio recording

The purpose of this section is to introduce the respondent to the study and request consent for audio recording.

Thank you for taking the time for this interview today. My name is [insert name], and I am

working on the USAID/Ghana Evaluate for Health midline study of health services in Ghana,

which is funded by the US Agency for International Development and supported by Ghana

Health Service. The goal of this study is to help inform decision-makers about the availability

and integration of health services at the community and sub-district levels, the strength of the

health system at these levels, and health sector governance.

The purpose of this interview is to gather information from District Directors of Health

Services about the quality of the healthcare system and services in your district, and specifically

about the supply chain, use of GHS protocols, referrals, volunteer support to CHPS and use

of DHIMS2 data for management. The survey focuses on sub-district health centers and CHPS

zones.

Your responses will be confidential, that is, none of your responses will be identified as yours

with anyone outside of the study team.

I have a consent form you would need to sign to show you agree to participate in this

interview. Could you read it now?

Once the form is signed: Do you have any questions about the interview?

Before we start, I would like to get your permission to record the interview. This will ensure

that I remember your responses correctly. The recordings from everyone interviewed will be

used for analysis only and will not be published or shared with anyone outside of the study

team. You will not be identified in study reports. Do I have your permission to record the interview?

If yes, turn on voice recorder.

Background information

1. Before we get into the interview, could you tell me your name and how long you have served

as the District Director of Health Services in this district?


Quality of care

2. I would like to start with a few questions about the quality of health care and services in your

district. What is your overall assessment of the quality of health care and services in your

district?

PROBE: In terms of staff, infrastructure/equipment/supplies, access?

3. What do you consider to be the district’s best practices in terms of quality care and services?

4. What challenges does the district face in terms of providing quality health care and achieving

equitable improvements in the health status of Ghanaians in your district, sub-districts and

communities?

5. For CHPS:

a. Is there anything you would like to see improved about your CHPS?

i. If yes, What would you like to see improved?

b. In the last two years, have you noticed any changes in types of services offered at the CHPS

in your district?

i. If yes, What have the changes in services been?

c. In the last two years, have you noticed any changes in the quality of services at the CHPS in

your district?

i. If yes, Please describe what those changes have been.

6. For health centers:

a. Is there anything you would like to see improved about your health centers?


b. In the last two years, have you noticed any changes in types of services offered by health

centers in your district?

i. If yes, What have the changes in services been?

c. In the last two years, have you noticed any change in the quality of services given by health



Collaborating with USAID on health systems strengthening

7. Is your District Health Management Team currently working with the U.S. Agency for

International Development, which is also known as USAID, or any USAID-funded projects?

If yes,

a. What is the current relationship between your District Health Management Team and

USAID?

b. Has your relationship with USAID changed in any way over the last two years?

c. What projects have you worked on together, if any?

If worked together,

i. What have been some of the successes of your organizations working together?

ii. What have been some of the challenges faced in working together?

iii. What would improve your ability to work together well?

Access to supplies and medicines through the supply chain

8. How would you describe access to essential commodities and equipment through the supply

chain within CHPS zones and health centers?


a. Are necessary supplies available at the CHPS and health centers?

9. In the last two years, has access to essential supplies and medicines changed in CHPS zones and

Health Centers, and if so, how?

a. In the last 2 years has the frequency of stock outs in the health centers and CHPS zones in

your district changed, and if so, how and why?

b. In the last 6 months, which basic commodities have been stocked out in health centers and

CHPS in your district?

c. How often do you review and approve requests for basic medicines or supplies from CHPS

zones and Health Centers?

10. What process is used to monitor the stock and use of medicines and supplies at CHPS zones

and health centers? What data are collected? How are these data used?

a. Has this process changed in the last two years, and if so, how?

b. How could data be better used to help ensure constant supplies of commodities and

medicines in your district?

11. In the last 2 years, have there been any changes in the procedure for health centers and CHPS

in reporting when supplies run out or are running low, and if so, how have these procedures

changed?

a. How well does that system work for ensuring supplies and medicines are re-stocked in

time?

b. What are the main challenges to ensuring the availability of basic medicines and supplies?

c. Do you know if data are used to forecast supply needs for Rapid Diagnostic tests – or

RDTs, in CHPS and Health Centers in this district?

i. If yes, What data are used and how are they used?

12. Are there any other reasons for stock-outs to occur in a Health Center or CHPS?

a. What could be done to avoid these causes?

Protocols

13. Do staff at both Health Centers and CHPS in your district have the most current GHS

protocols available to them on Reproductive health?

Probe to determine if the answer is the same or different for Health Centers and CHPS, if necessary.

a. If yes, In your opinion, do staff apply these protocols?

i. If not, Why not?


protocols available to them on Maternal and newborn care?


b. If yes, In your opinion, do staff apply this protocol?

i. If not, Why not?


protocols available to them on Infection Prevention and control?


a. If yes, In your opinion, do staff apply this protocol?

i. If not, Why not?



protocols available to them on Community-Based Management of Acute Malnutrition?


a. If yes, In your opinion, do staff apply this protocol?

i. If not, Why not?

17. What if any system is in place to monitor the use of these protocols by staff in health centers

and CHPS zones?

a. How successful do you think this is?

Referrals

18. Are referrals and follow-up care tracked and information shared between CHPS zones and

health centers?

a. If so, how is this information shared?

i. PROBE: Do clients have their own folders or records, which they bring to

appointments?

b. Is this an effective way to share information?

i. PROBE: Do facilities use the system?

c. Do you think that all clients follow up on referrals from CHPS, that is, end up going to the

other health center the CHPS referred them to?

d. If someone does follow a referral, do you think there is a good system for them to let

CHPS know what happened at the other health facility?

i. If yes, How do you think this tracking system affects the quality of care?

Volunteers

19. We are interested in learning more about whether the district health management team has any

engagement with community health volunteers or CHVs. Has your district health management

team interacted with any of the CHVs within the last 6 months?

If yes,

a. Can you tell me the types of interactions that occurred? Clarify if needed: like trainings,

meetings, etc.

b. What are the most common types of interactions?

c. Are there any challenges in working with the volunteers?

d. What is the most effective method of working with volunteers to encourage positive health

behaviors??

20. In your opinion, have CHVs been effective in encouraging community members to adopt

positive health behaviors?

a. Why or why not?

Supporting CHPS Compounds in the district

21. In the past year, has the District Assembly allocated funds to your District Health Management

Team for health activities?

If yes,

a. To what activities were those funds allocated?

b. Do any of these activities support the CHPS Compounds or Health Centers in the district?

c. How were decisions made regarding which activities to fund? By whom?


d. Are data used to determine what kind of activities are funded to support the health system?

If yes,

i. What data are used?

ii. How are they used?

e. In the past year, has the District Health Management Team received any of the allocated

funds?

i. If yes, were the planned activities implemented with the funds?

i.1. If yes, how were they implemented?.

i.2. During the last two years, have these funds increased, decreased or stayed the

same?

22. In the past year, apart from the District Assembly, has any other agency or organization

allocated funds to your District Health Management Team for health activities?

PROBE: for example: UNICEF, USAID, World Vision, CARE, or other NGOs

If yes,

a. Can you tell me what activities those funds were used for?

b. Are any of these activities directed at supporting CHPS Compounds or Health Centers in

the district?

c. How were decisions made regarding which activities to fund?

d. Has the District Health Management Team received any of the funds yet?

e. During the last two years, have these funds increased, decreased or stayed the same?

23. In your role as DDHS, in what ways if any have you worked with your district assembly?

PROBE: member of District social or health committee, etc. Please describe this interaction.

24. How does the district assembly support CHPS Compounds and Health Centers in your district?

a. Of this support, what do you consider routine support through the central government or

Ghana Health Service, and what do you consider innovative support?

Probe: Please describe any innovative support provided.

b. Probe: In what [other] non-financial ways does the District Health Management Team

provide support to CHPS Compounds and Health Centers in your district?

c. In the last two years has this support increased, decreased, or stayed the same?

Data Use

25. How do you make use of DHIMS 2 data?

a. What district level decisions are informed by theDHIMS-2 data?

b. What types of data from DHIMS 2 are most useful in decision-making?

c. How often do you use DHIMS 2 data in decision-making?

d. Can you tell me about any decisions made in the last two months that were informed by

data from DHIMS 2?

i. What about in the last year?

e. Over the last two years, has your use of DHIMS-2 data changed?

i. If so, How?

f. Do you think the DHIMS data are reliable, that is do they provide an accurate picture of the

situation at the facilities?

g. What challenges or issues have you faced when trying to use the data?

h. In the last two years, has the quality of these data changed?


i. If yes, In what way(s)?

Those are all the questions I have for you today. Is there anything else you think is important

for us to know about how your District Health Management Team and the District Health

Administration supports the health services and system in your district?

Thank you so much for your time.

Save your file, and turn off voice recorder.

Don’t forget to make notes and record them as soon as you are done.

Save file as: [District]_[Respondent Type]_[Respondent Name]_[Date].docx;

(e.g. AOWIN_DA_Joseph Apiah_25-3-2015.docx)

District

Sub-district

Date of Interview

Start and time end time of

interview

Location of Interview

Name/s of Respondents

Respondent/s’ Gender

Language/s Used

Interviewer Name

Note Taker Name

Interview Guide Type: DA, DDHS,

SDHO2, Leader, Client, CHC

Notes: Special circumstances, clarifications, things seen, participation in groups, etc.

2 Also referred to as Subdistrict Health Team Leaders (SDHT)


2. District assembly members


To be conducted with two district assembly members in each district: make an effort to interview the district

coordinating director and the social services subcommittee head.




Thank you for taking the time for this interview today. My name is [insert name], and I am

working on the USAID/Ghana Evaluate for Health midline study of health services in Ghana,

which is funded by the U.S. Agency for International Development and supported by Ghana

Health Service. The goal of this study is to help inform decision-makers about the availability

and integration of health services at the community and sub-district levels, the strength of the

health system, and health sector governance.

The purpose of this interview is to gather information from District Assembly members about

the how their District Assembly supports the health services provided in their district. We

will be asking about how decisions are made about support to the health system, and the

extent to which data is used to inform decision-making. Your responses will be confidential,

that is, none of your responses will be identified as yours with anyone outside of the study

team.

I have a consent form you would need to sign to show you agree to participate in this interview. Could you read it now?



that I remember your responses correctly. The recordings from everyone interviewed will be

used for analysis only and will not be published or shared with anyone outside of the study

team. You will not be identified in study reports. Do I have your permission to record the

interview?



1. Before we get into the interview, could you tell me your name, position in the District

Assembly, and how long you have served in the District Assembly?

2. Since you started working in the district assembly, can you tell me the kind of work you have

focused on, or some examples of projects you have worked on recently?

3. Can you tell me in general the kind of work that the district assembly does in health?

Quality of care

4. What is your overall assessment of the quality of health care and services in your district?

PROBE: in terms of staff, infrastructure, equipment, supplies, access

5. What do you consider the strong points of health care and services in your district?


6. What challenges does the district face in terms of providing quality health care and services?

7. For CHPS:

a. In the last two years, has there been any changes in types of services provided by the CHPS

in your district?

i. If yes, What have the changes in the services been?

b. In the last two years, have you noticed any changes in the quality of services provided by

CHPS in your district?


c. Are there any things you would like to see improved about your CHPS?

8. For health centers:

a. In the last two years, has there been a change in types of services provided by the health



b. In the last two years, have you noticed any change in the quality of services by the health



c. Are there any things you would like to see improved about your health centers?

Supporting CHPS zones in the district

9. Can you show me or describe for me the organogram for the District Assembly and tell me

who in the district assembly is responsible for addressing health system issues?

10. How are decisions made on what support to provide to the health system in your district, for

example, logistical (equipment or supplies) or financial support?

a. Does the District collect data or receive data from GHS on CHPS?

b. If yes, are these data used to help make decisions on how to support the health system?

i. If yes, What data are used, how, and by whom?

PROBE FOR DATA SOURCES.

11. Based on your understanding of the CHPS system, what are the roles and responsibilities of the

CHPS in their respective communities?

INTERVIEWER: WE ARE JUST LOOKING FOR A BRIEF IDEA REGARDING WHAT THE PARTICIPANT

KNOWS ABOUT CHPS.

12. There are many different health projects going on in Ghana. Are the results of any health

projects going on in your district discussed at your quarterly district assembly meetings?

If yes,

a. How often are the results of health projects discussed?

b. What types of health projects get discussed?

13. Has your District Assembly incorporated any community action plans, or CAPs, or any projects

from CAPs into your current district development plans?

INTERVIEWERS: WE EXPECT SOME DAs ARE DOING THIS, BUT NOT ALL.

If yes,

a. Are there any CAPs health related projects incorporated in the plans, such as projects

related to health supply chain issues or CHPS?

If yes,


i. What health issues are addressed in the plans?

ii. How were decisions made to incorporate any health projects in the district plans?

b. Are there any projects from CAPS dealing with nutrition priorities incorporated in the

plans?

If yes,

i. How much funding has been allocated for CAP nutrition priorities?

ii. What percentage of district assembly funding does that represent?

c. Have any actions been undertaken in implementing any of the health or nutrition in the

current or most recent plans?

If yes,

i. Please tell me the steps that have been taken.

14. In your current or most recent budgets, has any money been allocated for District Health

Management Teams for health activities?

If yes,

a. Can you tell me what activities money has been allocated for?

b. How were decisions made to include funding for these activities?

c. Has the District health Management Team received any of the allocated money yet?

d. In the last two years, has the level of support given to the District Health Management

teams increased, decreased, or stayed the same?

i. Why?

15. How else does the District Assembly help support CHPS zones and health centers?

16. Do you have any suggestions about ways District Assemblies and their individual members

could provide more support for CHPS zones and Health Centers?

Collaborating with USAID

17. Are you familiar with the U.S. Agency for International Development, which is also known as

USAID?

PROBE. IF THEY DON’T KNOW ANYTHING ABOUT USAID AT ALL, SKIP THIS SECTION.

OTHERWISE, CONTINUE.

18. Does your District Assembly have any relationship with USAID or have you done any work

with USAID?

If yes,

a. What is the relationship between your district assembly and USAID?

b. What projects have you worked on together, if any?

If worked together,

i. What have been some of the successes of your organizations working together?

ii. What would improve your ability to work together well?

19. What ideas do you have for how USAID and your District Assembly could work together in

the future on health system issues and issues related specifically to CHPS zones?


for us to know about how your District Assembly supports the health services and system in

your district?







District

Sub-district

Date of Interview

Start and time end time of

interview




Language/s Used

Interviewer Name

Note Taker Name


SDHO, Leader, Client, CHC



3. Sub-district health officers


To be conducted with two sub-district health officers in each sub-district. Make an effort to interview the sub-

district health management team leader. This could be a HC in-charge, but it should be the person who

coordinates the management of the sub-district health team- this is often a public health nurse or disease

control officer. Do not read aloud what is in italics nor in bold.


The purpose of this section is to introduce the respondent to the study and request consent for audio

recording.

Thank you for taking the time for this interview today. My name is [insert name] and I am working on

the USAID/Ghana Evaluate for Health midline study of health services in Ghana, which is funded by

the U.S. Agency for International Development and supported by GHS. The goal of this study is to

help inform decision-makers about the availability and integration of health services at the

community and sub-district levels, the strength of the health system at these levels, and health sector governance.

The purpose of this interview is to gather information from Sub-District health workers about

community engagement in health care, data collection and quality improvement in the CHPS zones

and health centers. Your responses will be confidential, that is, none of your responses will be identified as yours with anyone outside of the study team.

I have a consent form you would need to sign to show you agree to participate in this interview. Could you read it now?


Before we start, I would like to get your permission to record the interview. This will ensure that I

remember your responses correctly. The audio recordings from everyone interviewed will be used

for analysis only and will not be published or shared with anyone outside of the study team. You will not be identified in study reports. Do I have your permission to record the interview?



1. Before we get into the interview, could you tell me your name, position, and how long you have

served in your role?

Quality of care

2. What is your overall assessment of the quality of care given by CHPS in your sub-district?

a. Can you tell me about anything you would like to see improved about the CHPS in your

sub-district?

b. In the last two years, have you noticed any changes in types of services offered by CHPS in

your sub-district?


c. In the last two years, have you noticed any changes in the quality of services offered by

CHPS in your sub-district?

i. If yes, Please describe what those changes have been?


3. What is your overall assessment of the quality of care given by health centers in your sub-

district?

a. Can you tell me about anything you would like to see improved about the health centers in

your sub-district?

b. In the last two years, have you noticed any changes in types of services offered by the

health centers in your sub-district?


c. In the last two years, have you noticed any changes in the quality of services offered by the

health centers in your sub-district?

i. If yes, Please describe what those changes have been?

Community engagement

4. Are you are a member of or leader of the Sub-district Health Management Team or SDHMT?

5. We are interested in learning more about the sub-district health management team’s ongoing

engagement with community health volunteers, which could be known as community health

agents or other names for such volunteers.

To that end, do you have a list of the community health volunteers who work in your

subdistrict?

If yes,

a. Has that list been updated within the past year?

b. May I look at it?

NOTE NUMBER OF VOLUNTEERS, WHICH COMMUNITIES THEY ARE IN OR SERVE OR OTHER

RELEVANT INFORMATION. PUT NOTES ON NOTE SHEET AT END.

6. Has the sub-district health management team had any interactions with any of the community

health volunteers within the last 6 months?

If yes,

a. Can you tell me the types of interactions that occurred? LIKE TRAINING, ETC.

b. Are these typical interactions?

c. What is the ideal pattern of interactions?

d. Are there any challenges in meeting the ideal?

e. How do these interactions encourage positive health behaviors?

7. As far as you know, are volunteers encouraging community members to adopt positive health

behaviors?

If yes,

a. How is that being done, and what role does the sub-district health management team play

in that?

Referrals

8. Are referrals and follow-up care tracked and information shared between CHPS zones and

health centers?

a. If so, How is this information shared?

PROBE: Do clients have their own folders or records, which they bring to appointments?

b. Is this an effective way to share information?

PROBE: Do facilities use the system?


9. How often do you think that individuals follow referrals?

a. If someone does follow a referral, do you think there is a good system for them to let

CHPS know what happened at the other health facility?

b. How do you think this tracking system affects the quality of care?

Data

10. Now I would like to ask you about the data that you collect for DHIMS 2. Regarding the

DHIMS 2 data that you receive from the CHPS zones, can you tell me whether the CHPS staff

generally follow the GHS guidelines regarding how they report their data?

a. Do you validate the data you receive from the CHPS zones?

b. What could be done better by the CHPS in regards to data collection and reporting?

c. Overall, how is the quality of the data that you receive from the CHPS for DHIMS 2?

11. Do you enter data received from CHPS zones or this health center into DHIMS 2?

If yes,

a. Regarding the DHIMS 2 data that you receive from the CHPS zones and this Health Center,

can you tell me how that data is entered in the database and specifically whether any of the

data can be disaggregated by gender?

b. Can the data that is entered be disaggregated to the level of a CHPS zone?

i. What data, if any, can be disaggregated to a level lower than the sub-district?

YES OR NO - ASK TO LOOK AT REPORTS THAT ARE SUBMITTED. LOOK AT VARIABLES THAT CAN

BE DISAGGREGATED BY GENDER. LIST THE VARIABLES THAT CAN BE GENDER DISAGGREGATED.

NOTE WHAT YOU SEE IN THE NOTES AT THE END.

12. Can all data you would like to use at the sub-district level be disaggregated to a level that is of

use to you?

13. In your opinion, are these data of high quality?

a. Please describe any challenges or issues you have faced when trying to use the data.

14. How does your health center use the DHIMS 2 data to inform how you are doing, what issues

exist in your community, and decision-making?

a. Can you tell me about any decisions your health center made in the last two months that

were informed by data from DHIMS 2?

b. What about in the last year?

15. Can you give me an example of when a CHPS Compound used the data they submitted to

inform their decision-making?

16. Do you think that the data that are collected and entered in DHIMS 2 are useful to CHPS zones

and health centers in improving community care?

a. Why do you say that?

Outbreak and Disease control

17. When an outbreak of a disease occurs, are forms completed according to the type and severity

of the outbreak?

If yes,

a. What are these forms and who fills them out?

18. When an outbreak of a disease occurs, is a special investigation conducted?


If yes,

a. How many cases of a disease have to be reported for a disease outbreak investigation to be

introduced?

b. Who conducts the disease outbreak investigations and how are these investigations done?

c. Are health center staff, community health officers, and volunteers equipped with skills and

materials to do disease outbreak investigations?

19. How are data collected from CHPS zones and health centers used to investigate or trigger

investigations of disease outbreaks?

20. Where are the disease outbreak investigation data sent?

21. In the last year, have any CHPS zones in your sub-district or this Health Center reported any

cases of the following diseases?

READ

Cholera

Meningitis

Yellow fever

Measles

Neonatal tetanus

Acute flaccid paralysis

Guinea Worm disease

Buruli Ulcer

22. Are disease outbreaks recorded and reported differently, depending on the type and severity of

the disease?

If yes,

a. Which diseases require the most prompt reporting?

Probe these diseases, if not mentioned

Cholera

Meningitis

Yellow fever

Measles

Neonatal tetanus

Acute flaccid paralysis

Guinea Worm disease

Buruli Ulcer

b. Is there a ranking of diseases that require the most prompt reporting?

Use list above if necessary to probe.

Supplies

23. In your opinion, do CHPS Compounds and Health Centers have access to the basic medicines

and supplies they need?

a. Is the supply usually reliable?

24. Who monitors the supply of medicines and goods at CHPS Compounds and Health Centers?

25. What is the process for conducting this monitoring?

a. Is data used in the monitoring of supplies?

If yes,

i. Can you tell me what those data are and how they are used?

26. Is there a procedure for reporting when supplies run low or out?


If yes,

a. What is the procedure?

PROBE: Is there a designated person or system from which CHPS Compounds and Health Centers

order new supplies?

b. How well does that procedure for reporting when supplies run low or out work in keeping

health facilities well stocked?

27. What is your opinion regarding how well data are used to ensure constant supplies of

medicines and commodities?

28. Are data used to ensure small equipment such as blood pressure cuffs and stethoscopes are

repaired or replaced in a timely manner?

If yes,

a. What is the system for ensuring small equipment gets repaired or replaced in a timely way?

b. How well does that system work?

Guidelines and protocols

29. Do staff at your health center have the most current version of the following treatment

guidelines or protocols available to them?

IF YES, ASK TO SEE THEM AND NOTE WHETHER YOU ARE ABLE TO SEE THEM OR NOT AT THE

END, ALONG WITH THE DATE OF ANY VERSION ON HAND.

a. Reproductive health?

b. Maternal and newborn care?

c. Prevention and control of infections?

d. Community-Based Management of Acute Malnutrition?

If yes to any,

i. Do staff use these guidelines or protocols?

ii. Why or why not?

iii. Which ones do they apply less often or do not apply at all?

30. From your experience, do staff at CHPS Compounds in your sub-district have the most current

version of the same treatment guidelines or protocols available to them in their facilities:

a. Reproductive health?

b. Maternal and newborn care?

c. Prevention and control of infections?

d. Community-Based Management of Acute Malnutrition?

If yes to any,

i. Do staff use these guidelines or protocols?

ii. Why or why not?

iii. Which ones do they apply less often or do not apply at all?

31. In your opinion, are data such as DHIMS 2, survey data, or databases being used to determine if

staff are following guidelines such as these?

If yes,

a. How is this done?

b. How successful do you think this is?


Quality assurance and quality improvement

32. Does the work plan of your health center include quality assurance and quality improvement,

also known as QA/QI?

If yes,

a. Is QA/QI integrated into your routine activities, and if so, can you tell me how QA/QI is

integrated into your routine activities and the work plan of the health center?

b. In the past year, what QA/QI activities have been implemented, if any?

33. How are QA/QI data used to guide service quality improvement, that is, can you describe any

data that are used by CHPS or Health Center staff to improve the services they provide?

34. Are you involved in overseeing whether any CHPS or Health Center staff have quality

improvement or QI plans?

a. If yes, Do you know whether any CHPS or Health Center staff have taken any steps to

implement their quality improvement or QI plans in the last 60 days?

If yes,

i. Can you tell me what steps have been taken?

Those are all the questions I have for you today. Is there anything else you think is important for us

to know about your sub-district’s community engagement in health care, or data collection and quality improvement in the CHPS zones and health center here?




Save file as: [District]_[Respondent Type]_[Respondent Name]_[Date].docx; (e.g. AOWIN_DA_Joseph Apiah_25-3-2015.docx)

District

Sub-district

Date of Interview

Start and time end time of interview




Language/s Used

Interviewer Name

Note Taker Name





4. Client satisfaction/perception of quality of care

INTERVIEW GUIDE

To be conducted with four community members in each community: Three women and one man. Find

participants who have had some interaction with services in the CHPS zone within which their community is

and perhaps a health center as well in the last 12 months.


1. Introduction and consent for audio recording


Thank you for taking the time for this interview today. My name is [insert name] and I am working on

the USAID /Ghana Evaluate for Health midline study of health services in Ghana. The study is funded

by the U.S. Agency for International Development and supported by Ghana Health Services. The

goal of this study is to help inform decision-makers about the availability of health resources at the

community level, the quality of the health services at the community level, and how well the health

system is governed.

The purpose of this interview is to gather information from members of the community like yourself

regarding the quality of healthcare services you receive. I will be asking about your satisfaction with

healthcare services, the communication between health care providers about your care when more

than one facility provides care to you, and the extent of health insurance coverage in your

community. Your responses will be kept confidential, that is, none of your responses will be identified as yours with anyone outside of the study team and study sponsors.

I have a consent form you would need to sign to show you agree to participate in this interview. Could we go through it now?



remember your answers correctly. The recordings from everyone interviewed will be used for

analysis and will not be shared with anyone outside of the study team, and you will not be identified in study reports. Do I have your permission to record the interview?


2. Background Information

1. Before we get into the interview, could you tell me your name and age? Note gender of

respondent in your notes at the end!

2. Where do you live?

a. What is the name of the closest CHPS zone to where you live?

3. In total how many people live in your house with you?

a. Of those people, how many are children?

i. If any children: Can you tell me their ages?

4. In the past 12 months, have you had any health services provided to you by CHPS staff either at

a CHPS compound or at your home?

THIS CAN INCLUDE COUNSELING, ANTENATAL CARE, OTHER SERVICES OR TREATMENT.

a. If yes: In general, what kind of services were provided to you?


3. Patients’ rights

5. I’d like to ask you about rights people have as clients of the health system. I will briefly describe the

rights and then ask you to tell me what, if anything, you have ever heard of.

READ

Health rights all Ghanaians have include:

The right to accessible healthcare

The right to equitable healthcare

The right to healthcare that covers all health issues

The protection from discrimination based on things like ethnicity, language, religion, gender, and

other characteristics.

Have you ever heard anything about these rights?

If yes,

a. Where have you heard about these rights?

b. What thoughts do you have about these rights?

6. What health services do you think are supposed to be available from the CHPS in your

community?

PROBES:

What services should they provide to you and the community?

INTERVIEWER, YOU CAN ASK ABOUT AREAS THAT WERE NOT MENTIONED:

Do you think CHPS are supposed to provide services for…?

i. Maternal and reproductive health

ii. Child health services

iii. Disease surveillance and control

iv. Treatment of minor ailment

v. Referrals

vi. Health education and counseling

vii. Follow-up of people who need health services but haven’t gotten them in time and discharged

patients

7. Do you think that your CHPS provides the services they are supposed to?

4. Perceptions of quality of care at CHPS

8. How satisfied are you with the services and care you receive from your CHPS?

a. Tell me about what you like about your CHPS.

b. Is there anything you would like to see improved about your CHPS?


c. What could you or would you do if there was something you were not happy with in the

quality of services or care you received from the CHPS?

d. In the last two years, have you noticed any change in types or quality of services being

offered by the CHPS in your community?


9. In the last 12 months, have you received care or treatment at a CHPS compound, if there is one, or

have you brought someone there to receive care?


If yes, ask questions a - c.

If not, skip to question 11.

a. I would like to ask you about the last time or last few times you received care at the CHPS

compound. The last time or last few times you went to the CHPS compound, about how

long did you have to wait to be attended to or seen by staff of the facility?

i. How satisfied are you with the amount of time you had to wait to be attended to?

b. About how long did the care provider spend in consulting or examining you?

i. How satisfied are you with the amount of time the care giver spent with you in

consulting or examining you?

ii. How satisfied are you with the overall time spent with you during the visit?

c. Did you have any tests taken during your visit at the CHPS compound?

If yes,

i. About how long did you have to wait for tests to be performed at the CHPS

compound?

ii. How satisfied are you with the amount of time you had to wait for tests to be

performed?

iii. About how long did you have to wait for test results?

iv. How satisfied are you with the amount of time you had to wait for test results?

10. Now I would like to ask you a bit about the CHPS staff. The last time you received services

from a CHPS staff member, either at your home or at the CHPS compound, did they take the

time to listen to you and answer your questions about why you wanted to see them?

PROBE: Tell me about that.

a. How satisfied were you with the CHPS staff regarding how they listened to you?

b. In general, what was the attitude of staff towards you?

c. Did you feel that they understood what your issue was?

d. Did you like the way the CHPS staff gave you advice and information on options for your

treatment?

i. Did you feel like they gave you enough options and ones that would work for you?

ii. How well did the CHPS staff address your concerns and explain the treatment

strategy?

iii. Overall, how satisfied were you with the way the CHPS staff gave you advice and

information on options for treatment?

iv. How satisfied were you with the treatment itself and why?

v. Did the CHPS compound have all the supplies needed for your treatment? This includes

anything at all needed.

If not:

v.1. What were they missing?

v.2. Please describe how you felt about that.

e. Did the CHPS staff ask for your consent before providing treatment?

PROBE OR EXPLAIN IF NEED BE.

i. How did that make you feel?

f. Was the CHPS staff member friendly to you?


11. Has anyone at the CHPS ever referred you from the CHPS to another health facility?


If yes:

a. Which other health facility were you referred to?

b. Did you go?

c. Did you return to the CHPS staff to give them an update on what happened when you

went?

d. Were you satisfied with the amount of information the staff at the new health facility had

from the CHPS about your case?

i. What information did they have and how did they get it? Did you bring it with you?

e. Were you satisfied with the amount of information the staff at the new health facility sent

back to the CHPS after they cared for you?

i. What information went back to the CHPS? How did it get there? Did you carry any

records, notes, or folders back?

f. Were you satisfied with the services received at the referral facility?

g. Can you tell me how the referral process worked?

5. Perceptions of quality of care at health centers

12. Have you or anyone you care for received care at a Health Center? Not a hospital.

If yes: ask the following questions. If not, go to question 16, Health Promotion

a. What is the name of the health center you or your family member received care from?

b. In general, what kind of services were provided to you?

c. I would like to ask you some of the same questions I asked you about your experience at

the CHPS. First, how satisfied are you with the quality of services and care you or they

received from the health center?

d. Tell me about what you liked about the services received?

e. Is there anything you or they would like to see improved in the health center?

13. Now I would like to ask you about your experiences the last time you or someone you care for

received care at a health center.

a. The last time you went to a health center, about how long did it take you to be attended to

by the health center staff?

i. How satisfied are you with the amount of time you had to wait to be seen?

b. Tell me about the amount of time the care provider spent in consulting or examining you

or the person you care for?

i. How satisfied are you with the amount of time the staff spent consulting or examining

you?

c. About how long did you have to wait for tests to be performed at the health center, if you

had any?

If yes,

i. How satisfied are you with the amount of time you had to wait for tests to be

performed?

ii. How satisfied are you with the amount of time you had to wait for test results?

d. Did you need to get anything from the pharmacy or dispensary?

If yes:

i. About how long did you have to spend at the pharmacy or dispensary to get what you

needed?

ii. How satisfied are you with the amount of time you had to wait for what you needed at the pharmacy or dispensary?


14. Now I would like to ask you a bit about the Health Center staff.

a. Did they take the time to listen to you regarding what you went to see them about?

b. How satisfied were you with the Health Center staff regarding how they listened to you?

c. Did the Health Center staff repeat to you what they heard you say about the condition that

brought you to the Health Center?


ii. Did you feel that the staff understood what your condition was?

d. Would you go back to this health center to receive treatment if you were sick again?

i. If not, Why not?

e. What is your general impression about the way the health center staff gave you information

on options for treatment?

i. Did you feel they understood your situation?

ii. Did you feel like they gave you enough options and ones that would work for you?

iii. How well did the staff address your concerns and explain the treatment strategy?

iv. Overall, how satisfied were you with the way the health center staff gave you

information on options for treatment?

v. How satisfied were you with the treatment itself and why?

f. Did the health center have all the health supplies needed for your treatment, including

anything at all needed?

i. If not, What were they missing?

ii. Please describe how you felt about that.

g. Did the health center staff ask for your consent before providing treatment?

PROBE OR EXPLAIN IF NEED BE.


h. In general, was the health center staff member friendly to you?


6. Health promotion

15. Have you heard or seen anything on the GoodLife, Live it Well campaign?

If yes,

a. What have you heard or seen about it?

b. From what source did you hear or see something about GoodLife, Live it Well?

16. Have you changed any of your behaviors because of the GoodLife, Live it Well messages?

a. If so, What behaviors and why?

If not,

b. Why not?

c. What would make you change any of your behaviors?

7. Community care linkage

17. Is there a community health officer or CHO who visits your community?

If yes,

a. How frequent are the visits?

b. What services does the CHO provide?


8. Community engagement

18. Overall, do you feel like you are able to influence or have a say in what happens at the CHPS in

your community?

If so, probe if necessary:

a. How are you able to influence things?

b. How do you contribute to supporting the CHPS in your community?

c. Do you think your contributions and that of community members has influenced CHPS operations

or services in any way?

19. Now I would like to ask you a bit about the Community Health Committee in your community.

Do you have a Community Health Committee in this community?

If yes, ask these questions. If not, probe. If the answer is no, go to Insurance.

a. Do you know who is on the Community Health Committee?

b. How often do the Community Health Committee meet?

c. Do you know what the Community Health Committee is supposed to do?

i. If yes: Tell me a bit about what it is they are supposed to do.

d. How well do you think the Community Health Committee is doing in improving health care

services in the CHPS zone?

e. How well do you think the Community Health Committee is advocating for patients’ rights

on behalf of your community?

i. Can you give any examples?

PROBE if necessary:

ii. The right to accessible healthcare

iii. The right to equitable healthcare

iv. The right to healthcare that covers all issues, especially

a. Maternal and reproductive health

b. child health services

c. disease and surveillance and control

d. treatment of minor ailment referrals

e. health education and counseling

f. follow-up of defaulters and discharged patients

v. The right to healthcare without discrimination based on culture, ethnicity, language, religion,

gender, age and type of illness or disability

vi. CHC is supposed to promote communal health

f. Would you go to the Community Health Committee if you had ideas for things that should

be improved at the CHPS?

i. If yes: How would that work – what would you do?

ii. If no, Why not?

9. Insurance

20. Finally, I would like to ask you about health insurance.

a. Are you a registered member of the National Health Insurance Scheme, or NHIS?

If yes, ask


i. How long have you had NHIS insurance? Probe for NHIS membership card.

ii. Has having insurance changed where you receive health care?

iii. Has having insurance changed how you receive health care?

iii.1. Will you join the next registration, after your current NHIS subscription expires?

1. If no, What is your main reason for not joining?

b. In your opinion, do NHIS card holders get better, the same, or worse service than non-

NHIS card holders?

i. Why do think that is so?

c. Are there any health care providers that patients with insurance or NHIS can see that those

without NHIS insurance cannot?

i. If yes, Which health care providers can NHIS card holders see that others cannot?

d. Are there any health services that one would need from a health provider that are not

covered by NHIS?

i. If yes, Which are they?

21. Do many people in your community have NHIS?

a. Has the number of community members with health insurance increased or decreased over

the past year?

b. Why do you think that is?

Those are all the questions I have for you today. Is there anything else you think is important for us to know about health services and care in your community?



Save file as: [District]_[Respondent Type]_[Respondent Name]_[Date].docx; (e.g. AOWIN_DA_Joseph Apiah_25-3-2015.docx)

District

Sub-district

Date of Interview





Language/s Used

Interviewer Name

Note Taker Name





5. Community leaders

INTERVIEW GUIDE

To be conducted with two community leaders. Such individuals may include village chiefs, queen

mothers, and others who play an important role in their villages or towns.



The purpose of this section is to introduce the respondent to the study and request consent for audio

recording.

Thank you for taking the time for this interview today. My name is [insert name] and I am

working on the USAID/Ghana Evaluate for Health midline study of health services in Ghana.

The study is funded by the U.S. Agency for International Development and supported by

Ghana Health Services. The goal of this study is to help inform decision-makers about the

availability of health resources at the community level, the quality of the health services at the

community level, and how well the health system is governed.

The purpose of this interview is to gather information from community leaders regarding the

quality of healthcare in your community. I will be asking about the links between your

community and the CHPS, the role of the Community Health Committee and community

action plans in how health care is delivered here, how the community is engaged in health

care service decisions, and the extent of insurance coverage in your community. Your

responses will be confidential, that is, none of your responses will be identified as yours with

anyone outside of the study team and study sponsors.

I have a consent form you would need to sign to show you agree to participate in this

interview. Could we go through it now?



that I remember your answers correctly. The recordings from everyone interviewed will be

used for analysis and will not be published or shared with anyone outside of the study team.

You will not be identified in study reports. Do I have your permission to record the interview?



1. Before we get into the interview, could you tell me your name and your role in the community?

Perceptions of quality of care

2. What is your overall assessment of the quality of care given by CHPS in your community?

a. Can you tell me about anything you would like to see improved about your CHPS?

b. In the last two years, have you noticed any changes in types or quality of services offered by

CHPS in your community?


3. What is your overall assessment of the quality of care given by health centers in your

community?


a. Can you tell me about anything you would like to see improved about your health centers?

b. In the last two years, have you noticed any changes in the types or quality of services

offered by the health center in your sub-district?


Community action plan

4. We want to speak with the community leaders because we know you have a good perspective

of the whole community. One aspect of your community that we are interested in is your

community action plan, or CAP.

Could you tell me, does your community have a Community Action Plan, also known as a CAP?

If yes,

a. Does this CAP include health activities?

5. Does this community have a Community Health Action Plan, also known as a CHAP?

Note: If so, in some communities this will be a part of the CAP and for others they will have a separate

CHAP document.

IF THEY DO NOT HAVE A CHAP OR CAP WITH HEALTH ACTIVITIES SKIP TO THE NEXT SECTION

6. Who created the Community Health Action Plan?

a. Can you describe the process and how it worked?

b. When was this done?

c. Was data used to create the Action plan?

i. If yes, What data were used and how were the data used?

7. What activities are included in the community health action plan or CAP?

i. Does the action plan contain Health Centers and CHPS activities?

ii. What areas of health does the community health action plan or CAP address?

iii. Does your community action plan contain any activities related to nutrition?

iv. Has any part of this action plan been implemented?

a. If yes, which parts?

Role of the CHC

8. Does the community action plan support the goals of the CHPS?

If yes,

a. Which goals of the CHPS does it support?

b. What activities in the community action plan support these goals?

9. Is there a Community Health Committee or CHC in your community?

If yes,

a. How often does it meet?

b. How many members are there?

10. Does the Community Health Committee or CHC in your community support the goals of the

CHPS?

If yes,


a. How do they do that?

b. How well do they do it?

11. How does the CHC support CHPS activities?

a. Has this support changed over the last two years, either increasing or decreasing?

i. If decreased, Why?

12. How does the CHC provide support for the CHPS delivery of service?

a. How well does the CHC support the CHPS delivery of service?

13. Does the CHC ensure that the CHPS has adequate resources to provide health care to the

community?

14. How does the CHCs monitor the CHPS?

h. Does the CHC give feedback to the CHPS that helps the CHPS do their work better?

If yes,

i. Tell me how this works?

ii. How does the CHC communicate feedback to the CHPS staff?

iii. Do you have any examples?

15. Does your community have community health volunteers, or CHVs?

a. If yes, In what ways does the CHC support community health volunteers, or CHVs?

Probes:

i. Do they facilitate getting trainings for CHVs?

ii. Do they make sure CHVs have all the resources they need?

iii. Do they monitor and give feedback to CHVs?

b. Do you know whether the CHC has up-to-date names and contact information for the

CHVs?

16. How well do you think the CHC supports the CHPS through their support of the community

health volunteers?

17. How well do you think the CHC advocates for the CHPS to get support?

a. Can you give an example of how the CHC has tried to get support for the CHPS?

i. Does the CHC advocate on behalf of the community health officer to district assembly

members and politicians to get their support for your CHPS?

b. What do you think has been their most successful advocacy work?

c. What do you think they have to work on to get more support for the CHPS and health

services for your community?

Community engagement

18. Do you think that the CHC tries to generate community support for the CHPS?

If yes,

a. Can you give an example of how the CHC generates community support for the CHPS?

19. Does your CHC try to engage the community on an on-going basis?

Health rights

20. I’d like to ask you now about the health rights of community members. What rights do

community members have as clients of the health system?


Probe to see if they recognize these as rights or ever heard of them:

a. The right to accessible healthcare

b. The right to equitable healthcare

c. The right to healthcare that covers all health issues

d. The right to be protected from discrimination based on culture, ethnicity, language, religion, gender,

age and type of illness or disability

21. In your opinion, how well do you think community members know their health rights?

22. Do you think the CHC helps to promote the rights of people in the community?

23. Could you please tell me the services CHPS supposed to provide?

Probes:

a. What are they supposed to do?

b. What are they supposed to take care of?

c. Probe for areas that were not mentioned

i. Maternal and reproductive health

ii. Child health services

iii. Disease and surveillance and control

iv. Treatment of minor ailment

v. Referrals

vi. Health education and counseling

vii. Follow-up of defaulters and discharged patients

24. Do you think that your CHPS is providing these services, or the services they are supposed to?

If yes, How are these services being provided?

25. How satisfied are you with the quality of services and care you receive from your CHPS?

26. Tell me about what you like about the CHPS.

27. Tell me what you would like to see improved at the CHPS.

Insurance

28. Finally, I would like to ask you about the National Health Insurance Scheme, or NHIS. Do

people in your community have access to the NHIS?

If yes,

a. Are many of your community members currently registered with NHIS?

b. Has the number of community members with health insurance changed over the past year?

i. Why do you think so?

29. Do you think insurance changes how and where people who are insured receive care?

a. If yes, How?

30. In your opinion, do NHIS card holders get better, the same, or worse service than others.

a. Why do you say that?

31. Are there any services that one would need from a health provider that are not covered by

NHIS?

a. If yes, which are they?


Community care linkage

32. I would like to hear your thoughts on the relationship between your community and the CHPS.

Please describe the relationship between community members, health care leaders, and

community organizations.

a. How strong or weak do you think these relationships are and why?

b. How could these relationships be strengthened?

33. How easy or difficult is it for community members to see the CHO for any questions they

might have?


for us to know about health services and care in your community?






District

Sub-district

Date of Interview





Language/s Used

Interviewer Name

Note Taker Name

Interview Guide Type: DA, DDHS, SDHO, Leader, Client, CHC



6. Community Health Committee (CHC)

INTERVIEW GUIDE

To be conducted with up to six Community Health Committee members in each selected community. Do not read aloud what is in italics nor in bold.

a. Introduction and consent for audio recording


Thank you for taking the time for this interview today. My name is [insert name] and I am working on the

U.S. Agency for International Development /Ghana Evaluate for Health midline study of health services

in Ghana, which is funded by the U.S. Agency for International Development and supported by GHS.

The goal of this study is to help inform decision-makers about the availability of health resources at the

community level, the quality of the health services at the community level, and how well the health system is governed.

The purpose of this discussion is to gather information from members of the Community Health

Committee about their relationship with communities and how this affects healthcare. Specifically we

will be asking about CHC roles and responsibilities, how CHCs support CHPS zones, and the links

between communities and the CHPS. Your responses will be confidential, that is, none of your responses will be identified as yours with anyone outside of the study team and study sponsors.

I have a consent form you would need to sign to show you agree to participate in this interview. Could we go through it now?



remember your answers correctly. The recordings from everyone interviewed will be used for analysis

only and will not be published or shared with anyone outside of the study team. You will not be identified in study reports. Do I have your permission to record the interview?


b. Background information

1. Before we get into the interview, would you tell me your name and more about your position

within the CHC?

IF NEEDED: Again, no one other than the study team will know what you say here.

2. Are there any members of the CHC who are not here today?

If yes,

a. How many are not here?

b. Are the missing people male or female?

c. History and operation of CHC

3. I want to begin by getting to know more about the history, operation, and composition of this

CHC. Based on your knowledge, when and how was this CHC first established here?

Probe for year of formation.

a. Are members elected to your CHC?


i. If yes, How do the CHC elections work?

4. Do members of your CHC receive an orientation?

If yes, ask:

a. Can you tell me about the orientation, for example who organized and led it, how long it

lasted, where it was held, and what the topics covered were?

b. What types of materials are distributed during the orientation?

5. How often do members of this CHC meet and where are meetings usually held?

6. Does this CHC have documentation of meetings and activities?

If yes, ask

a. What types of documentation do you keep from meetings and activities?

Provide examples if necessary: Agenda, Notes, Budgets, or Schedules.

b. Is this documentation available to the community or public?

c. Is there anything here that I can see?

NOTE: If they do not have documents with them or they are not easily available do not request them to

go get them. Record in your field notes at the end of the interview what documents you see.

d. CHC roles and responsibilities

7. In your own words, what is the mission or purpose of this CHC?

a. How well do you think this CHC is working to meet the mission or goals?

b. What has helped or hindered this work?

8. Based on your experiences, what are the key responsibilities of the CHC members and what do

you do on a day-to-day basis to support the CHO?

Probe social and financial responsibility areas with examples below, if necessary:

a. Serving as a liaison between the community and the CHPS or other health facilities

b. Ensuring the welfare and security of CHVs and the CHO.

c. Speaking for and ensure better health conditions for and within the community.

d. Supporting health programs such as health education, disease surveillance and advocacy.

e. Mobilizing resources and support for the CHC, the CHO, the CHPS compound, and CHPS programs in

the community.

f. Encourage cooperation and communication, and resolve conflict between community members and

CHPS.

9. In your opinion, what can be done to ensure that all CHC members understand their role and

responsibilities?

d. CHC support of CHPS zones

10. CHCs have a number of responsibilities. Which responsibilities has this CHC been the most

successful in fulfilling to support the CHPS?

Probe if necessary. What have you done the best at?

You can encourage responses related to categories: Funding? Facilitating and encouraging communication?

Community outreach work? Volunteer work?


11. What areas do you think this CHC could work to improve on, if any?

e. Finances

12. How are CHC finances and records managed?

Ask to see any records that might be available. Note at end what was seen.

Probe, if necessary:

a. Does the CHC record transactions?

b. Does the CHC track finances on a budget?

c. Does the CHC record account balances?

f. Linkages with the district assembly

13. Can you describe the relationship, if any, this CHC has with the Assembly members of this

electoral area?

a. Does the CHC meet regularly with the assembly members?

i. If so, How often do you meet?

b. In the past quarter, what support have the assembly members provided the CHC, the CHO or

the CHPS?

g. Health programs and volunteers

14. Focusing on your work, what health programs and activities does the CHC support?

a. Does the CHC help support durbars?

If yes,

i. Usually, how many durbars are held every month or year?

ii. Is this number of meetings appropriate, or would you like to see more or fewer?

iii. Is the CHO at every durbar?

15. How are community health volunteers, or CHVs, chosen?

a. Does the CHC have up-to-date names and contact information for the CHVs?

iv. If yes, When was the list last updated?

b. Does the CHC ensure that all CHVs are adequately trained?

c. How are CHVs currently supervised or monitored?

i. How is the quality of supervision ensured?

d. How does your CHC provide motivational support for volunteers?

i. What other types of support does the CHC offer volunteers?

Probe types of support if necessary: Financial, social, transportation, food, training, guidance or

administrative.

h. Community Health Action Plan (CHAP)

16. Does this community have a Community Action Plan, also known as a CAP?

If yes,


a. Does this CAP include health activities?

17. Does this community have a Community Health Action Plan, also known as a CHAP?

Note: If so, in some communities this will be a part of the CAP and for others they will have a separate

CHAP document.

IF THEY DO NOT HAVE A CHAP OR CAP WITH HEALTH ACTIVITIES SKIP TO THE NEXT SECTION

18. Did this CHC participate in the process to come up with the Community Health Action Plan or

the health activities in the CAP?

If yes,

a. Can you describe the process and how it worked?

b. When was this done?

c. How long did it take?

d. Was data used to create the Action plan?

i. If yes, What was the data source and how was the data used?

18. What activities are included in the community health action plan or CAP?

a. Does the action plan contain Health Centers and CHPS activities?

b. What areas of health does the community health action plan or CAP address?

c. Has any part of this action plan been implemented?

i. If yes, which parts?

19. Does this CHC have a separate work plan or action plan?

If yes,

a. What types of activities are on the plan?

b. How do you implement these activities?

i. Community care linkage

20. I would like to hear your thoughts on the existing relationships between your community and the

CHPS. Please describe the relationship between community members and leaders, health care

leaders, and community organizations.

a. How strong or weak do you think these relationships are and why?

b. How could these relationships be strengthened?

c. How strong or weak do you think the relationships between the CHPS and the community

leaders are?

21. How easy or difficult is it for community members to see the CHO for any questions they might

have?

22. Can you tell me what health rights community members have?

a. Do you think community members know about their health rights?

i. Why or why not?

23. I would like to hear about how the CHC advocates for the health rights of community members?

a. Can you give any examples of advocacy work the CHC has done?

b. Do you think your CHC has to demand services for your community?


i. Why or why not?

24. Do you think that your advocacy has been helpful?

a. How or Why not?

j. Referrals and insurance

25. I would like to ask you a bit about the patient or client referral system. From your perspective, do

you think that individual clients follow referrals they receive from the CHPS, that is, do clients go

to other health facilities if the CHPS staff refer them to go?

a. If not, What are the reasons people do not follow referrals?

b. If yes, If someone does follow a referral, do you think there is a good system for them to let the

CHO know what happened at the other health facility they were referred to?

26. Finally, I would like to ask you about the National Health Insurance Scheme, or NHIS. Do people in

your community have access to the NHIS?

a. Does having insurance change how and where community members can receive health care?

i. If yes, How?

b. In your opinion, do NHIS card holders get better, the same, or worse service than others?

If worse or better, Why?

c. Are there any health services that one would need from a health service provider that are not

covered by NHIS?

i. If yes, which services are these?

Those are all the questions I have for you today. Is there anything else you think is important for us to

know about how your Community Health Committee works and supports the health services and

system in your community and community to care linkages?






District

Sub-district

Date of Interview





Language/s Used

Interviewer Name

Note Taker Name

Interview Guide Type: DA, DDHS, SDHO, Leader, Client, CHC


quality of health services at the sub-district and

Documents