2 WHO Service Availability and Readiness Assessment · 12/10/2013 · Assessment: Approach WHO and...

Service Availability and Readiness Assessment | December 10, 20131 |

Service Availability and Readiness Assessment (SARA)

An annual system for monitoring service readiness

Kavitha ViswanathanDepartment of Health Statistics and Information System

Service Availability and Readiness Assessment (SARA)

An annual system for monitoring service readiness

Kavitha ViswanathanDepartment of Health Statistics and Information System


Service Availability and Readiness and Data quality

Assessment: Approach


Assessment: Approach

� WHO and partners working on a set of tools to improve availability, quality and use /analysis of facility data

� Builds on experiences of SAM, SPA - other facility surveys and country

experiences

� Harmonized standard approach and toolkit for annual monitoring of

service delivery and data quality

• Fills critical data gaps in service delivery (availability and readiness including

information on private sector) – as a complement to the routine HMIS

• Provides objective verification of whether or not a facility meets a required

condition

• Objective and systematic approach to data quality ascertainment

�Strong links to country review and planning processes


IHP+ M&E Results Chain Framework IHP+ M&E Results Chain Framework

Inputs & processes Outputs Outcomes Impact

Data

collection

Indicator

domains

Analysis &

synthesis

Communi-

cation & use

Improved

health outcomes

& equity

Social and financial

risk protection

Responsiveness

Fin

an

cin

g

Infrastructure

/ ICT

Health

workforce

Supply chain

Information

Intervention

access &

services

readiness

Intervention

quality, safety

and efficiency

Coverage of

interventions

Prevalence risk

behaviours &

factors

Go

ve

rna

nce

Administrative sourcesFinancial tracking system; NHA

Databases and records: HR,

infrastructure, medicines etc.

Policy data

Facility assessments Population-based surveysCoverage, health status, equity, risk protection, responsiveness

Facility reporting systemsService readiness, quality, coverage, health status

Vital registration

Data quality assessment; Estimates and projections; Use of research results;

Assessment of progress and performance; Evaluation

Targeted and comprehensive reporting; Regular country review processes; Global reporting



Assessment: The Toolkit


Assessment: The Toolkit

Facility assessment methodology (indicators, data

collection instruments and analytical tools and outputs):

� Service availability = physical presence of facilities, staff, beds

� Service readiness = capacity to delivery services (trained staff

+guidelines, equipment, diagnostics, medicines & commodities)

� Data verification (record review) – facility visit to verify reliability

of monthly facility reports

� Data Quality report card – indicators, tools and methodology for

systematic assessment of facility data –based on desk review


SARA & Data verification MethodologySARA & Data verification Methodology

� Census required for service availability (recommend every 5-10

years)

� Facility sampling :

– Usually – national sample ( ~150 health facilities )

– Stratified by type and managing authority (public/private)

– Oversampling or including all hospitals

– Random sample within strata → Margin of error of ~10%

� Electronic data collection (CSPro questionnaires + PDAs/Tablets)

� Automated analysis (Excel) for report

� Recommend annually (Average time = 5 -6 weeks; average cost

100k-150 k)

� Ideally conducted 2-3 months before a health sector review)


(1) Service availability(1) Service availability

1. Infrastructure

– Facility density

– Inpatient bed density

– Maternity bed density

2. Workforce

– Core health worker density

3. Service utilization– Outpatient visits

– Inpatient visits (admission)


Density of health facilities per 10,000 population,

and by management authority,15 districts, Tanzania

Density of health facilities per 10,000 population,

and by management authority,15 districts, Tanzania

•On average,

there are 1.5

facilities /10,000

population

•Global target: 2

•Ownership

varies


Density of core health personnel,15 districts, Tanzania 2

•On average,

there are 7.2

core health

professionals

per 10 000

population.

•WHO target: 23


2. General service readiness2. General service readiness

5 domains- Each domain requires a number of tracer items that capture different aspects of service delivery:

1. Basic amenities: mean % availability of 7 items (power, improved water source, room with privacy, adequate sanitation facilities, communication equipment, access to computer with internet, emergency transportation)

2. Basic equipment: mean % availability of 6 items (blood pressure apparatus, stethoscope, adult scale, child scale, thermometer, light source, neonatal bag and mask)

3. Standard precautions: mean % availability of 9 items ( safe final disposal of sharp, safe final disposal of infectious wastes, appropriate storage of sharps waste, of infectious water, disinfectant, single use disposable /auto-disable syringes, soap and running water or alcohol based hand rub, latex gloves, guidelines for standard precautions)

4. Diagnostic capacity: mean % availability of 8 tests on site with appropriate equipment (haemoglobin, blood glucose, malaria diagnostic capacity, urine dipstick for protein, urine dipstick for glucose, HIV diagnostic capacity, syphilis RDT and urine pregnancy test)

5. Essential medicines: mean % availability of 20 essential medicines


61% 62%

79%

83%

47%

35%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

General servicereadiness index

Basic amenitiesmean score

Basic equipmentmean score

Standardprecautions mean

score

Diagnostics meanscore

Essential medicinesmean score

Index

2. General service readiness index score Uganda 2013 (n = 209)

•Overall facilities

have mean

readiness score

of 61%

•With lowest

readiness in the

medicines

domains (35%)

and diagnostic

capacity (47%)


3. Service specific readiness3. Service specific readiness

� Family planning

� Antenatal care

� Basic and comprehensive emergency obstetric care

� Maternal & newborn care

� Child and adolescent health

� HIV/AIDS (VCT, Care and support, PMTCT, ART)

� Malaria

� Tuberculosis

� Non-communicable disease

� Basic and comprehensive surgical care

� Blood transfusion

"Readiness" to deliver services =

Trained staff +Guidelines + Equipment/supplies + Diagnostics + +Medicines/commodities


ImmunizationImmunization

SERVICE AVAILABILITY

Health interventions offered by facilities

SERVICE READINESS

Tracer items for delivery of intervention

% of facilities offering routine child immunization services

% of facilities offering outreach services

• BCG immunization

• Polio immunization

• DTP-Hib-HepB immunization

• Measles immunization

• Rotavirus immunization*

• Pneumococcal immunization*

Availability of trained staff and guidelines:

• Guidelines for EPI

• Staff trained in EPI in the last two years

Availability and functionality of equipment:

• Cold box/vaccine carrier with ice packs

• Refrigerator (functioning)

• Sharps container

• Single-use syringes

• Continuous temperature monitoring device in

refrigerator

• Energy source and power supply

• Immunization cards

• Immunization tally sheets

Availability and validity of medicines and commodities:

• Available and valid (not expired and VVM not turned) on

day of assessment

• Stock out- Inability to give vaccine anytime in past three

due to unavailable stock)* If included in national immunization schedule


Service Availability% of facilities offering routine child immunization services

Service Availability% of facilities offering routine child immunization services


Uganda 2012% of facilities offering immunization with tracer items (N=84)

Uganda 2012% of facilities offering immunization with tracer items (N=84)

•% of facilities with

staff trained in EPI in

last 2 years – low

(34%)

•1/3 of facilities

have no refrigerator

•Stock outs in about

1/3 facilities

• Only 18% with all

basic items

•Mean availability of

items = 76%


Service Readiness% of facilities offering immunization services with tracer items

Service Readiness% of facilities offering immunization services with tracer items

* Mean availability of 4 antigens

(BCG, OPV, DTP-Hib-HepB, measles)

** Overall scores for Zambia exclude

EPI guidelines and trained staff


Basic emergency obstetric careBasic emergency obstetric care



SERVICE READINESS


% of facilities that offer basic obstetric care services• Parenteral administration of antibiotics

• Parenteral administration of oxytocic drug

• Parenteral administration of anticonvulsants

• Assisted vaginal delivery

• Manual removal of placenta

• Manual removal of retained products

• Neonatal resuscitation

• Basic emergency obstetric care


• Guidelines for Integrated management of pregnancy and

childbirth (IMPAC)

• Staff trained in IMPAC in the past two years


Availability and validity of medicines and commodities:

* If included in national immunization schedule

• Antibiotic eye ointment for

newborn

• Injectable uterotonic

• Injectable antibiotic

• Magnesium sulphate

(injectable)

• Diazepam (injectable)

• Skin disinfectant

• Intravenous solution with

infusion set

• Emergency transport

• Sterilization equipment

• Examination light

• Delivery pack

• Suction apparatus (mucus

extractor)

• Manual vacuum extractor

• Vacuum aspirator or D&C kit

• Neonatal bag and mask

• Delivery bed

• Partograph

• Gloves

• Blood pressure apparatus


Service Availability Basic emergency obstetric care - Uganda

Service Availability Basic emergency obstetric care - Uganda

100%

100%

100%

100%

77%

100%

100%

100%

77%

99%

99%

99%

75%

76%

99%

97%

99%

58%

0% 20% 40% 60% 80% 100% 120%

Offers delivery services

Parenteral administration of antibiotics

Parenteral administration of oxytocic drugs

Parenteral administration of anti-convulsants

Assisted vaginal delivery

Manual removal of placenta

Manual removal of retained products

Neonatal resuscitation

Basic emergency obstetric care (BEmOC)*

National/regional referral hospital General hospital and HC IV


Service ReadinessBasic emergency obstetric care - Uganda

Service ReadinessBasic emergency obstetric care - Uganda

0% 20% 40% 60% 80% 100% 120%

Guidelines for IMPAC

At least one staff trained in IMPAC

Emergency transport

Sterilization equipment

Examination light

Delivery pack

Suction apparatus

Manual vacuum extractor

Vacuum aspirator or D&C kit

Neonatal bag and mask

Delivery bed

Partograph

Gloves

Antibiotic eye ointment

Injectable uterotonic

Injectable antibiotic

Magnesium sulphate (injectable)

Diazepam (injectable)

Skin disinfectant

Intravenous solution with infusion set

Percent of facilities with all items

Mean availability of tracer items



Comprehensive emergency obstetric careComprehensive emergency obstetric care



SERVICE READINESS


% of facilities that offer comprehensive obstetric

care services

• Caesarean section• Blood transfusion

• Comprehensive emergency obstetric care


• Guidelines for CEmOC

• Staff trained in CEmOC

• Staff trained in surgery

• Staff trained in anaesthesia


• Anaesthesia equipment

• Incubator

Availability of Diagnostics

• Blood typing

• Cross match testing

Availability and validity of medicines and commodities

• Blood supply sufficiency

• Blood supply safety


Service Availability Comprehensive emergency obstetric care - Uganda

Service Availability Comprehensive emergency obstetric care - Uganda

100%

100%

77%

11%

6%

5%

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

Caesarean section

Blood transfusion

CEmOC*

Percentage availability

National/regional referral hospitals Other health facilities


Service ReadinessComprehensive emergency obstetric care - Uganda

Service ReadinessComprehensive emergency obstetric care - Uganda

100%

72%

63%

47%

34%

25%

51%

30%

28%

21%

0%

47%

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

Staff trained in anaesthesia

Staff trained in surgery

At least 1 trained staff CEmOC

Guidelines available CEmOC

Anaesthesia equipment

Incubator

Blood typing

Cross match testing

Blood supply safety

Blood supply sufficiency




Staff and Guidelines Equipment Diagnostics Medicines and Commodities Readiness Score


Basic surgeryBasic surgery



SERVICE READINESS


% of facilities that offer basic surgery

• Basic surgical services• Incision and drainage of abscesses

• Wound debridement• Acute burn management• Suturing

• Closed treatment of fracture• Cricothyroidotomy

• Male circumcision• Hydrocele reduction• Chest tube insertion


• Guidelines for IMEESC

• Staff trained in IMEESC



• Oxygen

• Skin disinfectant

• Sutures (both absorbable and non-absorbable)

• Ketamine (injectable)

• Lidocaine (1% or 2% injectable)

• Needle holder

• Scalpel handle with blade

• Retractor

• Surgical scissors

• Suction apparatus

• Nasogastric tubes (10-16

FG)

• Tourniquet

• Adult and paediatric

resuscitators


Service Availability Basic surgery - Uganda

Service Availability Basic surgery - Uganda

0% 20% 40% 60% 80% 100% 120%

Offers basic surgical services

Incision and drainage of abscesses

Wound debridement

Acute burn management

Suturing

Closed treatment of fracture

Cricothyroidotomy

Male circumcision

Hydrocele reduction

Chest tube insertion

Tracheostomy



Service Readiness Basic surgery - Uganda

Service Readiness Basic surgery - Uganda

0% 20% 40% 60% 80% 100% 120%

Guidelines available IMEESC*

At least 1 trained staff IMEESC*

Needle holder

Scalpel handle with blade

Retractor

Surgical scissors

Nasogastric tubes

Tourniquet

Adult and paediatric resuscitators

Suction apparatus

Oxygen

Skin disinfectant

Sutures

Ketamine (injectable)

Lidocaine (1% or 2% injectable)





Comprehensive surgeryComprehensive surgery



SERVICE READINESS


% of facilities that offer comprehensive surgery


• Guidelines for IMEESC (WHO Integrated Management for

Essential and Emergency Care)

• Staff trained in IMEESC

• Staff trained in surgery

• Staff trained in anaesthesia



• Oxygen

• Anaesthesia equipment

• Spinal needle


• Thiopental (powder)

• Suxamethonium bromide

(powder)

• Atropine (injectable)

• Diazepam (injectable)

• Halothane (inhalation)

• Bupivacaine (injectable)

• Lidocaine 5% (heavy spinal

solution)

• Epinephrine (injectable)

• Ephedrine (injectable)

• Comprehensive surgical

services

• Tracheostomy

• Tubal ligation

• Vasectomy

• Dilatation & Curettage

• Obstetric fistula repair

• Episiotomy

• Appendectomy

• Hernia repair

• Cystostomy

• Urethral stricture

dilatation

• Laparotomy

• Congenital hernia repair

• Neonatal surgery

• Cleft lip repair

• Contracture release

• Skin grafting

• Open treatment of

fracture

• Amputation

• Cataract surgery


Service Availability Comprehensive surgery - Uganda

Service Availability Comprehensive surgery - Uganda

100%

100%

100%

100%

100%

100%

100%

92%

92%

92%

92%

92%

92%

85%

77%

77%

77%

69%

46%

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

Offers comprehensive surgical services

Tubal ligation

Dilatation and Curettage

Episiotomy

Appendectomy

Hernia repair

Laparotomy

Vasectomy

Congenital hernia repair

Skin grafting

Open treatment of fracture

Amputation

Cataract surgery

Cystostomy

Obstetric fistula repair

Urethral stricture dilatation

Neonatal surgery

Contracture release

Cleft lip repair



Service Readiness Comprehensive surgery - Uganda

Service Readiness Comprehensive surgery - Uganda

84%

84%

49%

29%

72%

47%

26%

99%

92%

87%

86%

63%

62%

43%

22%

21%

18%

4%

58%

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

Staff trained in surgery

Staff trained in anaesthesia

At least 1 trained staff IMEESC*

Guidelines available IMEESC*

Suction apparatus

Spinal needle

Anaesthesia equipment

Diazepam (injectable)

Epinephrine (injectable)

Atropine (injectable)

Oxygen

Lidocaine 5% (heavy spinal solution)

Bupivacaine (injectable)

Ephedrine (injectable)

Halothane (inhalation)

Thiopental (powder)

Suxamethonium bromide (powder)




Staff and Guidelines Equipment Medicines and Commodities Readiness Score


Equipment tracer itemsEquipment tracer items

Equipment index: tracer items that all health

facilities should have

Tracer items in hospital

• Adult scale

• Child scale

• Thermometer

• Stethoscope

• Blood pressure apparatus

• Light source

• Anaesthesia equipmento Anaesthesia machine to deliver aesthetic

gases and oxygen

o Tubings and connectors to connect to the

endotracheal tube

o Resuscitator bag and mask- adult and

paediatric

o Intubation set adult and paediatric:

(Oropharyangeal airway, endotracheal

tubes, laryngoscope, Magill’s forceps,

stylet)

• Oxygen (cylinder or concentrator)

• Spinal needle



Hospital equipmentHospital equipment

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Benin Burkina Faso Mauritania Uganda Zanzibar

Mean availability Anesthesia equipment (E29) Suction apparatus (E28) Spinal needle (E32)


Hospital equipment (cont.)Hospital equipment (cont.)

Benin (n=44)Burkina Faso

(n=22)

Mauritania

(n=20)Uganda (n=13) Zanzibar (n=9)

(All hospitals)(All hospitals and

polyclinics)(All hospitals)

(National and

Referral Hospitals)(Hospitals only)

2013 2013 2013 2013 2012

Anesthesia

equipment18% 36% 26% 26% 33%

Spinal needle 93% 91% 89% 47% 100%

Suction apparatus 95% 100% 100% 72% 100%

Mean availability 69% 76% 72% 48% 78%


Diagnostic capacityDiagnostic capacity

Diagnostic index: tracer items that all health

facilities should have

Lab capacity expected in hospitals

• Haemoglobin

• Blood glucose

• Malaria diagnostic capacity

• Urine dipstick – protein

• Urine dipstick – glucose

• HIV diagnostic capacity

• Syphilis rapid test

• Urine test for pregnancy

• Serum electrolytes

• Full blodd count with differential

• Blood typing (ABO and Rhesus) and cross

match (by anti-globulin or equivalent)

• Liver function test (ALT or other)

• Renal function test (serum creatinine

testing or other)

• CD4 count and percentage

• HIV antibody testing (ELISA)

• Syphilis serology

• Cryptococcal antigen

• Gram stain

• Urine microscopy testing

• CSF/body fluids counts


Basic lab capacityBasic lab capacity

0%

20%

40%

60%

80%

100%

120%

Benin Burkina Faso Mauritania Uganda Uganda Zanzibar

Mean availability Haemoglobin Blood glucose Malaria diagnostic capacity Urine dipstick- protein

Urine dipstick- glucose HIV diagnostic capacity Syphilis rapid test Urine test for pregnancy


Basic diagnostic capacity (cont.)Basic diagnostic capacity (cont.)

Benin

(n=44)

Burkina

Faso (n=22)

Mauritania

(n=20)

Uganda

(n=13)

Uganda

(n=34)

Zanzibar

(n=44)

(All

hospitals)

(All

hospitals

and

polyclinics)

(All

hospitals)

(National

and Referral

Hospitals)

(General

Hospitals

and HCIV

clinics)

(Hospitals

only)

2013 2013 2013 2013 2013 2012

Haemoglobin 52% 59% 55% 69% 86% 45%

Blood glucose 34% 18% 75% 100% 81% 48%

Malaria diagnostic capacity 100% 91% 85% 92% 100% 89%

Urine dipstick- protein 86% 64% 75% 92% 62% 73%

Urine dipstick- glucose 82% 73% 80% 92% 62% 66%

HIV diagnostic capacity 100% 91% 85% 100% 82% 84%

Syphilis rapid test 70% 77% 80% 54% 15% 48%

Urine test for pregnancy 63% 55% 75% 54% 95% 36%

Mean availability 73% 66% 76% 82% 82% 48%


Advanced lab capacityAdvanced lab capacity

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Mean availability HIV antibody testing (ELISA) (D23) Cryptococcal antigen (D30)


Advanced lab capacity (cont.)Advanced lab capacity (cont.)

Benin

(n=44)

Burkina Faso

(n=22)

Mauritania

(n=20)Uganda (n=13)

Zanzibar

(n=44)

(All

hospitals)

(All hospitals

and

polyclinics)

(All

hospitals)

(National and

Referral

Hospitals)

(Hospitals

only)

2013 2013 2013 2013 2012

CSF/body fluid counts 86% 68% 40% 100% 11%

Gram stain 91% 77% 20% 92% 33%

Full blood count with differential 68% 68% 70% 85% 22%

Blood typing and cross match 73% 55% 35% 85% 44%

Urine dipstick with microscopy . . 45% 85% 44%

Liver function test 73% 64% 55% 77% 33%

Renal function test 68% 64% 65% 77% 22%

CD4 count and percentage 39% 55% 20% 77% 33%

Serum electrolytes 54% 64% 45% 69% 11%

Syphilis serology 75% 73% 55% 69% 33%

Cryptococcal antigen 14% 27% 15% 54% 0%

HIV antibody testing (ELISA) 7% 9% 10% 0% 0%



High level diagnostic equipmentHigh level diagnostic equipment

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Mean availability X-ray (E33) Ultrasound (E35) CT scan (E36) ECG (E34)


High level diagnostic equipment (cont.)High level diagnostic equipment (cont.)

Benin

(n=44)

Burkina Faso

(n=22)

Mauritania

(n=20)Uganda (n=13)

Zanzibar

(n=44)

(All

hospitals)

(All hospitals

and

polyclinics)

(All

hospitals)

(National and

Referral

Hospitals)

(Hospitals

only)

2013 2013 2013 2013 2012

X-ray 68% 91% 85% 85% 78%

Ultrasound 89% 95% 90% 77% 67%

ECG 43% 73% 70% 31% 44%

CT scan 7% 23% 20% 15% 0%



SARA-HSARA-H

� Expansion of the hospital component of SARA

� Proposed modules:

o Module 1: Overview, Services, Governance, Management Systems, Human

Resources, and Capacity

o Module 2: Emergency services, procedures, and surgical services

o Module 3: Delivery and inpatient services

o Module 4: Blood transfusion, diagnostics and pharmaceutical commodities

o Module 5: Infrastructure and support services

o Module 6: Facility information system and service statistics


Next stepsNext steps

� Hospital census in Uganda in January 2014

� Hospital survey in Moldova in early 2014

� Revision of the hospital indicators in 2014

� Inclusion of the new hospital modules in subsequent SARAs

� Regionalization – basic minimum for low/middle income countries


For further information, please contact: [email protected]

For further information, please contact: [email protected]

THANK YOU

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