Dissemination of Service Availability and Readiness Assessment (SARA) study A methodology for...

Dissemination of Service Availability and Readiness Assessment (SARA)

study

A methodology for measuring health systems strengtheningConducted by IHI for MOH&SW in 2012

28th Jan 2014, Julius Nyerere International Convention Centre,DSM

Outline• What is SARA? Why measure SARA? What does SARA add?

• Design and methodology

• SARA findings• General service availability and readiness• Specific service availability and readiness

• Maternal, newborn• Communicable diseases• Non-communicable diseases• Surgical, blood transfusion services

• Summary of key points

What is SARA?• It measures general service availability (access to health

services) • Health infrastructure (density of facilities and inpatient beds)• Core health personnel, inpatient/outpatient service utilization

• It measures general service readiness (capacity of health facilities to provide general health services) • Presence of basic amenities, equipment, standard precautions for

infections, diagnostic capacity and essential medicines

• It measures specific service availability and readiness• Proportion of facilities providing specific key interventions and

their capacity to provide them.

Why measure health services availability and readiness?

• More demand for accountability and to demonstrate results

• Need to track how health systems respond to increased inputs and improved outputs

• Need for strong country monitoring system of health facilities (public & private) and their readiness to deliver services :

• Need for core indicators of service availability and readiness

and appropriate sustainable measurement strategies to generate required data over time

Why measure SARA in Tanzania?

• Commitment of the Government of Tanzania to equitable delivery of quality health services.

• Existence of a wide network of health facilities pre-dating Alma Ata declaration on Primary Health care

• Help address major challenges such as HRH, information systems and equipment and drugs for combating major diseases

• Global Fund Round 9 Health System Strengthening Proposal

What does SARA add?

• Independent data quality assessment of service delivery

• Establishes a baseline for monitoring progress in scale up of service delivery

• Strengthens the analysis for annual health sector and mid-term review

6

METHODOLOGYSERVICE AVAILABILITY AND READINESS ASSESSMENT, TANZANIA 2012

Service Availability and Readiness: Survey Tool

• Global core set of indicators and measurement methods to detect change and monitor progress in HSS

• Measurement tool for Service Availability and Readiness to address critical data gaps in service availability and readiness– Availability : Physical presence of services– Readiness : Capacity to deliver services

• Builds on experiences of SAM, SPA working with USAID and partners to scale up SARA in countries

SARA Questionnaire

• Standard questionnaire built on prior facility survey instruments • Primary level • Additional questions for hospitals and large

facilities

• Uses commonly accepted guidelines & recommendations• Sick child: IMCI• Family Planning: USAID; UNFPA; WHO• Maternal Health: Safe Motherhood Initiatives• STIs and TB: WHO/others• HIV/AIDS: variety of initiatives

• Adapted to country needs• Technical meeting with MOH • Pretested and adjusted

Main domains assessed

• Service availability• Facility density, health worker density, service utilization

• General service readiness• Basic amenities, equipment & supplies, diagnostics,

essential medicines & commodities

• Specific service readiness areas:• Family planning, antenatal care• Obstetric care• Neonatal care and child health (curative, immunization)• HIV, PMTCT, TB, Malaria• Chronic Diseases

Where was SARA data collected?

Sentinel Panel of Districts (District Observatory)

How was SARA data collected?

• Conducted a 5 day training including field practice

• Data collection was done in three phases in May, June and December 2012

• Facility Based Information System coordinators in collaboration with CHMT members

• Data was collected on paper forms and entered electronically into a central database developed in google forms

• Respondents: facility in-charge, plus most knowledgeable person present day of survey for particular service.

Sample and sample weights

• A total of 1,297 health facilities in 27 districts were visited

• This a national representative sample of district selected by National Bureau of Statistics

• Two-stage, population-weighted probability sample

• Sampling weights at first stage were calculated as a reciprocal of the probability of a district to be included in SPD sample.

• No weights in the second stage since all facilities were included in the district

Quality Control

• Field supervision (by a joint team from MOHSW&IHI)

• Spot checks (based on information received during data entry)

• Validation through sample of facilities to be re-surveyed by supervisors

• Regular conference calls using IHI closed user group for rapid problem solving and information sharing

14

RESULTS

General Service Availability

Health InfrastructureHeath workforce

Number of health facilities by type

Characteristic Hospitals HealthCenters Dispensary MCH

Clinics Percent Total

Managing authority

Government/Public 23 93 800 7 71% 923

Mission/Faith based 17 14 100 1 10% 132NGO/Not-for-profit - - 9 - 1% 9Private-for-profit 12 30 191 - 18% 233OwnershipGovernment/Public 23 93 800 7 71% 923Private 29 44 300 1 29% 374ResidenceRural 19 73 749 3 65% 844Urban 33 64 351 5 35% 453 Percent by level 4% 11% 85% 1% Total 52 137 1,100 8 1,297

Distribution of facilities by level and residence

Dispensary Health Centre MCH Clinic Hospital Total0

10

20

30

40

50

60

70

80

90

100

77

60

46 47

73

24

40

54 54

27

Rural Urban

Percent of facilities by residence

Source: SARA Tanzania 2012

Health workforce density

Dispensary

Health Centre

MCH Clinic

Hospital

Public/Govt.

Private

Rural

Urban

Total

0 1 2 3 4 5 6 7 8

2.7

1.3

0.7

2.3

4.8

2.3

2.2

4.9

7.1

Skilled health personnel per 10,000 population


General Service Readiness

• Basic amenities• Basic equipment• Standard precautions• Laboratory diagnostics• Medicines

is a composite score summarizing information from five domains of health service delivery

It refers to the capacity of health facilities to provide general health services

Basic amenities

Computer with internet/email

Private consultation room

Improved sanitation facilities

Power(grid/generator)

Communication equipment

Improved water source

Emergency Transportation

0 10 20 30 40 50 60 70 80 90 100

12

15

19

21

40

45

47

Percent of basic amenities


Basic equipment

Light source

Child/infant scale

Thermometer

Adult scale

Blood pressure apparatus

Stethoscope

0 10 20 30 40 50 60 70 80 90 100

30

75

81

82

85

87

Percent with basic equipment


Standard precautions for infection prevention

Safe final disposal of infectious wastes

Sterilization equipment

Eye protection

Safe final disposal of sharp waste

Masks

Gowns

Guidelines for standard precautions

Appropriate storage of infectious waste

Soap and water or alcohol-based hand rub

Latex gloves

Appropriate storage of sharp waste

Disinfectant

Disposable or auto-disable syringes

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

11%

23%

24%

30%

33%

34%

38%

46%

50%

64%

67%

77%

87%

Diagnostic capacity

ALT and creatinine

Tuberculosis microscopy

General microscopy

Urine dipstick – glucose

Haemoglobin test

Urine pregnancy test

Dried Blood Spot collection

Syphilis rapid test

HIV diagnostic capacity

Malaria diagnostic capacity

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

4%

6%

14%

18%

19%

22%

32%

44%

70%

74%

Diagnostic capacity by facility level

Haemoglobin

Blood glucose


Urine dipstick- protein

Urine dipstick- glucose


DBS collection

TB microscopy

Syphilis rapid test

General microscopy

Urine test for pregnancy

ALT and creatinine

0 10 20 30 40 50 60 70 80 90 100

HospitalHealth CentreDispensary

Percent of diagnostic capacity

Essential medicines

Simvastatin (high cholesterol)

Amitryptyline (depression)

Captropril (hypertension)

Atenolol (hypertension)

Omeprazole (gastroesophogal reflux)

Gilbenclamide (diabetes)

Salbutamol inhaler (asthma)

Diazepam (muscle relaxant)

Diclofenac (pain medication)

Amoxicillin (respiratory antibiotic for adults)

Cetriaxone injection (2nd line antibiotic)

Cotrimoxazole suspension (oral antibiotic for children)

Ciprofloxacin (2nd line antibiotic)

Paracetamol suspension (fever in children)

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

3%

12%

13%

15%

18%

19%

20%

46%

55%

57%

62%

77%

80%

100%

Percent of essential tracer medicines


General Service Readiness (GSR) Index

General ser-vice readiness

index

Basic amenities

Basic equipment

Standard precautions

Diagnostics Medicines0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

42%

27%

73%

45%

25%

41%


Mean availability of components of service provision and GSR index

General Services Readiness: Comparison with other countries

General service readiness index

Basic amenities

Basic equipment Standard precautions

Diagnostics Medicines0

10

20

30

40

50

60

70

80

90

42

27

73

45

3541

48

57

75

60

11

35

64 65

85

77

42

49

Tanzania2012

Sierra Leone2011

Zambia2010

Key Message: General Service Availability and Readiness

• Basic equipment availability scored the highest• Fewer facilities had basic amenities such as power, computers

with email/internet, private consultation room and sanitation facilities

• Diagnostic capacity was surprisingly low even in health centers and hospitals

• Medicines score was also low. 30%-40% was out of stock of 4 basic medicine

• General service readiness index was 42%.

Maternal, Newborn, Child and Adolescent Health

• Family Planning• Antenatal• Delivery• Routine immunization• Preventive and

Curative• Adolescent Health


Availability of Family Planning services

Percent of family planning services

Male sterilization

Female sterilization

Female condoms

IUCD

Implant

Cycle beads for standard days method

Combined injectable contraceptives

Emergency contraceptive pills

Progestin-only contraceptives

Progestin-only injectable contraceptives

Male condoms

Combined oral contraceptives

Offers at least two modern methods of FP

Offers FP services

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

6%

8%

9%

18%

23%

26%

37%

44%

54%

54%

68%

69%

70%

83%

Readiness to provide FP services


At least one trained staff family planning

Guidelines available family planning


Combined oral contraceptive pills

Injectable contraceptives

Condoms

Readiness score

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

45%

57%

89%

79%

75%

88%

72%

Readiness score Medicines and commoditiesEquipement Staff and training

Availability of ANC services


Monitoring for hypertensive disorder of pregnancy

Iron supplementation

IPT

Folic acid supplementation

Tetanus toxoid vaccination

Offers antenatal care services

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

61%

70%

72%

72%

72%

85%

Readiness to provide ANC services


Guidelines available antenatal care

At least one trained staff antenatal care


Urine dipstick- protein test

Haemoglobin test

Folic acid tablets

Tetanus toxoid vaccine

Iron tablets

Readiness score

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

60%

49%

88%

17%

8%

92%

91%

90%

58%

Readiness score Medicines and commodities DiagnosticsEquipement Staff and training

Availability of emergency obstetric and new born care

BEmOC (7 signal functions)

Parenteral administration of anti-convulsants

Neonatal resuscitation

Manual removal of retained products

Parenteral administration of oxytocic drugs

Manual removal of placenta

Parenteral administration of antibiotics

Assisted vaginal delivery

Offers delivery services

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

25%

40%

51%

56%

61%

61%

67%

67%

64%


Readiness to provide BEmOC services

At least one trained staff BEmOCGuidelines available BEmOC

Delivery packGloves

PartographEmergency transport

Suction apparatusExamination light

Neonatal bag and maskVacuum aspirator and D&C kit

Manual vacuum extractorDiazepam injectable

Skin disinfectantAntibiotic eye ointment for newbornIntravenous solution with infusion kit

Injectable uterotonicInjectable antibiotic

Magnesium sulphateReadiness score

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

20%20%

85%75%

69%52%

35%29%

21%14%

12%91%

85%84%

79%75%

67%35%

53%

Readiness score Medicine & CommoditiesEquipment Staff and training

Source: SARA Tanzania 2012BEmOC Basic Emergency Obstetric Care

Availability of child Immunization services

Routine measles immunization

Routine DPT-Hib+HepB immunization

Routine polio immunization

Routine BCG immunization

Offers child immunization services

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

73%

73%

73%

73%

73%


Readiness to provide immunization services


At least one trained staff EPI

Guidelines available EPI

Cold box with ice packs

Sharps container

Single use syringes

Refrigerator

Measles vaccine

DPT-Hib+HepB vaccine

Polio vaccine

BCG vaccine

Readiness score

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

74%

66%

79%

79%

79%

78%

81%

80%

80%

77%

77%

Readiness score Medicines and commoditiesEquipement Staff and training

Availability of preventive and curative services

ORS and zinc s

upplementation

to ch

ildren w

ith diarrh

ea

Child gro

wth

monitorin

g

Iron su

pplementation

Diagnosis/

treat m

alnutrition

Vitamin A

supplementation

Offers preventative and

curative ca

re for U

-5s

0%

20%

40%

60%

80%

100%

75%80% 82% 83% 83% 82%


Readiness to provide curative and preventive services

Guidelines available IMCIAt least one trained staff IMCI

Guidelines available growth monitoringAt least one trained staff growth monitoring

StethoscopeThermometer

Child scaleGrowth chart

Length/height measuring equipmentMalaria diagnostic capacity

HaemoglobinTest parasite in stool

Paracetamol syrup/suspensionMe-/albendazole cap/tab

Vitamin A capsulesORS packet

Amoxicillin syrup/suspensionCo-trimoxazole syrup/suspension

Zinc tabletsReadiness score

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

52%

42%

35%

33%

87%

81%

76%

75%

36%

42%

19%

12%

100%

92%

89%

87%

79%

77%

54%

65%



Availability of adolescent health services by ownership and residence

Pubiic/Government

Private Rural Urban0%

10%

20%

30%

40%

50%

60%

70%

80%75%

49%

73%

57%

75% of public facilities offered adolescent health services


Readiness to provide adolescent heath services

Staff providing HIV testing and counselling services trained in prevention, care, and management for adolescents

Staff providing family planning services trained in adolescent sexual and reproductive health

At least one trained staff provision of adolescent health services

Guidelines available service provision to adolescents

Condoms

Facility offers family planning services to adolescents

Facility offers HIV testing and counselling services to adolescents

Readiness score

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

39%

30%

20%

0%

88%

74%

54%

44%

Readiness score Adolescent health servicesMedicines and commodities Staff and training

No facility had guidelines for adolescent health services


Key Messages: Maternal, Newborn, Child and Adolescent Health

• Availability of maternal, newborn, child and adolescent health was generally good.

• Although ANC services were available in 85% of the facilities, readiness was found to be 58%

• More than three quarters of the facilities had the capacity to deliver immunization services

• Adolescent services were mostly present in public facilities and in rural compared to urban facilities though no facility had guidelines

• Availability and readiness for preventive and curative services for under fives was 82% and 65% respectively

Communicable Diseases


Malaria Tuberculosis HIV counseling and testing HIV care and support ARV prescription and client management PMTCT Sexually Transmitted Infections

Availability of malaria services

Malaria diagnosis verification

IPT

Malaria treatment

Malaria diagnosis

Offers diagnosis or treatment of

malaria

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

66%

72%

86%

86%

93%


93% of health facilities offer malaria diagnosis and treatment services

Readiness to provide malaria services

Guidelines available diagnosis and treatment of malaria

At least one trained staff diagnosis and treatment of malaria

Guidelines available IPT

At least one trained staff IPT


Paracetamol cap/tab

IPT drug

First-line antimalarial in-stock

ITN

Readiness score

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

60%

59%

45%

37%

75%

82%

78%

77%

61%

64%

Readiness score Medicines and commoditiesDiagnostics Staff and training


Availability of TB services

TB treatment strategy

TB treatment

TB diagnostic method

TB diagnosis

Offers TB services

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

14%

21%

23%

24%

38%


Less than 40% of facilities offered TB services

Readiness to provide TB services

Guidelines available management of HIV & TB co-infection

Guidelines available diagnosis and treatment of tuberculosis

At least one trained staff diagnosis and treatment of tuberculosis

At least one trained staff management of HIV & TB co-infection

At least one trained staff TB infection control

At least one trained staff MDR-TB

Guidelines available MDR-TB treatment

Guidelines available TB infection control


System for diagnosis of HIV among TB clients

TB microscopy

All first line TB medications

Readiness score

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

70%

30%

28%

28%

27%

23%

13%

10%

83%

33%

10%

60%

27%



Availability of HIV counseling and testing services

Public/Government

Private Rural Urban Overall0%

10%

20%

30%

40%

50%

60%

70%

80% 75%

49%

73%

57%

69%

Counseling and testing services were more likely to be offered in public facilities


Readiness to provide HIV counseling and testing


Guidelines available HIV counselling and testing

At least one trained staff HIV counselling and testing

Room with visual and auditory privacy


Condoms

Readiness score

0%10%

20%30%

40%50%

60%70%

80%90%

100%

58%

44%

11%

84%

70%

53%

Readiness score Medicine & Commodities DiagnosticsEquipment Staff and training

Availability of HIV care and support services

Treatment for Kaposi's sarcoma

Provide/prescribe fortified protein supplementation

Nutritional rehabilitation services

Provide/prescribe micronutrient supplementation

Preventative treatment for opportunistic infections

Provide condoms

Offers HIV care and support services

0 10 20 30 40 50 60 70 80 90 100

8

11

11

15

23

25

25

26

29

33

33

39

38

Chart Title

Percent of facilities with HIV care and support services


Readiness to provide HIV care and support services

Guidelines available clinical management HIV & AIDS

At least one trained staff clinical management HIV & AIDS

Guidelines available palliative care

System for diagnosis of TB among HIV+ clients

Condoms

Intravenous solution with infusion set

Co-trimoxazole

Palliative care pain management

All first line TB medications

IV treatment fungal infection

Readiness score

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

46%

44%

36%

35%

88%

69%

69%

63%

56%

24%

50%



ARV prescription and client management

Antiretroviral prescription

Provide treatment follow-up services for persons on ART

Offers ARV prescription or ARV treatment follow-up services

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

20%

20%

28%


Readiness to provide ARV prescription and client management services

At least one trained staff ART prescription and management

Guidelines available antiretroviral therapy

Liver function test

Renal function test

CD4 or viral load

Complete blood count (CBC)

Three first line antiretrovirals

Readiness score

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

45%

42%

60%

50%

11%

10%

36%

21%


One out of five facilities were ready to provide ARV prescription


Availability of PMTCT services

ARV prophylaxis to newborns born to HIV+ pregnant women

ARV prophylaxis to HIV+ pregnant women

Infant and young child feeding counselling

Family planning counselling to HIV+ women

HIV counselling and testing to infants born to HIV+ pregnant women

Nutritional counselling for HIV+ women and their infants

HIV counselling and testing to HIV+ pregnant women

Offers services for the prevention of mother-to-child transmission of HIV

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

67%

68%

70%

70%

71%

71%

72%

78%


Readiness to provide PMTCT services

Guidelines available PMTCT

At least one trained staff PMTCT

Guidelines infant and young child feeding

At least one trained staff infant and young child feeding

Room with visual and auditory privacy

HIV diagnostic capacity for adults

DBS for diagnosing newborn HIV

Nevirapine syrup

Maternal ARV prophylaxis

Zidovudine syrup

Readiness score

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

79%

71%

69%

64%

13%

79%

38%

50%

50%

32%

55%



Availability of STIs services

Prescribe treatment for STIs

Diagnosis of STIs

Offers services for STIs

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

66%

68%

78%


Readiness to provide STI services

Guidelines available diagnosis and treatment of STIs

At least one trained staff diagnosis and treatment of STIs

Syphilis rapid test

Metronidazole cap/tab

Condoms

Ciprofloxacin cap/tab

Ceftriaxone injectable

Readiness index

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

55%

36%

49%

100%

85%

79%

64%

67%



Two thirds of facilities were ready to provide STI service

Key Messages: Communicable Diseases

• Malaria, PMTCT, HIV counseling and testing services were available in more than 70% of facilities

• Diagnostic capacity for communicable diseases was high except for TB

• Availability of staff trained to deliver communicable services was better for malaria and PMTCT services

• Medicines for malaria and TB were more available compared to those for HIV


Non-Communicable Diseases


Diabetes Cardiovascular Disease (CVD) Chronic Respirator Disease (CRD)

Availability of diagnosis and/or management of NCDs

Diabetes

Chronic respiratory disease

Cardiovascular disease

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

12%

17%

18% Percent of facilities providing diagnosis and /or management of NCDs


Readiness to provide treatment or management of Diabetes, CVD and Chronic

Respiratory Disease

0%20%40%60%80%

100%

54% 51%

40%

Readiness score Staff and training EquipmentDiagnostics Medicine & Commodities


n=291n=248

n=316

Key message for NCDs

• Overall, availability of treatment and /or diagnosis of NCDs was low

• 91% of facilities had equipment available for CVD (blood pressure apparatus, stethoscope and adults scale)

• Staff trained in the last two years and guidelines were less common. Approximately 3 out of 10 facilities

• Readiness scores for Diabetes and CVD were better off compared for CRD


Basic surgical and blood transfusion services

Availability of basic surgical services

Cricothyroidotomy

Chest tube insertion

Hydrocele reduction

Closed treatment of fracture

Male circumcision

Acute burn management

Wound debridement

Suturing

Incision and drainage of abscesses

Offers basic surgical services

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

3%

4%

6%

7%

25%

40%

45%

50%

55%

28%

26% of facilities provided basic surgical services


Readiness to provide basic surgical services

At least one trained staff IMEESC

Guidelines available IMEESC

Needle holder

Scalpel handle with blade

Surgical scissors

Tourniquet

Suction apparatus

Nasogastric tubes

Retractor

Adult and paediatric resuscitators

Skin disinfectant

Oxygen

Sutures

Lidocaine

Ketamine

Readiness score

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

11%

9%

38%

33%

33%

24%

24%

14%

13%

11%

87%

63%

43%

42%

16%

31%

Readiness score Medicines and commoditiesEquipment Staff and training

Approximately one third of facilities were ready to provide basic surgical services

Source: SARA Tanzania 2012IMEESC Integrated Management for Emergency & Essential Surgical Care

Availability of blood transfusion services

Dis-pen-sary

Health Centre

Hospital MCH Clinic Public Private Total0

10

20

30

40

50

60

70

80

90

100

3

16

77

51

612

8

Chart TitlePercent availability of blood transfusion services by level and ownership


Readiness for provision of blood transfusion services

Guidelines available appropriate use of blood and safe blood trans-fusion

At least one trained staff appropriate use of blood and safe blood transfusion

Blood storage refrigerator

Blood typing

Blood supply sufficiency

Blood supply safety

Readiness score

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

34%

25%

24%

23%

52%

19%

25%



Readiness for blood transfusion services

Key messages surgical and blood transfusion services

• One quarter of the facilities offered basic surgical services

• Readiness score for surgical services was 31%

• Blood transfusion was available in only 8% of facilities.

• Private facilities were twice more likely to have blood transfusion service compared to public

• Readiness score was 23 out of 100


SARA take home messages• This is the first SARA in Tanzania and provides a good baseline for

future assessments

• General Service Readiness highlighted low scores in basic amenities and low diagnostic capacity to perform basic diagnostic tests

• Specific Service Availability was at two thirds or more for services such as malaria, child health, PMTCT and immunization but lower for TB and HIV care and support.

• Specific Service Readiness varied across with high scores for immunization and family planning scoring but lower for ARV prescription and client management and basic surgery

Acknowledgements

• Ministry of Health & Social Welfare• Global Fund• World Health Organization• HMIS focal persons in SPD districts• IHI members

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