Introduction. Methods. SARA design. Research

Transcription

1 Reserch Monitoring service delivery for universl helth coverge: the Service Avilility nd Rediness Assessment Kthryn O Neill, Mrin Tkne, Ashley Sheffel, Crl Aou-Zhr & Ties Boerm Ojective To descrie the (SARA) nd the results of its implementtion in six countries cross three continents. Methods The SARA is comprehensive pproch for ssessing nd monitoring helth service vilility nd the rediness of fcilities to deliver helth-cre interventions, with stndrdized set of indictors tht cover ll min progrmmes. Stndrdized dt-collection instruments re used to gther informtion on defined set of selected trcer items from pulic nd privte helth fcilities through fcility smple survey or census. Results from ssessments in six countries re shown. Findings The results highlight importnt gps in service delivery tht re ostcles to universl ccess to helth services. Considerle vrition ws found within nd cross countries in the distriution of helth fcility infrstructure nd workforce nd in the types of services offered. Weknesses in lortory dignostic cpcities nd gps in essentil medicines nd commodities were common cross ll countries. Conclusion The SARA fills n importnt informtion gp in monitoring helth system performnce nd universl helth coverge y providing ojective nd regulr informtion on ll mjor helth progrmmes tht feeds into country plnning cycles. Introduction The gol of universl helth coverge is to provide everyone with helth-cre services of good qulity tht meet their needs without the risk of finncil hrdship linked to pying for them. 1 Universl ccess to services is necessry precondition to chieving universl helth coverge. 2 The regulr monitoring of ccess to services nd service delivery is often wek component of country nd glol monitoring of progress nd performnce. Yet helth policy-mkers, plnners nd mngers need sound evidence on which to se decisions out resource lloction nd for progrmme monitoring nd evlution. Annul reviews of helth sector progress nd performnce t ntionl nd suntionl levels, sed on rod set of indictors tht cover ll res of performnce, should include up-to-dte, ccurte informtion on service delivery. A fundmentl component of the evidence se is the vilility of helth fcilities nd their rediness to deliver services. Some useful dt, such s stockouts or the functionlity of equipment, cn e gthered through routine helth fcility reporting systems. However, informtion out the vilility of helth-cre infrstructure, skilled helth workers nd resources for disese prevention, dignosis nd tretment is often incomplete or of poor qulity, oth in pulic nd privte fcilities. 3 Access is rod term tht encompsses vried dimensions, including vilility, ffordility nd cceptility. 4,5 The vilility dimension reltes to oth the physicl presence of fcilities nd the distriution of helth-cre infrstructure, helth workforce nd services. Severl progrmmes hve used tools to generte informtion out service vilility nd rediness; however these tools focus only on one prticulr service re This frgmented pproch runs the risk of leding to informtion gps nd dupliction of efforts nd limits the ility to monitor trends in vriety of key indictors. A comprehensive system is needed to ssess the vilility nd rediness of essentil services in rpid, regulr nd hrmonized wy. The Service Avilility nd Rediness Assessment (SARA) provides comprehensive pproch for monitoring the supply of helth services t the fcility level y using stndrd set of trcer indictors nd summry mesures to determine the extent to which minimum criteri for the provision of services re met This rticle descries the SARA nd the results of its implementtion in six countries cross three continents. Methods SARA design The strting point of the SARA is the mster fcility list. 13 This is the source for the compiltion of indictors out service vilility nd provides the smpling frme for the ssessment of service rediness. The mster list comprises ll pulic, privte non-profit, privte for-profit nd fith-sed helth fcilities, including hospitls, helth centres, dispensries nd specilized clinics. In ddition to informtion relting to fcility identifiction or signture domin nme, ddress nd geo-loction of the fcility, etc. 14 the mster list should include informtion on the eds, stffing nd services ville in ech fcility. For country in which mster helth fcility list does not exist or is incomplete, preliminry list should e creted on the sis of the country s helth mngement informtion system, which contins the list of fcilities reporting routine helth sttistics. The mster list lso provides the smpling frme for the rediness survey. The overll smple size will vry from country to country, depending on ville resources, precision requirements nd the need for domin estimtes. 15 In generl, smple size tht provides mrgin of error of less thn Deprtment of Helth Sttistics nd Informtion Systems, World Helth Orgniztion, venue Appi 20, 1211 Genev 27, Switzerlnd. Genev, Switzerlnd. Correspondence to Kthryn O Neill (e-mil: [email protected]) (Sumitted: 21 Decemer 2012 Revised version received: 20 June 2013 Accepted: 24 June 2013 Pulished online: 30 Septemer 2013 ) Bull World Helth Orgn 2013;91: doi: 923

2 Reserch Kthryn O Neill et l. 10% is recommended. Two smpling methods hve een used in the country ppliction of the SARA. A ntionlly representtive rndom smple of t lest 150 helth fcilities strtified y fcility type nd mnging uthority nd weighted ccording to fcility distriution mong districts cn e used to otin ntionl estimtes. If suntionl estimtes re desired, district-level ssessment with census of ll fcilities in selected districts cn generte results tht cn e used for locl mngement. Dt collection is performed y severl survey tems led y either ntionl ministries of helth or ntionl institutes. Dt re usully collected y tems of two surveyors who use oth pper forms nd CSPro (US Census Bureu, Wshington, United Sttes of Americ), n electronic census dt processing system. The in-person fcility visits tke 2 to 4 hours on verge nd involve interviews with key informnts nd verifiction of reported vilility nd functioning of essentil equipment nd supplies, long with oservtion of vilility of medicines nd commodities on the dy of the visit. This pproch minimizes the relince on recll nd enhnces dt qulity. The dt entered re checked nd vlidted nd the results re utomticlly produced using Excel (Microsoft, Redmond, USA). Results nd summry reports re disseminted to ll ntionl stkeholders. To promote trnsprency of results, dt nd reports should e posted on ntionl ministry of helth we sites or in other pulicly ville informtion repositories, with pproprite rchiving of dt nd metdt. The rediness survey should e repeted nnully. Indictors of service vilility The ssessment of service vilility comprises oth generl nd specific components. Generl service vilility is concerned with the physicl presence of items required for the delivery of services nd encompsses helth infrstructure, core helth personnel nd spects of service utiliztion. Indictors include numer nd distriution of helth fcilities nd core medicl professionls per popultion, to ssess levels nd distriution within the country. Service-specific vilility focuses on whether specific type of helth intervention is offered. Interventions my e defined y trget popultion (e.g. Tle 1. Trcer items for generl service rediness employed in the Service Avilility nd Rediness Assessment Ctegory Bsic menities nd equipment (14 items) Stndrd precutions (9 items) Lortory testing cpcity (8 items) Essentil medicines (14 items) HIV, humn immunodeficiency virus. For countries where mlri is endemic. pregnnt women, infnts or children) nd y specific progrmme. Indictors include the proportion of fcilities offering defined service nd the density nd distriution of the fcilities offering the service per popultion. Indictors of service rediness The ssessment of service rediness lso consists of oth generl nd servicespecific components. Generl service rediness reflects the overll cpcity of helth fcilities to provide sic services t minimum stndrds. Four domins of generl service rediness re included in the SARA nd indictors re trcked through trcer items tht were selected on the sis of consulttions with service delivery experts nd experiences with different fcility ssessments over the pst decde (Tle 1). 9,16,17 Individul trcer indictor scores my e summrized s composite mesures, nmely the proportion of fcilities with ll trcer items ville on the dy of the visit nd the men item vilility score, with the ltter mesure more sensitive to chnge over time. For exmple, the essentil medicines indictor comprises 14 trcer items. The composite mesures would look t the men of the 14 items ville in ech fcility s well s the percentge of fcilities with ll 14 items ville on the dy of the survey. Service-specific rediness reflects the cpcity of helth fcilities to provide interventions in 20 key progrmme Trcer items Amenities (7 items): electric power; improved wter source within 500 m of fcility; room with uditory nd visul privcy for ptient consulttions; dequte snittion fcilities for clients; communiction equipment (phone or short wve rdio); computer with emil/internet ccess; emergency trnsporttion. Equipment (7 items): weighing scles (child, dult); thermometer; stethoscope; lood pressure pprtus; light source; refrigertor. Sfe finl disposl of shrps, sfe finl disposl of infectious wstes; pproprite storge of shrps, pproprite storge of infectious wste; disinfectnt; single-use stndrd disposle or utodisposle syringes; sop nd running wter or lcohol-sed hnd ru; ltex gloves; guidelines. Blood hemogloin; lood glucose; lood smer or rpid test for mlri prsites; urine dipstick protein; urine dipstick glucose; HIV ntiody test; syphilis rpid test; urine pregnncy test. Amoxicillin, tenolol, cptopril, ceftrixone, ciprofloxcin, cotrimoxzole suspension, dizepm, diclofenc, glienclmide, omeprzole, mitriptyline, prcetmol suspension, slutmol, simvsttin. res: fmily plnning, ntentl cre, sic nd comprehensive delivery cre, child helth, routine child immuniztion, dolescent helth, mlri, tuerculosis, humn immunodeficiency virus (HIV) infection testing nd counselling, HIV cre nd support, ntiretrovirl therpy, prevention of mother-to-child trnsmission (PMTCT) of HIV, sexully trnsmitted diseses, dietes, crdiovsculr disese, chronic respirtory disese, sic nd comprehensive surgery, nd lood trnsfusion. The essentil inputs needed to deliver service-specific interventions re descried cross four domins: (i) trined stff nd relevnt nd up-to-dte guidelines; (ii) functioning equipment; (iii) dignostic cpcities; nd (iv) essentil medicines nd commodities. Within ech domin, men score is clculted cross the trcer items nd n overll composite rediness index is clculted for ech progrmme re sed on the men vilility of trcer items cross ll domins. For simplicity, ll trcer items re given equl weight. An exmple of service specific rediness indictor cn e seen in Tle 2. Country implementtion In Burkin Fso (2008), Cmodi (2008), Hiti (2008), United Repulic of Tnzni ( ) nd Zmi (2008), fcility ssessments were conducted on the sis of fcility censuses in selected districts using the SARA 924 Bull World Helth Orgn 2013;91: doi:

3 Kthryn O Neill et l. Tle 2. Exmple of service-specific rediness indictor for the Service Avilility nd Rediness Assessment Domin Antentl cre service Stff nd guidelines Equipment Dignostics Medicines nd commodities s prt of n evlution y the Glol Fund. 18 In 2010, Zmi repeted the SARA through census of fcilities in 17 districts. 19 In Sierr Leone, the SARA ws implemented in 2011 in rndom smple of helth fcilities drwn from the ntionl mster list nd results were weighted ccording to the distriution of helth fcilities. 20 The SARA ws repeted in 2012 in Sierr Leone to enle nnul progress trcking. In Sierr Leone, the survey ws performed efore the nnul helth sector review so tht the results could e used nd nlysed s prt of the helth sector performnce ssessment. All fcility ssessments from the six countries included privte fcilities. The nlyses presented here focus on the common items cross the ssessments. Commonly ville sttisticl softwre pckges were used for nlysis. 21 Results Service vilility Tle 3 summrizes select spects of service vilility. Helth fcility density cross the countries rnged from 0.8 fcilities per popultion (in Hiti) to 3.6 fcilities per popultion (in Cmodi). In the ssessments in su- Shrn Afric, helth fcility density rnged etween 1.2 nd 2.2 fcilities per popultion. Privte for-profit helth fcilities were common in Cmodi (39% of ll fcilities) nd Zmi (35% in the 2008 survey, which included the cpitl, Lusk). By contrst, the privte sector ccounted for less thn 10% of fcilities in Burkin Fso. The density of helth workers (i.e. physicins, nurses, midwives nd clinicl officers) rnged from 3.6 workers per popultion (in Burkin Fso) to 22.4 workers per popultion (in Trcer items Guidelines on ntentl cre Stff trined in ntentl cre Blood pressure pprtus Hemogloin test Urine dipstick protein test Iron tlets Folic cid tlets Tetnus toxoid vccine Cmodi). There were lrge differences etween districts, with densities eing highest in urn districts. The presence of nurses on the dy of the visit ws pproximtely 80% in most ssessments ut frequencies were much lower in the United Repulic of Tnzni nd Zmi (2008). The proportion of fcilities offering specific service vried considerly cross countries. Child immuniztion services were offered y t lest two thirds of the fcilities, most of which were pulicly funded, in ll country ssessments. Fmily plnning services were lso commonly offered except in Cmodi, where less thn hlf of the fcilities offered such services. The proportion of fcilities offering childirth nd delivery services vried from 42% in Zmi to 91% in Sierr Leone in These vritions re to some extent driven y differences in orgniztionl structures for the delivery of childirth services. Generl service rediness Tle 4 shows results for the four indexes of generl service rediness, sed on items common to ll ssessments. The verge item vilility for menities nd sic equipment rnged from 64% to 81%, with scores of > 80% on individul equipment items. The verge scores for stndrd precutions ginst infection control were > 70% in ll countries except Hiti. The highest verge score 87% ws noted in Zmi (2010). Lortory dignostic cpcity ws very low (< 30%) in Burkin Fso, Cmodi nd Sierr Leone. The presence of 13 essentil medicines dizepm ws dded lter to the SARA instrument ws low in ll countries. It rnged from 27% in Burkin Fso, Hiti nd Sierr Leone to 53% in Zmi (in 2010). Reserch Two exmples illustrte further progrmme-relevnt spects. In Sierr Leone, privte fcilities scored higher thn pulic fcilities in ll four domins of generl service rediness, with overll scores of 62% nd 45%, respectively. The strkest differences were oserved in the domins of lortory dignostic cpcity (30% versus 8%) nd essentil medicines (61% versus 31%). In the 2010 Zmi SARA, the vilility of essentil medicines on the dy of the visit ws 49% overll ut rnged from 32% to 60% cross districts. In generl, overll vilility ws higher mong the four ssessed urn districts (rnge: 53 60%) nd lower in the nine ssessed rurl districts (rnge: 32 46%); vilility rnged from 39% to 59% mong the four periurn districts evluted. Although the vilility of ntiiotics to tret infectious diseses ws reltively high (71% on verge), the vilility of medicines to tret non-communicle diseses ws consistently low (37% on verge). Service-specific rediness The proportion of helth fcilities in Sierr Leone with trcer items for child immuniztion (mong fcilities offering immuniztion) is shown for 2011 nd 2012 in Fig. 1. The proportion of fcilities with pentvlent vccines (diphtheri-tetnus-pertussis [DPT], Hemophilus influenze type [Hi] nd heptitis B [HepB]) in stock declined from 81% to 70% etween 2011 nd 2012 (P = 0.049, Fisher s exct test). There were similr declines for other vccines. In Zmi, out 64% of fcilities in the 17 districts surveyed offered childirth nd delivery services in Fig. 2 shows the men rediness score, y fcility type, sed on 14 trcer items. On verge, helth fcilities hd 9 of the 14 trcer items, for n overll rediness score of 61%. For hospitls this ws 85%. Eighteen per cent of hospitls hd ll 14 trcer items, compred with 1% of primry cre fcilities. Only 38% of primry cre fcilities offering delivery services hd neontl g nd msk compred with 77% of hospitls, nd only 32% hd injectle mgnesium sulfte for the tretment of eclmpsi, compred with 91% of hospitls. Across ll fcility types, the vilility of stff who hd een trined in the Integrted Mngement of Pregnncy nd Childirth in the preceding two yers ws generlly low. Bull World Helth Orgn 2013;91: doi: 925

4 Reserch Kthryn O Neill et l. Tle 3. Service vilility in selected fcilities in six countries, ccording to the, Zmi Chrcteristic Burkin Fso Cmodi Hiti Sierr Leone United Repulic of Tnzni Design Census Census Census Smple survey Smple survey Census Census Census No. of districts smpled (totl 13 (63) 7 (77) 9 (42) NA (13) NA (13) 15 (113) 9 (72) 17 (72) districts) No. of fcilities smpled Popultion No. of fcilities per Privte for-profit, % Inptient eds per NA NA Helth workers per (rnge) 3.6 ( ) 22.4 ( ) 7.6 ( ) NA NA 7.2 ( ) 11.3 ( ) 12.1 ( ) Fcilities with nurse present on NA NA NA dy of visit, % Fcilities offering service, % Child immuniztion Fmily plnning Delivery NA, not ville. Popultion of the districts included in the ssessment. Sierr Leone conducted ntionl smple survey nd hence the figures presented re ntionl popultion figures. Bsed on ntionl mster fcility list (1264 fcilities). In Burkin Fso, Cmodi nd the United Repulic of Tnzni, the SARA reveled tht the proportion of helth fcilities offering mlri services ws > 90% in the two Africn ssessments nd 62% in Cmodi. Among fcilities offering mlri services, the mjority hd country-recommended nti-mlril drugs in stock nd trined stff nd tretment guidelines. However, dignostic tests (rpid test or lood smer) were less commonly ville, rnging from low of 6% in Burkin Fso to 57% in Cmodi. Artemisinin comintion therpy ws ville in 76% of fcilities offering mlri services in the United Repulic of Tnzni. Tuerculosis tretment services were offered y less thn hlf of the fcilities in Burkin Fso nd the United Repulic of Tnzni, ut y 52% of the fcilities in Cmodi. Four drugs (isonizid, rifmpicin, ethmutol nd pyrizmine) were commonly ville in Cmodi (84%) nd the United Repulic of Tnzni (74%) ut not in Burkin Fso, where vilility ws very low (39%). Aout one third of fcilities offering tuerculosis services did not hve trined stff or guidelines. PMTCT services re reltively new nd re offered y rther smll numer of fcilities in Burkin Fso, Cmodi nd the United Repulic of Tnzni. In the fcilities offering these services during ntentl cre in these three countries, trining nd guidelines were generlly present ut medicines (nevirpine or zidovudine) nd dignostic tests (rpid or other test) were not. This rought down the overll rediness score to elow 25%. In Zmi, the proportion of fcilities offering PMTCT services incresed from 50% in 2008 to 66% in Rediness to provide PMTCT services lso incresed. The percentge of fcilities with ll trcer items for PMTCT services incresed from 33% in 2008 to 56% in 2010, while men rediness scores incresed from 71% to 83% (Fig. 3). A mrked increse in the vilility of ntiretrovirl drugs ws oserved etween the two surveys, indicting significnt scle-up in these services. Discussion As countries seek to scle up nd monitor progress towrds the gol of universl helth coverge, there is likely to e incresed demnd for regulr nd 926 Bull World Helth Orgn 2013;91: doi:

5 Kthryn O Neill et l. Reserch Tle 4. Men scores for service rediness in selected fcilities in six countries, ccording to the Service Avilility nd Rediness Assessment, Chrcteristic Burkin Fso Cmodi Hiti Sierr Leone United Repulic of Tnzni Zmi No. of fcilities Bsic menities nd equipment, % c (11 items ) Stndrd precutions, % (6 items d ) Dignostics (on site), % (8 items) Medicines, % (13 items e ) Overll men Includes fcilities from the eight districts in common with the 2008 Zmi ssessment. Excludes snittion fcilities, room with privcy, light source. c Emergency trnsport missing. d Includes sop nd running wter, disinfectnt, disposle needles, infectious wste nd shrps disposl, guidelines. e Dizepm not included. Fig. 1. Percentge of fcilities in Sierr Leone equipped with trcer items for child immuniztion services, mong fcilities providing such services ccording to the 2011 nd 2012 (n 2011 = 190, n 2012 = 90) Stff nd guidelines Equipment Overll Medicines nd commodities Trined stff Guidelines Single-use syringes Shrps continer Cold ox with ice pcks Refrigertor DPT-Hi-HepB vccine Mesles vccine Polio vccine BCG vccine All items Child immuniztion men score Fcilities (% with item) BCG, cillus Clmette-Guérin; DPT, diphtheri-tetnus-pertussis; HepB, heptitis B; Hi, Hemophilus influenze type. Stff trined in the Expnded Progrmme on Immuniztion. Guidelines on Expnded Progrmme on Immuniztion relile dt on helth-cre infrstructure, on the vilility of skilled helth workers nd on the cpcity of helth fcilities nd stff to provide the full rnge of essentil services required to offer coverge with qulity helth-cre services to ll those who need cre. Use of the SARA hs severl potentil dvntges. It encourges the mintennce of hrmonized ntionl service monitoring system with stndrdized set of indictors tht includes ll key helth services. It is likely to cost less thn frgmented dt collection nd promotes country ownership nd trnsprency. The most effective ppliction is when the SARA is plnned nd conducted on n nnul sis just efore country plnning cycle to inform helth sector reviews. Results re disseminted to ll key ntionl stkeholders nd nlysed together with dt from other dt sources, such s popultion surveys, qulity-of-cre surveys nd routine fcility reports, to provide comprehensive nlysis of helth system progress nd performnce. Deficiencies nd gps need to e ddressed s prt of nnul opertionl helth plns nd investment plns. And, s shown y the results of the eight surveys, the SARA genertes ojective nd comprehensive informtion on the sttus of country s helth services tht cn e used to support opertionl progrmme plnning nd mngement nd to monitor country progress towrds improving ccess to helth services s necessry Bull World Helth Orgn 2013;91: doi: 927

6 Reserch Fcilities (% with item) Fig. 2. Percentge of fcilities in Zmi equipped with trcer items for sic ostetric cre services, y district, mong fcilities providing such services (n = 362), ccording to the, Hospitl (n = 34) Overll rediness score Guidelines Prtogrph Emergency trnsport 59 Helth centre (n = 300) Helth post (n = 27) All fcilities (17 districts) Trined stff Gloves Delivery ed Suction pprtus Neontl g nd msk Exmintion light Intrvenous infusion kit Skin disinfectnt Neontl eye prophylxis Injectle uterotonic Injectle mgnesium sulphte All items Guidelines on sic emergency ostetric cre nd Mnul on essentil cre prctice guidelines for pregnncy, childirth nd neworn. Stff trined in sic emergency ostetric cre nd in the Mnul on essentil cre prctice guidelines for pregnncy, childirth nd neworn. Fig. 3. Percentge of fcilities in eight Zmin districts comined equipped with trcer items for prevention of mother-to-child trnsmission (PMTCT) services, mong fcilities providing such services (n 2008 = 162, n 2010 = 207), ccording to the, 2008 nd 2010 Overll Guidelines Trined stff HIV test Nevirpine Zidovudine Mternl ARV prophylxis Fcilities (% with item) Percentge of fcilities with ll items ARV, ntiretrovirl; HIV, humn immunodeficiency virus. Guidelines on PMTCT nd on infnt nd young child feeding counselling. Stff trined in PMTCT nd in infnt nd young child feeding counselling Kthryn O Neill et l. precondition to chieving universl helth coverge. Severl issues concerning methodology with potentil vritions cross countries nd over time should e orne in mind. In plces where the mster fcility list is sufficiently complete nd up to dte, s is the cse in Keny, 22 strong multi-stkeholder coordinting groups or regultory odies for the licensing of helth fcilities hve een estlished through vrious ntionl institutes, including ntionl sttisticl offices, mpping gencies nd in-country prtners. In other countries, however, mintining the mster fcility list continues to e difficult. The completeness of the helth fcility mster list is likely to improve if systemtic ssessment is conducted through, for instnce, fcility ccredittion system nd there is regulr district reporting of new, continuing nd discontinued/ closed fcilities, coupled with complete fcility census once every 5 or 10 yers. The SARA does not ddress other dimensions of ccess tht require more complex mesurement strtegies, such s geogrphic rriers, trvel time nd fcility use ptterns. A potentilly vlule indictor would e the proportion of the popultion living within specified distnce (e.g. 5 km) or trvel time (e.g. within 1 hour) from helth fcility. Such figure cn e computed through sptil nlysis if fcility loctions nd geocodes, popultion distriution, rod network nd trnsport fcilities re known exctly. This method hs not found lrge-scle ppliction ecuse of its dt demnds nd nlyticl complexity. Some countries rely on sujective reporting y fcilities nd districts of the proportions of their popultions living within specific trvel time or distnce to helth fcilities, ut the dt re often of questionle qulity. The SARA does not generte dt on service ffordility or qulity. Dt on service costs hve een collected during previous fcility ssessments ut did not pper to e relile reflection of the cost to users. Both service vilility nd rediness re preconditions for qulity cre ut they re not indictors of qulity in themselves. The SARA is designed to ssess only the underlying prerequisites of service qulity. Other instruments hve een developed to mesure client stisfction nd knowledge nd helth worker 928 Bull World Helth Orgn 2013;91: doi:

7 Kthryn O Neill et l. Reserch prctices through provider interviews, client provider oservtions nd client exit interviews. 17 A qulity-of-cre study or disese-specific survey could e comined with nd implemented long with the SARA s n dditionl module. This would reduce field costs nd promote hrmoniztion in dt collection nd nlysis. In light of the incresing demnd for hrmoniztion nd lignment of prtner support for strong ntionl helth strtegy through the Interntionl Helth Prtnerships (IHP+), there is renewed impetus to reduce frgmenttion of dt collection nd prllel disese reporting systems nd to invest in more hrmonized pproch to dt collection nd nlysis through common monitoring nd evlution pltform. 3,16 The cll for etter ccountility of results within the context of the recommendtions of the Commission on Informtion nd Accountility is lso dding weight to this pproch. 23 The SARA is n exmple of such hrmonized pproch to dt collection. A greter numer of progrmmes nd donors, including the Glol Fund nd the GAVI Allince, re lening towrds investing in nd using the SARA s the stndrd method for monitoring service delivery in comprehensive wy, with reduced frgmenttion nd dupliction in tools nd expenditures. Acknowledgements The Service Avilility nd Rediness Assessment (SARA) method ws developed through joint collortion of the World Helth Orgniztion (WHO) nd the United Sttes Agency for Interntionl Development (US- AID). The method uilds upon previous nd current pproches designed to ssess service delivery, including the service vilility mpping (SAM) tool developed y WHO nd the service provision ssessment (SPA) tool developed y ICF Interntionl under the USAID-funded MEASURE DHS project. It drws on est prctices nd lessons lernt from the mny countries tht hve implemented helth fcility ssessments, s well s on guidelines nd stndrds developed y WHO technicl progrmmes. The uthors re grteful for the inputs of WHO stff with expertise in specific intervention res nd would like to thnk the Ministries of Helth of Burkin Fso, Cmodi, Hiti, Sierr Leone, the United Repulic of Tnzni nd Zmi for their collortion nd support in dt collection nd in country-specific nlyses. Competing interests: None declred. ملخص رصد إيتاء اخلدمات من أجل التغطية الصحية الشاملة: تقييم توفر اخلدمات والتأهب الغرض وصف تقييم توفر اخلدمات والتأهب )SARA( ونتائج تنفيذه يف ستة بلدان عرب ثالث قارات. الطريقة تقييم توفر اخلدمات والتأهب عبارة عن هنج شامل لتقييم ورصد توفر اخلدمات الصحية وتأهب املرافق إليتاء تدخالت الرعاية الصحية باستخدام جمموعة موحدة من املؤرشات التي تغطي مجيع الربامج الرئيسية. وتستخدم أدوات مجع البيانات املوحدة جلمع املعلومات حول جمموعة حمددة من عنارص اقتفاء األثر املختارة من مرافق الصحة العامة واخلاصة من خالل التعداد أو املسح اخلاص بعينات املرافق. ويتم عرض نتائج التقييامت يف ستة بلدان. النتائج تربز النتائج ثغرات مهمة يف إيتاء اخلدمات متثل عقبات أمام اإلتاحة الشاملة للخدمات الصحية. وتم التوصل إىل وجود تفاوت كبري داخل البلدان وبينها يف توزيع البنية التحتية والقوى العاملة يف املرافق الصحية ويف أنواع اخلدمات املقدمة. وكان الضعف يف القدرات التشخيصية املخربية والثغرات يف األدوية والسلع األساسية شائعا بني مجيع البلدان. االستنتاج يسد تقييم توفر اخلدمات والتأهب ثغرة معلوماتية مهمة يف رصد أداء النظام الصحي والتغطية الصحية الشاملة عن طريق تقديم معلومات موضوعية ومنتظمة عن مجيع الربامج الصحية الكربى التي تؤثر عىل دورات التخطيط القطرية. 摘 要 全 民 医 疗 保 障 的 服 务 交 付 监 控 : 服 务 可 及 性 和 准 备 情 况 评 估 目 的 描 述 服 务 可 及 性 和 准 备 情 况 评 估 (SARA) 及 其 在 结 果 结 果 凸 显 了 服 务 交 付 的 重 要 缺 口, 这 些 缺 口 正 是 三 大 洲 六 个 国 家 中 的 实 施 效 果 普 及 医 疗 服 务 的 障 碍 在 卫 生 基 础 设 施 和 劳 动 力 的 分 方 法 SARA 有 一 套 覆 盖 所 有 主 要 计 划 的 标 准 化 指 标 集 配 以 及 所 提 供 的 服 务 类 型 方 面, 在 各 个 国 家 内 部 和 各 合, 是 评 估 和 监 控 卫 生 服 务 可 及 性 和 设 施 准 备 情 况 的 个 国 家 之 间 存 在 相 当 大 的 差 异 实 验 室 诊 断 能 力 薄 弱 综 合 方 案, 以 便 于 提 供 医 疗 卫 生 干 预 使 用 标 准 化 数 基 本 药 品 和 商 品 的 缺 口 是 所 有 国 家 共 有 的 情 况 据 采 集 工 具, 通 过 设 施 抽 样 调 查 或 普 查, 从 公 共 和 私 人 结 论 SARA 提 供 了 所 有 关 于 主 要 健 康 计 划 的 客 观 和 定 设 施 收 集 已 确 定 的 一 组 所 选 示 踪 项 目 方 面 的 信 息 显 期 的 信 息 注 入 到 国 家 计 划 周 期 中, 填 补 了 健 康 卫 生 系 示 六 个 国 家 的 评 估 结 果 统 绩 效 和 全 民 医 保 的 重 要 信 息 缺 口 Résumé Surveillnce de l presttion de services pour l couverture snitire universelle: évlution de l disponiilité et de l étt de préprtion des services Ojectif Décrire l Évlution de l Disponiilité et de l Étt de Préprtion Méthodes L évlution de l Disponiilité et de l Étt de Préprtion des Services, insi que les résultts de s mise en œuvre dns six pys, des Services est une pproche glole permettnt d évluer et de sur trois continents. surveiller l disponiilité des services de snté et l étt de préprtion des Bull World Helth Orgn 2013;91: doi: 929

8 Reserch instlltions pour ssurer des interventions médicles, vec un ensemle normlisé d indicteurs qui couvre tous les progrmmes principux. Des instruments normlisés de collecte de données sont utilisés pour recueillir des informtions concernnt une série définie d éléments trceurs sélectionnés dns des instlltions puliques et privées pr le iis d une enquête ou d un recensement uprès d un échntillon de prticipnts. Les résultts des évlutions dns six pys sont présentés. Résultts Les résultts soulignent les importntes lcunes en termes de presttions des services qui constituent des ostcles à l ccès universel ux services de snté. Des vritions considérles ont été consttées u sein de et entre les pys en termes de l distriution des infrstructures Kthryn O Neill et l. des étlissements de snté, des effectifs et des services offerts. Les défillnces en termes de cpcités dignostiques dns les lortoires et les insuffisnces u niveu des médicments et des produits essentiels sont communes dns tous les pys. Conclusion L évlution de l Disponiilité et de l Étt de Préprtion des Services comle un mnque importnt d informtions dns le domine de l surveillnce de l performnce des systèmes de snté et de l couverture snitire universelle en fournissnt des données ojectives et régulières sur tous les principux progrmmes de snté qui limentent les cycles de plnifiction des pys. Резюме Мониторинг предоставления услуг в целях всеобщего охвата медико-санитарной помощью: оценка доступности услуг и готовности Цель Описать Оценку услуг и готовности (SARA), а также недостатках в предоставлении услуг, которые являются результаты ее проведения в шести странах на трех континентах. препятствием для обеспечения всеобщего доступа к медикосанитарным услугам. Существенные различия были обнаружены Методы SARA это всеобъемлющий подход к оценке и мониторингу доступности медико-санитарных услуг и как внутри стран, так и между ними в части распределения готовности объектов здравоохранения к оказанию мер инфраструктуры и персонала медицинских объектов и по типам медико-санитарной помощи с использованием набора предлагаемых услуг. Общие недостатки всех стран нехватка стандартизированных показателей, охватывающих все основные лабораторно-диагностических возможностей и основных программы. Стандартизированные инструменты сбора данных лекарственных средств и товаров. используются для сбора информации об определенном Вывод Подход SARA восполняет важный пробел в мониторинге наборе избранных показателей государственных и частных эффективности работы системы здравоохранения и всеобщего медицинских учреждений в рамках выборочного обследования охвата медико-санитарной помощью, предоставляя объективную или статистического исследования объекта. Здесь приводятся и регулярную информацию о всех крупных программах в области результаты оценок, проведенных в шести странах. здравоохранения для учета в циклах планирования в странах. Результаты Результаты свидетельствуют о существенных Resumen Control de l prestción de servicios pr l coertur universl de slud: evlución de l disponiilidd y preprción de los servicios Ojetivo Descriir l evlución de l disponiilidd y preprción de en l prestción de servicios que ostculizn el cceso universl los servicios (SARA), sí como los resultdos de su plicción en seis los servicios de slud. Tnto en cd pís como entre los píses se píses de tres continentes. oserv un vrición relevnte en l distriución de l infrestructur Métodos L evlución de l disponiilidd y preprción de los de ls instlciones de slud y del personl snitrio, sí como en los servicios es un enfoque integrl que tiene como ojeto evlur y relizr tipos de servicios que se ofrecen. En todos los píses se oservó un un control de l disponiilidd de servicios de slud y l preprción de flt de fiilidd en l cpcidd de dignóstico de lortorio y un ls instlciones pr relizr intervenciones de tención snitri, y que insuficienci de medicmentos esenciles y de productos ásicos. incluye un conjunto estndrizdo de indicdores que rcn todos Conclusión L evlución de l disponiilidd y preprción de los los progrms principles. Se emplen instrumentos estndrizdos servicios colm un crenci importnte de informción pr el control de recolección de dtos pr recopilr informción sore un conjunto del desempeño del sistem de slud y l coertur universl de slud, definido de indicdores selecciondos trvés de un censo o encuest y proporcion informción ojetiv y periódic sore los progrms muestrl sore ls instlciones de los servicios de slud púlicos y de slud principles que se incorpor los ciclos de plnificción de privdos. Se muestrn los resultdos de ls evluciones en seis píses. los píses. Resultdos Los resultdos ponen en relieve deficiencis importntes References 1. The world helth report: helth systems finncing: the pth to universl coverge. Genev: World Helth Orgniztion; Aville from: whqlidoc.who.int/whr/2010/ _eng.pdf [ccessed 25 Novemer 2012]. 2. Evns DB, Hsu J, Boerm T. Universl helth coverge nd universl ccess. Bull World Helth Orgn 2013;91: A. doi: BLT PMID: Monitoring the uilding locks of helth systems: hndook of indictors nd their mesurement strtegies. Genev: World Helth Orgniztion; Aville from: index.html [ccessed 27 August 2013]. 4. Tnhshi T. Helth service coverge nd its evlution. Bull World Helth Orgn 1978;56: PMID: Penchnsky R, Thoms JW. The concept of ccess: definition nd reltionship to consumer stisfction. Med Cre 1981;19: doi: dx.doi.org/ / PMID: Bull World Helth Orgn 2013;91: doi:

9 Kthryn O Neill et l. Reserch 6. Edwrd A, Mtsuiyshi T, Fpohund B, Becker S. A comprtive nlysis of select helth fcility survey methods pplied in low income countries. Chpel Hill: University of North Crolin, Crolin Popultion Center; 2009 (MEASURE Evlution Working Pper Series WP-09-11). 7. Bryce J, Victor CG, Hicht JP, Vughn JP, Blck RE. The multi-country evlution of the integrted mngement of childhood illness strtegy: lessons for the evlution of pulic helth interventions. Am J Pulic Helth 2004;94: doi: PMID: Needs ssessment of emergency ostetric nd neworn cre. New York: Columi University; Aville from: content/needs-ssessments [ccessed 27 August 2013]. 9. Cmeron A, Ewen M, Ross-Degnn D, Bll D, Ling R. Medicine prices, vilility, nd ffordility in 36 developing nd middle-income countries: secondry nlysis. Lncet 2009;373: doi: org/ /s (08) PMID: Gupt N, Dl Poz MR. Assessment of humn resources for helth using cross-ntionl comprison of fcility surveys in six countries. Hum Resour Helth 2009;7:22. doi: PMID: MEASURE DHS Demogrphic nd Helth Surveys [Internet]. The Service Provision Assessment (SPA). Clverton: Mesure DHS; Aville from: [ccessed 27 August 2013]. 12. Fronczk N, Fpohund B, Buckner B, Schenk-Yglesis C. Using helth fcility profiles s monitoring tool: n exmple sed on dt from three Afric countries. Chpel Hill: University of North Crolin, Crolin Popultion Center; 2007 (MEASURE Evlution Working Pper Series WP ). 13. Creting mster helth fcility list. Genev: World Helth Orgniztion; Aville from: WHO_CretingMFL_drft.pdf [ccessed 27 August 2013]. 14. Helth Fcility Assessment Technicl Working Group. The signture domin nd geogrphic coordintes: stndrdized pproch for uniquely identifying helth fcility. Chpel Hill: University of North Crolin, Crolin Popultion Center; 2007 (MEASURE Evlution Working Pper Series WP-07-91). 15. Turner AG, Angeles G, Tsui AO, Wilkinson M, Mgnni R. Smpling mnul for fcility surveys: for popultion, mternl helth, child helth nd STD progrms in developing countries. Chpel Hill: University of North Crolin, Crolin Popultion Center; 2001 (MEASURE Evlution Mnul Series, No.3). 16. Monitoring nd evlution of ntionl helth strtegies: country-led pltform for informtion nd ccountility. Genev: World Helth Orgniztion; Aville from: evlution/documenttion/en/index.html [ccessed 27 August 2013]. 17. Helth Fcility Assessment Technicl Working Group. Guidnce for selecting nd using core indictors for cross-country comprisons of helth fcility rediness to provide services. Chpel Hill: University of North Crolin, Crolin Popultion Center; 2007 (MEASURE Evlution Working Pper Series WP en). 18. The Glol Fund to Fight AIDS, Tuerculosis nd Mlri [Internet]. The five-yer evlution. Genev: Glol Fund; Aville from: theglolfund.org/en/terg/evlutions/5yer/ [ccessed 27 August 2013]. 19. Zmi service vilility nd rediness ssessment 2010 summry report. Lusk: Repulic of Zmi, Ministry of Helth; Aville from: [ccessed 27 August 2013]. 20. Sierr Leone service vilility nd rediness ssessment 2011 report. Freetown: Government of Sierr Leone, Ministry of Helth nd Snittion; Aville from: en/index.html [ccessed 27 August 2013]. 21. United Sttes Census Bureu [Internet]. Interntionl progrms Census nd Survey Processing System overview people nd households. Wshington: US Census Bureu; Aville from: gov/popultion/interntionl/softwre/cspro/ [ccessed 27 August 2013]. 22. Noor AM, Alegn VA, Gething PW, Snow RW. A sptil ntionl helth fcility dtse for pulic helth sector plnning in Keny in Int J Helth Geogr 2009;8:13. doi: PMID: Keeping promises, mesuring results: report of the Commission on Informtion nd Accountility for Women s nd Children s Helth. Genev: World Helth Orgniztion; Aville from: ccountility/resources/coi_resources/en/index.html [ccessed 27 August 2013]. Bull World Helth Orgn 2013;91: doi: 931