Integrated Health Facility Assessment

Abstract

• Name: Integrated Health Facility Assessment
• Purpose: The Integrated Health Facility Assessment (IHFA) is a tool that assists in planning the introduction and improvement of integrated management of infants and children at outpatient health facilities. It is designed to measure the core elements of integrated case-management practices and availability of mechanisms and tools required to support these practices at facility level.
• Type of Design: Descriptive, cross sectional
• Sample Size: 25-30 facilities is recommended
• Where Used: Africa, NIS and Latin America

To survey tool

Basic Information

Name: Integrated Health Facility Assessment: Using Local Planning to Improve the Quality of Child Care at Health Facilities

Origin: John Murray, Serge Manoncourt; The Basic Support for Institutionalizing Child Survival Project (BASICS)

Source: BASICS

Basic Description: Local planning tool used to collect information on the quality of integrated child health care at facility level.

Country Applications: Africa: Benin, Eritrea, Ethiopia, Ghana, Guinea, Mali, Madagascar, Morocco, Senegal, Zambia; NIS: Kazakhstan, Kyrgystan, Uzbekhistan; Latin America: Bolivia, Ecuador, Honduras.

Languages Available: English; Spanish and eventually French

Technical Scope: Integrated Management of Childhood Illness.

Purpose: The Integrated Health Facility Assessment (IHFA) is a tool that assists in planning and monitoring the introduction and improvement of integrated management of infants and children at outpatient health facilities.

Type of method: Quantitative

Design: Descriptive, cross sectional health facility survey.

Frequency of Administration: Dependent on district planning needs. Follow-up in Zambia and Madagascar was conducted two years after baseline assessment and program implementation.

Key Users of Information

Managers of primary health care programs; health workers.

Objectives and Scope of Tool

This assessment has five key characteristics. It is designed to be:

1. rapid;
2. conducted before IMCI training has been implemented;
3. cost-effective;
4. a local-level program planning tool;
5. one step in a process of integrated infant and child health program development.

The objectives of the health facility assessment are:

1. To determine --

• Current knowledge and practices of health workers at outpatient clinics related to the assessment and management of sick children.
• Principal barriers to effective case-management practices.
• Adequacy of training and supervision of health workers.

2. To use the information to --

• Prioritize and plan improvements in the quality of care at outpatient health facilities, including changes in staffing, clinic organization, equipment requirements, drug and material supplies and case-management practices.
• Improve or develop pre- and in-service training for outpatient health workers.
• Improve or develop a strategy for supervising and monitoring health worker performance over time.

3. To train local health workers in survey techniques, collection and analysis of survey data, and the use of data to improve the quality of integrated case management in outpatient health facilities.

Key Indicators

The data collected will help managers and workers in primary health care programs to plan and improve service components that are essential for the delivery of integrated child health services, including:

1. Health worker training;
2. Health worker supervision;
3. Drug supply;
4. Availability of essential equipment;
5. Health facility organization.

Specifically, information is collected on the management of the following clinical presentations:

1. Fever (malaria, measles, ear infection);
2. Acute lower respiratory tract infection (pneumonia);
3. Diarrhea (simple watery diarrhea, persistent diarrhea, or dysentery);
4. Undernutrition.

Information collected on the quality of case management for children presenting at a health facility with fever, cough, difficulty breathing or diarrhea include:

1. The assessment, diagnosis and treatment of children with diarrhea, fever and malaria, and acute lower respiratory tract infections.
2. Whether the vaccination status of women of childbearing age and children is checked during the sick child visit and whether these women and children are vaccinated appropriately.
3. How well caretakers are able to provide home treatment for their children.
4. How well health workers counsel caretakers about preventive and curative care.
5. The quality of training and supervision received by health workers.

Examples of the type of information collected at facility level include:

1. Availability of essential equipment (e.g., weighing scales, sterilizer, refrigerator);
2. Availability of essential materials (e.g., measuring cups for oral rehydration salts, patient registers, maternal and child health cards, growth monitoring charts);
3. Availability of essential drugs and vaccines;
4. Adequacy of staffing and time spent with each caretaker and child;
5. Adequacy of vaccination sessions (e.g., that missed opportunities for vaccinating infants and women of childbearing age are avoided.

Research Design

This assessment requires approximately 15-30 days. This includes: training surveyors and supervisors (five days); conducting and supervising the assessment (eight days); data entry and analysis (nine days - or six days for data entry during field work and three days for analysis of data); and utilization of the information collected (two days).

A sampling unit should be selected (e.g., administrative region or district or catchment area) that is representative of the current or future program area. Health staff responsible for this catchment area should be involved in the planning, implementation, interpretation and follow-up of the survey. A sample size of 25-30 facilities is recommended. After eliminating certain facilities based on specific criteria (see manual) and sorting by type of facility, facilities are selected using simple random sampling.

Lessons from experience:
1. District staff should be involved in the planning and implementation of the assessment.

2. Instruments should be adapted to local policies, practices and guidelines.

3. Instruments should be translated, back-translated and field-tested.

4. No more than a total of 15 surveyors is recommended.

Implementation and Training

The objective of training is to prepare supervisors and surveyors to: 1) perform all survey tasks, including using the four survey instruments, manage survey activities at a health facility and identify solutions to problems; 2) reach agreement and establish rules on how to interpret questions or words; and 3) achieve intra- and inter-surveyor reliability for the completion of all questions.

Each survey team (of which there are five) is composed of three individuals -- a supervisor and two surveyors. A survey coordinator is essential for planning and overseeing all survey activities. Consideration should be given to seasonal patterns of the major causes of infant and child morbidity and mortality, road conditions, availability of surveyors and of transportation, local holidays and festivals.

Lessons from experience:
1. Training of survey teams should include field practice. Inter-surveyor reliability for survey questions should be 80 - 90 % by the end of the training.

2. Supervision of all field activities and daily review of completed instruments is critical.

Analysis

Questionnaires are checked and coded by supervisors at the end of each facility visit. Local data entry staff enter the data into an EpiInfo database each day. Use of a database has proved to be the most efficient method of analyzing data. However, it is possible to use tally sheets if computer resources are not available. Survey teams then analyze and discuss the data. All participants need not understand how to use EpiInfo during the data analysis. Rather, key members of the group are led through the analysis steps to ensure understanding of key indicators and methods for calculating them. Local staff work in groups of two or three to calculate indicators, with coordinators providing assistance as required. As each indicator is calculated, the group is encouraged to discuss the results and possible solutions to problems. The experience of surveyors and supervisors is used to help develop practical and realistic solutions.

The analysis plan focuses on those indicators thought to be the most useful for program planning and monitoring (see the Results section). During the analysis, other questions probably will be raised. Further analysis can be conducted to investigate these questions. Local survey staff work through the analysis plan and then discuss possible approaches and strategies for improving performance. The numerators and denominators required to calculate each key indicator as well as supporting information for each key indicator are described in the Results section.

Lessons from experience:
1. Data entry usually begins during field work so that it is completed within a week following data collection.

2. District teams should be involved in the process of analyzing and interpreting data.

3. District teams prioritize child health indicators based on public health importance, the feasibility of changing them, the resources required to change them and the time required to see a change.

4. Currently all analysis is done using EpiInfo. District teams require access to computers and some familiarity with this software.

Overall Lessons Learned from Use of this Instrument

There are four key lessons learned from the use of this method in developing countries.

1. District-level managers and health staff are able to use this approach to evaluate the quality of facility-based care in their own areas and then plan activities based on this assessment. In many countries, health systems have been decentralized and more autonomy has been given to district staff to manage their own programs and budgets. This type of method gives district managers a structured approach for designing and monitoring their own programs.

2. Routine supervision is possible in most countries. Action plans have focused on improving the quality of existing supervision by using a simple integrated checklist to improve health worker skills and solve problems at health facilities. District-level managers have worked on local mechanisms for improving supervision with existing resources. In general, district managers have developed their own systems for supporting regular supervision and have not followed a "blueprint" or rigid set of guidelines. It remains to be seen how well these systems will operate in the long term and whether initial commitment to supervision will be sustained over time.

3. The process is often more important than the data gathered. Use of this approach has strengthened program planning and enhanced the skills of district staff for improving programs in their areas. It is the process of collecting simple information using direct observation and then using this information to make decisions that has been useful. In a programmatic sense, the process has been more valuable than the data itself. If health staff can internalize this process and then recognize the benefits of solving problems for themselves, there is a chance that this type of approach will be sustainable in the longer term.

4. Further work is needed to ensure that district staff can replicate this method routinely. There is concern that the current method may not be replicable in the long term because it involves the entry and analysis of data using a software program. It is acknowledged that many districts in developing countries may not have these resources available to them for some time to come. For this reason, the method could be even further simplified to enable calculation of indicators by hand. The method requires further simplification for use by facility and lower level health staff.

Reporting and Dissemination of Results

The survey team selects five to ten key indicators to improve the quality of health care at facilities. Selection takes place on the third day of the final week of the survey. Indicators are prioritized and discussed, and short, medium and longer-term options are proposed. The survey coordinator and local supervisors should note the outcome of all discussions during the discussion sessions. A summary report is produced on the fourth day of the final week. It should be brief and present a background to the survey (objectives, sampling and methods used) as well as descriptive, key indicators and a few graphs that summarize information that is thought to be useful or important. The summary report is designed to provide immediate feedback to health staff at all levels (national, regional and district) and for facility level staff. Surveyors should be able to take copies of the report back to their areas. The summary report is most efficiently completed by a small group: possibly the survey coordinator and one or two supervisors. The survey coordinator should make enough copies of the summary report to allow distribution to all categories of health workers in the focus area.

Contact Person
Rene Salgado
BASICS Project
1600 Wilson Blvd.
Arlington, VA 22209
703-312-6800