Service Provision Assessment

Description

The Service Provision Assessment (SPA) survey is a nationwide facility-based survey that measures the capacity of health facilities to provide quality preventive, diagnostic and treatment services for key MCH and HIV/AIDS programmes. The SPA collects information on availability of services, existence of critical equipment, supplies and procedures (including management), provider capacity, performance and perceptions, and the client’s perspectives on the services she received.

Key Elements

STRENGTHS OF THE TOOL

• The SPA survey is comprehensive; it assesses not only the reported presence of an
   item, but verifies its existence on the day of the survey, as well as its functionality.

• The SPA offers up to four independent means to assess capacity and quality of services:
   an inventory; a dynamic observation of a service; an exit interview with clients, and a
   health worker interview. It provides detailed baseline data.

• The SPA is nationally representative, and reports by level of care, by public-private
   institutions, and by geographic locations.

• Though most of the examples of the surveys are at the national level, it is also 
   possible to conduct them at subnational level.

LIMITATIONS OF THE TOOL

• The instrument is large and the analysis plan is quite involved.

• Training and supervision need to be intensive in order to collect quality data.

• The survey’s size and complexity make it unsuitable for short-term monitoring.

• Costs are relatively high, though information is valuable for long term policy making.

• It takes about 15 to 18 months to complete the assessment.

• Technical assistance is usually required.

Principles and Steps for Using the Tool

PARTNERS The survey is implemented by a local organization, typically the Ministry of Health, with the assistance or at least concurrence of the National Statistical Institute. A steering committee, with representatives from government, non-governmental organizations, donors and international agencies, helps shape the final instruments, fix the scope of the survey, and provide ongoing monitoring, and ensures successful completion of the survey.

TARGET Data are collected from a representative sample of health facilities at primary, secondary and tertiary levels of health care. Attention is paid to include a representative sample of facilities such as public, private (large facilities) and not-for-profit – NGO or 
faith-based. Data are broken down by type, size and complexity of facilities, for example hospitals; health centres; and health posts, dispensaries and standalone centres 
(e.g. VCT)

Data can also be disaggregated by regional characteristics (e.g., regions or provinces), depending on the size of the country and its political divisions. SPAs do not typically disaggregate data by district level.

METHODOLOGY

• A facility inventory. It collects data on infrastructure, equipment, supplies and
   pharmaceuticals, guidelines and protocols, meeting minutes, registries and other, 
   as observed by the interviewer.

• Clinical observation checklists. They collect information on providers’ performance and
   adherence to guidelines and protocols, during direct client-provider interactions.

• Health worker interviews. They gather information on providers’ offer of services,
   training, supervision, and perceptions on the workplace.

• Client exit interviews. They are applied to clients at the point when they are leaving the 
   facility, to obtain information on services received and their cost, accessibility to the 
   services, and client perception of services.

The instruments have been developed through extensive consultations with technical working groups and subject area specialists. Specific elements included in the survey have benefitted from:

• IMCI and UNICEF immunization guidelines (child health);

• Generally accepted standards within USAID, WHO, UNFPA materials (FP and STI);

• Safe motherhood and neonate/child survival initiatives (maternal and neonatal care);

• Working groups and standards from WHO, UNAIDS, and USAID (HIV and TB).

Sampling technique
The SPA collects data on:

• Child health (immunization and sick child consultations)

• Family planning

• Maternity care (antenatal care, post-partum care, delivery services, and newborn care),

• HIV/AIDS

• Other infectious illnesses – sexually transmitted infections (STIs), 
   tubeulrcosis (TB), and malaria.

The sample size varies, ranging from around 400 to 600 facilities. In some cases the survey becomes a census of all facilities. Facilities are selected randomly from a comprehensive list of all facilities in the country. Since there are fewer hospitals than other types of facilities, hospitals are often oversampled or all are included in the sample. Data are weighted during the analysis to compensate for over- or under-sampling, in order to represent the true picture in the country. Depending on the country and service dynamics, SPAs typically include observations of several hundred client-provider interactions and interviews with health care providers.

TIME REQUIRED Actual times vary depending on country and sample size, questionnaire content and other factors but the estimated time frame is about 15-18 months from 
survey design and instrument development to production of final reports and regional 
and national dissemination.

HUMAN RESOURCES For a national-level SPA survey, depending on the complexity of operations, a typical survey project usually requires a technical manager and assistant, an accountant or financial person, one statistician, data entry supervisor(s). Interviewers can be hired and trained.

Data are collected by trained health personnel, usually nurses, complemented by other personnel as needed, such as social scientists. Interviewers usually spend one day in most facilities and two days in large hospitals.

BUDGET LINE ITEMS The survey costs depend on: size of country; size of sample; roads and other communication networks; country’s living standards; technical assistance required and local capacity; local resources, such as vehicles. Costs are between $800-1,500 per facility, depending on these and other factors.

Adaptation and Technical Assistance

EXPERIENCE WITH THE TOOL Over the last 11 years, Macro has conducted over a dozen nationwide facility surveys in Africa, Latin America and the Caribbean, Arab states and Asia. Currently, Macro conducts SPA surveys as part of the MEASURE DHS project, funded by USAID, with contributions from several national and international agencies, including UNICEF. See below for a full list of surveys conducted over time, by topic.

#	YEAR	LOCATION	TOPIC
1	1997	Guatemala	MCH
2	1999	Kenya	MCH
3	1999/2000	Bangladesh	MCH
4	2001	Rwanda	MCH
5	2002	Egypt	MCH
6	2002	Ghana	MCH
7	2004	Egypt	MCH
8	2004	Guyana	HIV/AIDS
9	2004	Kenya	MCH + HIV/AIDS
10	2005	Zambia	HIV/AIDS
11	2006	Tanzania	MCH + HIV/AIDS
12	2007	Rwanda	MCH + HIV/AIDS
13	2007	Uganda	MCH + HIV/AIDS

 

RECOMMENDATIONS FOR ADAPTATION The questionnaires must be adapted to local needs, and to the programmes being implemented, for example names of guidelines and protocols published in-country; names of medicines and supplies. Pre-testing of questionnaires and procedures allows for further adaptation of questions, skips and 
flow, as well as for language and local expressions. Translation is done as required for further adaptation.

Samples of questionnaires used by this tool can be found at: 
the Bank of Sample Questionnaires

POSSIBILITIES FOR TECHNICAL ASSISTANCE AND CONTACT INFORMATION
MEASURE DHS has an experienced roster of staff qualified in each of the components of a complex SPA: senior managers, questionnaire designers, samplers, survey coordinators, data programmers, analysts and publication and dissemination specialists. There are public health physicians and nurses, epidemiologists, biomarker specialists, and biostatisticians among the staff who are experienced in SPA design and conduct, and understand the need to improve country health systems through the collection and dissemination of accurate and objective health facility data – the “supply side” of health service delivery.

More information on the capacity of MEASURE DHS to conduct health facility surveys, and specific qualifications of key staff is available upon request. For information, contact Dr. Alfredo L. Fort at alfredo.fort@macrointernational.com.