Dissemination of Service Availability and Readiness Assessment (SARA) study

1. Dissemination of Service Availability and Readiness Assessment (SARA)study A methodology for measuring health systems strengtheningConducted by IHI for MOH&SW in 2012 28thJan 2014, Julius Nyerere International Convention Centre,DSM

2. 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

3. 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.

4. 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

5. 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

6. What does SARA add? 6 • 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

7. SERVICE AVAILABILITY AND READINESS ASSESSMENT, TANZANIA 2012 Methodology

8. 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

9. 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

10. 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

11. Where was SARA data collected? Sentinel Panel of Districts (District Observatory)

12. How was SARA data collected? • Conducted a 5 day training including field practice • Data collection was done in three phases inMay, 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.

13. 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

14. Quality Control 14 • 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

15. Results

16. General Service Availability Health Infrastructure Heath workforce

17. Number of health facilities by type

18. Distribution of facilities by level and residence Percent of facilities by residence Source: SARA Tanzania 2012

19. Health workforce density Skilled health personnel per 10,000 population Source: SARA Tanzania 2012

20. General Service Readiness is a composite score summarizing information from five domains of health service delivery • Basic amenities • Basic equipment • Standard precautions • Laboratory diagnostics • Medicines It refers to the capacity of health facilities to provide general health services

21. Basic amenities Percent of basic amenities Source: SARA Tanzania 2012

22. Basic equipment Percent with basic equipment Source: SARA Tanzania 2012

23. Standard precautions for infection prevention

24. Diagnostic capacity

25. Diagnostic capacity by facility level

26. Essential medicines Percent of essential tracer medicines Source: SARA Tanzania 2012

27. General Service Readiness (GSR) Index Mean availability of components of service provision and GSR index Source: SARA Tanzania 2012

28. General Services Readiness: Comparison with other countries

29. 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%.

31. Maternal, Newborn, Child and Adolescent Health • Family Planning • Antenatal • Delivery • Routine immunization • Preventive and Curative • Adolescent Health Source: SARA Tanzania 2012

32. Availability of Family Planning services Percent of family planning services

33. Readiness to provide FP services Source: SARA Tanzania 2012

34. Availability of ANC services Source: SARA Tanzania 2012

35. Readiness to provide ANC services Source: SARA Tanzania 2012

36. Availability of emergency obstetric and new born care Source: SARA Tanzania 2012

37. Readiness to provide BEmOC services BEmOC Basic Emergency Obstetric Care Source: SARA Tanzania 2012

38. Availability of child Immunization services Source: SARA Tanzania 2012

39. Readiness to provide immunization services Source: SARA Tanzania 2012

40. Availability of preventive and curative services Source: SARA Tanzania 2012

41. Readiness to provide curative and preventive services Source: SARA Tanzania 2012

42. Availability of adolescent health services by ownership and residence 75% of public facilities offered adolescent health services Source: SARA Tanzania 2012

43. Readiness to provide adolescent heath services No facility had guidelines for adolescent health services Source: SARA Tanzania 2012

44. 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

46. Communicable Diseases Malaria Tuberculosis HIV counseling and testing HIV care and support ARV prescription and client management PMTCT Sexually Transmitted Infections Source: SARA Tanzania 2012

47. Availability of malaria services 93% of health facilities offer malaria diagnosis and treatment services Source: SARA Tanzania 2012

48. Readiness to provide malaria services Source: SARA Tanzania 2012

49. Availability of TB services Less than 40% of facilities offered TB services Source: SARA Tanzania 2012

50. Readiness to provide TB services Source: SARA Tanzania 2012