Monitoring service delivery for universal health coverage: the Service Availability and Readiness Assessment

Bull World Health Organ 2013;91:923–931 | doi: http://dx.doi.org/10.2471/BLT.12.116798 Research 923 Monitoring service delivery for universal health coverage: the Service Availability and Readiness Assessment Kathryn O’Neill,a Marina Takane,a Ashley Sheffel,a Carla Abou-Zahrb & Ties Boermaa Introduction The goal of universal health coverage is to provide everyone with health-care services of good quality that meet their needs without the risk of financial hardship linked to paying for them.1 Universal access to services is a necessary precondition to achieving universal health coverage.2 The regular monitor- ing of access to services and service delivery is often a weak component of country and global monitoring of progress and performance. Yet health policy-makers, planners and managers need sound evidence on which to base decisions about resource allocation and for programme monitoring and evaluation. Annual reviews of health sector progress and performance at national and subnational levels, based on a broad set of indicators that cover all areas of performance, should include up-to-date, accurate information on service delivery. A fundamental component of the evidence base is the availability of health facilities and their readiness to deliver services. Some useful data, such as stockouts or the functionality of equipment, can be gathered through routine health facility reporting systems. However, information about the availability of health-care infrastructure, skilled health workers and resources for disease prevention, diagnosis and treatment is often incomplete or of poor quality, both in public and private facilities.3 Access is a broad term that encompasses varied dimen- sions, including availability, affordability and acceptability.4,5 The availability dimension relates to both the physical presence of facilities and the distribution of health-care infrastructure, health workforce and services. Several programmes have used tools to generate information about service availability and readiness; however these tools focus only on one particular service area.6–11 This fragmented approach runs the risk of leading to information gaps and duplication of efforts and limits the ability to monitor trends in a variety of key indica- tors. A comprehensive system is needed to assess the avail- ability and readiness of essential services in a rapid, regular and harmonized way. The Service Availability and Readiness Assessment (SARA) provides a comprehensive approach for monitoring the supply of health services at the facility level by using a standard set of tracer indicators and summary mea- sures to determine the extent to which minimum criteria for the provision of services are met.7–12 This article describes the SARA and the results of its implementation in six countries across three continents. Methods SARA design The starting point of the SARA is the master facility list.13 This is the source for the compilation of indicators about service availability and provides the sampling frame for the assess- ment of service readiness. The master list comprises all public, private non-profit, private for-profit and faith-based health facilities, including hospitals, health centres, dispensaries and specialized clinics. In addition to information relating to facility identification or signature domain – name, address and geo-location of the facility, etc.14 – the master list should include information on the beds, staffing and services avail- able in each facility. For a country in which a master health facility list does not exist or is incomplete, a preliminary list should be created on the basis of the country’s health manage- ment information system, which contains the list of facilities reporting routine health statistics. The master list also provides the sampling frame for the readiness survey. The overall sample size will vary from coun- try to country, depending on available resources, precision requirements and the need for domain estimates.15 In general, a sample size that provides a margin of error of less than Objective To describe the Service Availability and Readiness Assessment (SARA) and the results of its implementation in six countries across three continents. Methods The SARA is a comprehensive approach for assessing and monitoring health service availability and the readiness of facilities to deliver health-care interventions, with a standardized set of indicators that cover all main programmes. Standardized data-collection instruments are used to gather information on a defined set of selected tracer items from public and private health facilities through a facility sample survey or census. Results from assessments in six countries are shown. Findings The results highlight important gaps in service delivery that are obstacles to universal access to health services. Considerable variation was found within and across countries in the distribution of health facility infrastructure and workforce and in the types of services offered. Weaknesses in laboratory diagnostic capacities and gaps in essential medicines and commodities were common across all countries. Conclusion The SARA fills an important information gap in monitoring health system performance and universal health coverage by providing objective and regular information on all major health programmes that feeds into country planning cycles. a Department of Health Statistics and Information Systems, World Health Organization, avenue Appia 20, 1211 Geneva 27, Switzerland. b Geneva, Switzerland. Correspondence to Kathryn O’Neill (e-mail: oneillk@who.int) (Submitted: 21 December 2012 – Revised version received: 20 June 2013 – Accepted: 24 June 2013 – Published online: 30 September 2013 ) Bull World Health Organ 2013;91:923–931 | doi: http://dx.doi.org/10.2471/BLT.12.116798924 Research Service Availability and Readiness Assessment Kathryn O’Neill et al. 10% is recommended. Two sampling methods have been used in the country application of the SARA. A nationally representative random sample of at least 150 health facilities – stratified by facil- ity type and managing authority and weighted according to facility distribu- tion among districts – can be used to obtain national estimates. If subnational estimates are desired, a district-level assessment with a census of all facilities in selected districts can generate results that can be used for local management. Data collection is performed by several survey teams led by either na- tional ministries of health or national institutes. Data are usually collected by teams of two surveyors who use both paper forms and CSPro (US Census Bureau, Washington, United States of America), an electronic census data processing system. The in-person facility visits take 2 to 4 hours on average and involve interviews with key informants and verification of reported availability and functioning of essential equipment and supplies, along with observation of availability of medicines and commodi- ties on the day of the visit. This approach minimizes the reliance on recall and enhances data quality. The data entered are checked and validated and the results are automatically produced using Excel (Microsoft, Redmond, USA). Results and summary reports are disseminated to all national stakeholders. To promote transparency of results, data and reports should be posted on national ministry of health web sites or in other publicly available information repositories, with appropriate archiving of data and meta- data. The readiness survey should be repeated annually. Indicators of service availability The assessment of service availability comprises both general and specific components. General service availability is concerned with the physical pres- ence of items required for the delivery of services and encompasses health infrastructure, core health personnel and aspects of service utilization. Indi- cators include number and distribution of health facilities and core medical professionals per 10 000 population, to assess levels and distribution within the country. Service-specific availability focuses on whether a specific type of health intervention is offered. Interventions may be defined by target population (e.g. pregnant women, infants or children) and by specific programme. Indicators include the proportion of facilities offer- ing a defined service and the density and distribution of the facilities offering the service per 10 000 population. Indicators of service readiness The assessment of service readiness also consists of both general and service- specific components. General service readiness reflects the overall capacity of health facilities to provide basic services at minimum standards. Four domains of general service readiness are included in the SARA and indicators are tracked through tracer items that were selected on the basis of consultations with service delivery experts and experiences with different facility assessments over the past decade (Table 1).9,16,17 Individual tracer indicator scores may be summa- rized as composite measures, namely the proportion of facilities with all tracer items available on the day of the visit and the mean item availability score, with the latter measure more sensitive to change over time. For example, the essential medicines indicator comprises 14 tracer items. The composite measures would look at the mean of the 14 items available in each facility as well as the percentage of facilities with all 14 items available on the day of the survey. Service-specific readiness reflects the capacity of health facilities to pro- vide interventions in 20 key programme areas: family planning, antenatal care, basic and comprehensive delivery care, child health, routine child immuniza- tion, adolescent health, malaria, tuber- culosis, human immunodeficiency virus (HIV) infection testing and counselling, HIV care and support, antiretroviral therapy, prevention of mother-to-child transmission (PMTCT) of HIV, sexually transmitted diseases, diabetes, cardio- vascular disease, chronic respiratory dis- ease, basic and comprehensive surgery, and blood transfusion. The essential inputs needed to deliver service-specific interventions are described across four domains: (i) trained staff and relevant and up-to-date guidelines; (ii) func- tioning equipment; (iii) diagnostic capacities; and (iv) essential medicines and commodities. Within each domain, a mean score is calculated across the tracer items and an overall composite readiness index is calculated for each programme area based on the mean availability of tracer items across all domains. For simplicity, all tracer items are given equal weight. An example of a service specific readiness indicator can be seen in Table 2. Country implementation In Burkina Faso (2008), Cambodia (2008), Haiti (2008), United Republic of Tanzania (2009–2010) and Zambia (2008), facility assessments were con- ducted – on the basis of facility censuses in selected districts – using the SARA Table 1. Tracer items for general service readiness employed in the Service Availability and Readiness Assessment Category Tracer items Basic amenities and equipment (14 items) Amenities (7 items): electric power; improved water source within 500 m of facility; room with auditory and visual privacy for patient consultations; adequate sanitation facilities for clients; communication equipment (phone or short wave radio); computer with email/internet access; emergency transportation. Equipment (7 items): weighing scales (child, adult); thermometer; stethoscope; blood pressure apparatus; light source; refrigerator. Standard precautions (9 items) Safe final disposal of sharps, safe final disposal of infectious wastes; appropriate storage of sharps, appropriate storage of infectious waste; disinfectant; single-use standard disposable or auto- disposable syringes; soap and running water or alcohol-based hand rub; latex gloves; guidelines. Laboratory testing capacity (8 items) Blood haemoglobin; blood glucose; blood smear or rapid test for malaria parasites;a urine dipstick protein; urine dipstick glucose; HIV antibody test; syphilis rapid test; urine pregnancy test. Essential medicines (14 items) Amoxicillin, atenolol, captopril, ceftriaxone, ciprofloxacin, co- trimoxazole suspension, diazepam, diclofenac, glibenclamide, omeprazole, amitriptyline, paracetamol suspension, salbutamol, simvastatin. HIV, human immunodeficiency virus. a For countries where malaria is endemic. Bull World Health Organ 2013;91:923–931 | doi: http://dx.doi.org/10.2471/BLT.12.116798 925 Research Service Availability and Readiness AssessmentKathryn O’Neill et al. as part of an evaluation by the Global Fund.18 In 2010, Zambia repeated the SARA through a census of facilities in 17 districts.19 In Sierra Leone, the SARA was implemented in 2011 in a random sample of health facilities drawn from the national master list and results were weighted according to the distribution of health facilities.20 The SARA was repeated in 2012 in Sierra Leone to en- able annual progress tracking. In Sierra Leone, the survey was performed before the annual health sector review so that the results could be used and analysed as part of the health sector performance assessment. All facility assessments from the six countries included private facilities. The analyses presented here focus on the common items across the assessments. Commonly available statistical software packages were used for analysis.21 Results Service availability Table 3 summarizes select aspects of ser- vice availability. Health facility density across the countries ranged from 0.8 facilities per 10 000 population (in Haiti) to 3.6 facilities per 10 000 population (in Cambodia). In the assessments in sub- Saharan Africa, health facility density ranged between 1.2 and 2.2 facilities per 10 000 population. Private for-profit health facilities were common in Cam- bodia (39% of all facilities) and Zambia (35% in the 2008 survey, which included the capital, Lusaka). By contrast, the private sector accounted for less than 10% of facilities in Burkina Faso. The density of health workers (i.e. physicians, nurses, midwives and clini- cal officers) ranged from 3.6 workers per 10 000 population (in Burkina Faso) to 22.4 workers per 10 000 population (in Cambodia). There were large differences between districts, with densities being highest in urban districts. The presence of nurses on the day of the visit was ap- proximately 80% in most assessments but frequencies were much lower in the United Republic of Tanzania and Zambia (2008). The proportion of facilities offering a specific service varied considerably across countries. Child immunization services were offered by at least two thirds of the facilities, most of which were publicly funded, in all country assessments. Family planning services were also commonly offered except in Cambodia, where less than half of the facilities offered such services. The pro- portion of facilities offering childbirth and delivery services varied from 42% in Zambia to 91% in Sierra Leone in 2008. These variations are to some extent driven by differences in organizational structures for the delivery of childbirth services. General service readiness Table 4 shows results for the four index- es of general service readiness, based on items common to all assessments. The average item availability for amenities and basic equipment ranged from 64% to 81%, with scores of > 80% on individ- ual equipment items. The average scores for standard precautions against infec- tion control were > 70% in all countries except Haiti. The highest average score – 87% – was noted in Zambia (2010). Laboratory diagnostic capacity was very low (< 30%) in Burkina Faso, Cambodia and Sierra Leone. The presence of 13 es- sential medicines – diazepam was added later to the SARA instrument – was low in all countries. It ranged from 27% in Burkina Faso, Haiti and Sierra Leone to 53% in Zambia (in 2010). Two examples illustrate further programme-relevant aspects. In Sierra Leone, private facilities scored higher than public facilities in all four domains of general service readiness, with overall scores of 62% and 45%, respectively. The starkest differences were observed in the domains of laboratory diagnostic capacity (30% versus 8%) and essential medicines (61% versus 31%). In the 2010 Zambia SARA, the availability of essential medicines on the day of the visit was 49% overall but ranged from 32% to 60% across districts. In general, overall availability was higher among the four assessed urban districts (range: 53–60%) and lower in the nine assessed rural districts (range: 32–46%); availability ranged from 39% to 59% among the four periurban districts evaluated. Although the availability of antibiotics to treat in- fectious diseases was relatively high (71% on average), the availability of medicines to treat non-communicable diseases was consistently low (37% on average). Service-specific readiness The proportion of health facilities in Sierra Leone with tracer items for child immunization (among facilities offer- ing immunization) is shown for 2011 and 2012 in Fig. 1. The proportion of facilities with pentavalent vaccines (diphtheria-tetanus-pertussis [DPT], Haemophilus influenzae type b [Hib] and hepatitis B [HepB]) in stock de- clined from 81% to 70% between 2011 and 2012 (P = 0.049, Fisher’s exact test). There were similar declines for other vaccines. In Zambia, about 64% of facilities in the 17 districts surveyed offered childbirth and delivery services in 2010. Fig. 2 shows the mean readiness score, by facility type, based on 14 tracer items. On average, health facilities had 9 of the 14 tracer items, for an overall readiness score of 61%. For hospitals this was 85%. Eighteen per cent of hospitals had all 14 tracer items, compared with 1% of primary care facilities. Only 38% of primary care facilities offering delivery services had a neonatal bag and mask compared with 77% of hospitals, and only 32% had injectable magnesium sulfate for the treatment of eclampsia, compared with 91% of hospitals. Across all facility types, the availability of staff who had been trained in the Integrated Management of Pregnancy and Child- birth in the preceding two years was generally low. Table 2. Example of a service-specific readiness indicator for the Service Availability and Readiness Assessment Domain Tracer items Antenatal care service Staff and guidelines Guidelines on antenatal care Staff trained in antenatal care Equipment Blood pressure apparatus Diagnostics Haemoglobin test Urine dipstick protein test Medicines and commodities Iron tablets Folic acid tablets Tetanus toxoid vaccine Bull World Health Organ 2013;91:923–931 | doi: http://dx.doi.org/10.2471/BLT.12.116798926 Research Service Availability and Readiness Assessment Kathryn O’Neill et al. In Burkina Faso, Cambodia and the United Republic of Tanzania, the SARA revealed that the proportion of health facilities offering malaria services was > 90% in the two African assess- ments and 62% in Cambodia. Among facilities offering malaria services, the majority had country-recommended anti-malarial drugs in stock and trained staff and treatment guidelines. However, diagnostic tests (rapid test or blood smear) were less commonly available, ranging from a low of 6% in Burkina Faso to 57% in Cambodia. Artemisinin combination therapy was available in 76% of facilities offering malaria services in the United Republic of Tanzania. Tuberculosis treatment services were offered by less than half of the fa- cilities in Burkina Faso and the United Republic of Tanzania, but by 52% of the facilities in Cambodia. Four drugs (isoniazid, rifampicin, ethambutol and pyrizamine) were commonly available in Cambodia (84%) and the United Republic of Tanzania (74%) but not in Burkina Faso, where availability was very low (39%). About one third of facilities offering tuberculosis services did not have trained staff or guidelines. PMTCT services are relatively new and are offered by a rather small number of facilities in Burkina Faso, Cambodia and the United Republic of Tanzania. In the facilities offering these services during antenatal care in these three countries, training and guidelines were generally present but medicines (ne- virapine or zidovudine) and diagnostic tests (rapid or other test) were not. This brought down the overall readiness score to below 25%. In Zambia, the proportion of facilities offering PMTCT services increased from 50% in 2008 to 66% in 2010. Readiness to provide PMTCT services also increased. The percentage of facilities with all tracer items for PMTCT services increased from 33% in 2008 to 56% in 2010, while mean readiness scores increased from 71% to 83% (Fig. 3). A marked increase in the availability of antiretroviral drugs was observed between the two surveys, indicating a significant scale-up in these services. Discussion As countries seek to scale up and monitor progress towards the goal of universal health coverage, there is likely to be increased demand for regular and Ta bl e 3. Se rv ice av ai la bi lit y i n se le ct ed fa cil iti es in si x c ou nt rie s, ac co rd in g to th e Se rv ice A va ila bi lit y a nd R ea di ne ss A ss es sm en t, 20 08 –2 01 0 Ch ar ac te ris tic Bu rk in a Fa so Ca m bo di a Ha iti Si er ra Le on e Un ite d Re pu bl ic of Ta nz an ia Za m bi a 20 08 20 08 20 08 20 11 20 12 20 10 20 08 20 10 D es ig n Ce ns us Ce ns us Ce ns us Sa m pl e su rv ey Sa m pl e su rv ey Ce ns us Ce ns us Ce ns us N o. o f d ist ric ts sa m pl ed (t ot al di st ric ts ) 13 (6 3) 7 (7 7) 9 (4 2) N A (1 3) N A (1 3) 15 (1 13 ) 9 (7 2) 17 (7 2) N o. o f f ac ili tie s s am pl ed 54 2 20 7 21 0 20 7 10 6 69 1 32 6 56 5 Po pu la tio na 3 33 0 99 8 57 2 81 3 2 70 4 09 5 5 74 6 80 0 5 91 9 20 4 4 60 6 66 7 2 64 9 17 8 3 76 6 66 7 N o. o f f ac ili tie s p er 1 0 00 0 1. 6 3. 6 0. 8 2. 2b 2. 1 1. 5 1. 2 1. 5 Pr iv at e fo r- pr ofi t, % 9. 9 39 .0 22 .2 13 .5 13 .2 17 .0 34 .6 18 .7 In pa tie nt b ed s p er 1 0 00 0 7. 0 10 .4 6. 6 N A N A 14 .0 14 .0 8. 4 H ea lth w or ke rs p er 1 0 00 0 (ra ng e) 3. 6 (0 .5 –1 0. 7) 22 .4 (6 .1 –9 3. 1) 7. 6 (4 .3 –1 1. 6) N A N A 7. 2 (3 .4 –1 9. 7) 11 .3 (2 .3 –2 6. 9) 12 .1 (2 .7 –2 8. 8) Fa ci lit ie s w ith n ur se p re se nt o n da y of v isi t, % 77 .2 80 .0 84 .5 N A N A 49 .4 59 .4 N A Fa ci lit ie s off er in g se rv ic e, % Ch ild im m un iz at io n 66 .0 68 .1 81 .0 92 .0 92 .0 80 .0 67 .8 84 .0 Fa m ily p la nn in g 69 .7 47 .1 81 .3 89 .0 96 .0 78 .0 72 .6 89 .0 D el iv er y 67 .0 60 .9 46 .7 91 .0 91 .0 67 .0 42 .0 64 .0 N A, n ot a va ila bl e. a Po pu la tio n of th e di st ric ts in cl ud ed in th e as se ss m en t. Si er ra L eo ne c on du ct ed a n at io na l s am pl e su rv ey a nd h en ce th e fig ur es p re se nt ed a re n at io na l p op ul at io n fig ur es . b Ba se d on n at io na l m as te r f ac ilit y lis t ( 12 64 fa ci lit ie s) . Bull World Health Organ 2013;91:923–931 | doi: http://dx.doi.org/10.2471/BLT.12.116798 927 Research Service Availability and Readiness AssessmentKathryn O’Neill et al. reliable data on health-care infrastruc- ture, on the availability of skilled health workers and on the capacity of health facilities and staff to provide the full range of essential services required to offer coverage with quality health-care services to all those who need care. Use of the SARA has several po- tential advantages. It encourages the maintenance of a harmonized national service monitoring system with a stan- dardized set of indicators that includes all key health services. It is likely to cost less than fragmented data collection and promotes country ownership and trans- parency. The most effective application is when the SARA is planned and con- ducted on an annual basis just before a country planning cycle to inform health sector reviews. Results are dissemi- nated to all key national stakeholders and analysed together with data from other data sources, such as population surveys, quality-of-care surveys and routine facility reports, to provide a comprehensive analysis of health system progress and performance. Deficiencies and gaps need to be addressed as part of annual operational health plans and investment plans. And, as shown by the results of the eight surveys, the SARA generates objective and comprehensive information on the status of a country’s health services that can be used to support operational programme plan- ning and management and to monitor country progress towards improving access to health services as a necessary Table 4. Mean scores for service readiness in selected facilities in six countries, according to the Service Availability and Readiness Assessment, 2008–2010 Characteristic Burkina Faso Cambodia Haiti Sierra Leone United Republic of Tanzania Zambia 2008 2008 2008 2011 2012 2010 2008 2010 No. of facilities 542 207 210 207 106 691 326 312a Basic amenities and equipment, % (11 itemsb) 74 67 76 64 64 70c 81 81 Standard precautions, % (6 itemsd) 74 72 67 74 81 74 84 87 Diagnostics (on site), % (8 items) 21 13 39 13 30 32 58 52 Medicines, % (13 itemse) 27 34 27 34 27 29 46 53 Overall mean 49 47 52 46 51 45 67 68 a Includes facilities from the eight districts in common with the 2008 Zambia assessment. b Excludes sanitation facilities, room with privacy, light source. c Emergency transport missing. d Includes soap and running water, disinfectant, disposable needles, infectious waste and sharps disposal, guidelines. e Diazepam not included. Fig. 1. Percentage of facilities in Sierra Leone equipped with tracer items for child immunization services, among facilities providing such services according to the Service Availability and Readiness Assessment 2011 and 2012 (n2011 = 190, n2012 = 90) 97 76 97 98 77 62 81 80 79 78 36 82 88 85 99 96 86 67 70 69 69 67 43 80 Facilities (% with item) 2011 2012 0 20 40 60 80 100 Trained staffa Guidelinesb Single-use syringes Sharps container Cold box with ice packs Refrigerator DPT-Hib-HepB vaccine Measles vaccine Polio vaccine BCG vaccine All items Child immunization mean score St af f a nd gu id el in es Eq ui pm en t Ov er al l M ed ici ne s a nd co m m od iti es BCG, bacillus Calmette-Guérin; DPT, diphtheria-tetanus-pertussis; HepB, hepatitis B; Hib, Haemophilus influenzae type b. a Staff trained in the Expanded Programme on Immunization. b Guidelines on Expanded Programme on Immunization. Bull World Health Organ 2013;91:923–931 | doi: http://dx.doi.org/10.2471/BLT.12.116798928 Research Service Availability and Readiness Assessment Kathryn O’Neill et al. precondition to achieving universal health coverage. Several issues concerning meth- odology – with potential variations across countries and over time – should be borne in mind. In places where the master facility list is sufficiently complete and up to date, as is the case in Kenya,22 strong multi-stakeholder coordinating groups or regulatory bod- ies for the licensing of health facilities have been established through various national institutes, including national statistical offices, mapping agencies and in-country partners. In other countries, however, maintaining the master facility list continues to be difficult. The com- pleteness of the health facility master list is likely to improve if systematic assessment is conducted – through, for instance, a facility accreditation system – and there is regular district reporting of new, continuing and discontinued/ closed facilities, coupled with a complete facility census once every 5 or 10 years. The SARA does not address other dimensions of access that require more complex measurement strategies, such as geographic barriers, travel time and facility use patterns. A potentially valuable indicator would be the propor- tion of the population living within a specified distance (e.g. 5 km) or travel time (e.g. within 1 hour) from a health facility. Such a figure can be computed through spatial analysis if facility loca- tions and geocodes, population dis- tribution, road network and transport facilities are known exactly. This method has not found large-scale application because of its data demands and analyti- cal complexity. Some countries rely on subjective reporting by facilities and dis- tricts of the proportions of their popula- tions living within a specific travel time or distance to health facilities, but the data are often of questionable quality. The SARA does not generate data on service affordability or quality. Data on service costs have been collected during previous facility assessments but did not appear to be a reliable reflec- tion of the cost to users. Both service availability and readiness are precondi- tions for quality care but they are not indicators of quality in themselves. The SARA is designed to assess only the underlying prerequisites of service quality. Other instruments have been developed to measure client satisfac- tion and knowledge and health worker Fig. 2. Percentage of facilities in Zambia equipped with tracer items for basic obstetric care services, by district, among facilities providing such services (n = 362), according to the Service Availability and Readiness Assessment, 2010 Fa cil iti es (% w ith it em ) 100 80 60 40 20 0 Overall readiness score Suction apparatus Neonatal bag and mask Injectable magnesium sulphate Guidelinesa Partograph Intravenous infusion kit All items Skin disinfectant Neonatal eye prophylaxis Injectable uterotonic Emergency transport Trained staffb Delivery bedGloves Examination light Hospital (n = 34) Health centre (n = 300) Health post (n = 27) All facilities (17 districts) 61 52 59 85 a Guidelines on basic emergency obstetric care and Manual on essential care practice guidelines for pregnancy, childbirth and newborn. b Staff trained in basic emergency obstetric care and in the Manual on essential care practice guidelines for pregnancy, childbirth and newborn. Fig. 3. Percentage of facilities – in eight Zambian districts combined – equipped with tracer items for prevention of mother-to-child transmission (PMTCT) services, among facilities providing such services (n2008 = 162, n2010 = 207), according to the Service Availability and Readiness Assessment, 2008 and 2010 Overall Guidelinesa Trained staffb HIV test Nevirapine Zidovudine Maternal ARV prophylaxis 71 81 86 94 55 54 52 83 94 84 88 85 80 70 Facilities (% with item) 2008 2010 Percentage of facilities with all items 0 20 40 60 80 100 ARV, antiretroviral; HIV, human immunodeficiency virus. a Guidelines on PMTCT and on infant and young child feeding counselling. b Staff trained in PMTCT and in infant and young child feeding counselling. Bull World Health Organ 2013;91:923–931 | doi: http://dx.doi.org/10.2471/BLT.12.116798 929 Research Service Availability and Readiness AssessmentKathryn O’Neill et al. practices through provider interviews, client–provider observations and client exit interviews.17 A quality-of-care study or a disease-specific survey could be combined with and implemented along with the SARA as an additional module. This would reduce field costs and pro- mote harmonization in data collection and analysis. In light of the increasing demand for harmonization and alignment of partner support for a strong national health strategy through the Interna- tional Health Partnerships (IHP+), there is renewed impetus to reduce fragmentation of data collection and parallel disease reporting systems and to invest in a more harmonized approach to data collection and analysis through a common monitoring and evaluation platform.3,16 The call for better account- ability of results within the context of the recommendations of the Commission on Information and Accountability is also adding weight to this approach.23 The SARA is an example of such a har- monized approach to data collection. A greater number of programmes and donors, including the Global Fund and the GAVI Alliance, are leaning towards investing in and using the SARA as the standard method for monitoring service delivery in a comprehensive way, with reduced fragmentation and duplication in tools and expenditures. ■ Acknowledgements The Service Availability and Readi- ness Assessment (SARA) method was developed through a joint collabora- tion of the World Health Organization (WHO) and the United States Agency for International Development (US- AID). The method builds upon previ- ous and current approaches designed to assess service delivery, including the service availability mapping (SAM) tool developed by WHO and the ser- vice provision assessment (SPA) tool developed by ICF International under the USAID-funded MEASURE DHS project. It draws on best practices and lessons learnt from the many countries that have implemented health facility assessments, as well as on guidelines and standards developed by WHO technical programmes. The authors are grateful for the inputs of WHO staff with expertise in specific intervention areas and would like to thank the Ministries of Health of Burkina Faso, Cambodia, Haiti, Sierra Leone, the United Republic of Tanzania and Zambia for their col- laboration and support in data collection and in country-specific analyses. Competing interests: None declared. صخلم بهأتلاو تامدلخا رفوت مييقت :ةلماشلا ةيحصلا ةيطغتلا لجأ نم تامدلخا ءاتيإ دصر جئاتنو )SARA( بهأتلاو تامدلخا رفوت مييقت فصو ضرغلا .تاراق ثلاث برع نادلب ةتس في هذيفنت مييقتل لماش جنه نع ةرابع بهأتلاو تامدلخا رفوت مييقت ةقيرطلا تلاخدت ءاتيلإ قفارلما بهأتو ةيحصلا تامدلخا رفوت دصرو يتلا تاشرؤلما نم ةدحوم ةعوممج مادختساب ،ةيحصلا ةياعرلا تانايبلا عجم تاودأ مدختستو .ةيسيئرلا جمابرلا عيجم يطغت ءافتقا صرانع نم ةددمح ةعوممج لوح تامولعلما عملج ةدحولما دادعتلا للاخ نم ةصالخاو ةماعلا ةحصلا قفارم نم ةراتخلما رثلأا في تماييقتلا جئاتن ضرع متيو .قفارلما تانيعب صالخا حسلما وأ .نادلب ةتس تابقع لثتم تامدلخا ءاتيإ في ةمهم تارغث جئاتنلا زبرت جئاتنلا دوجو لىإ لصوتلا متو .ةيحصلا تامدخلل ةلماشلا ةحاتلإا مامأ ىوقلاو ةيتحتلا ةينبلا عيزوت في اهنيبو نادلبلا لخاد يربك توافت ناكو .ةمدقلما تامدلخا عاونأ فيو ةيحصلا قفارلما في ةلماعلا ةيودلأا في تارغثلاو ةيبرخلما ةيصيخشتلا تاردقلا في فعضلا .نادلبلا عيجم ينب ًاعئاش ةيساسلأا علسلاو ةمهم ةيتامولعم ةرغث بهأتلاو تامدلخا رفوت مييقت دسي جاتنتسلاا قيرط نع ةلماشلا ةيحصلا ةيطغتلاو يحصلا ماظنلا ءادأ دصر في ةيحصلا جمابرلا عيجم نع ةمظتنمو ةيعوضوم تامولعم ميدقت .ةيرطقلا طيطختلا تارود لىع رثؤت يتلا ىبركلا 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 三大洲六个国家中的实施效果。 方法 SARA 有一套覆盖所有主要计划的标准化指标集 合 , 是评估和监控卫生服务可及性和设施准备情况的 综合方案 , 以便于提供医疗卫生干预。使用标准化数 据采集工具 , 通过设施抽样调查或普查 , 从公共和私人 设施收集已确定的一组所选示踪项目方面的信息。显 示六个国家的评估结果。 结果 结果凸显了服务交付的重要缺口 , 这些缺口正是 普及医疗服务的障碍。在卫生基础设施和劳动力的分 配以及所提供的服务类型方面 , 在各个国家内部和各 个国家之间存在相当大的差异。实验室诊断能力薄弱、 基本药品和商品的缺口是所有国家共有的情况。 结论 SARA 提供了所有关于主要健康计划的客观和定 期的信息注入到国家计划周期中 , 填补了健康卫生系 统绩效和全民医保的重要信息缺口。 Résumé Surveillance de la prestation de services pour la couverture sanitaire universelle: évaluation de la disponibilité et de l’état de préparation des services Objectif Décrire l’Évaluation de la Disponibilité et de l’État de Préparation des Services, ainsi que les résultats de sa mise en œuvre dans six pays, sur trois continents. Méthodes L’évaluation de la Disponibilité et de l’État de Préparation des Services est une approche globale permettant d’évaluer et de surveiller la disponibilité des services de santé et l’état de préparation des Bull World Health Organ 2013;91:923–931 | doi: http://dx.doi.org/10.2471/BLT.12.116798930 Research Service Availability and Readiness Assessment Kathryn O’Neill et al. installations pour assurer des interventions médicales, avec un ensemble normalisé d’indicateurs qui couvre tous les programmes principaux. Des instruments normalisés de collecte de données sont utilisés pour recueillir des informations concernant une série définie d’éléments traceurs sélectionnés dans des installations publiques et privées par le biais d’une enquête ou d’un recensement auprès d’un échantillon de participants. Les résultats des évaluations dans six pays sont présentés. Résultats Les résultats soulignent les importantes lacunes en termes de prestations des services qui constituent des obstacles à l’accès universel aux services de santé. Des variations considérables ont été constatées au sein de et entre les pays en termes de la distribution des infrastructures des établissements de santé, des effectifs et des services offerts. Les défaillances en termes de capacités diagnostiques dans les laboratoires et les insuffisances au niveau des médicaments et des produits essentiels sont communes dans tous les pays. Conclusion L’évaluation de la Disponibilité et de l’État de Préparation des Services comble un manque important d’informations dans le domaine de la surveillance de la performance des systèmes de santé et de la couverture sanitaire universelle en fournissant des données objectives et régulières sur tous les principaux programmes de santé qui alimentent les cycles de planification des pays. 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 результаты ее проведения в шести странах на трех континентах. Методы SARA — это всеобъемлющий подход к оценке и мониторингу доступности медико-санитарных услуг и готовности объектов здравоохранения к оказанию мер медико-санитарной помощи с использованием набора стандартизированных показателей, охватывающих все основные программы. Стандартизированные инструменты сбора данных используются для сбора информации об определенном наборе избранных показателей государственных и частных медицинских учреждений в рамках выборочного обследования или статистического исследования объекта. Здесь приводятся результаты оценок, проведенных в шести странах. Результаты Результаты свидетельствуют о существенных недостатках в предоставлении услуг, которые являются препятствием для обеспечения всеобщего доступа к медико- санитарным услугам. Существенные различия были обнаружены как внутри стран, так и между ними в части распределения инфраструктуры и персонала медицинских объектов и по типам предлагаемых услуг. Общие недостатки всех стран — нехватка лабораторно-диагностических возможностей и основных лекарственных средств и товаров. Вывод Подход SARA восполняет важный пробел в мониторинге эффективности работы системы здравоохранения и всеобщего охвата медико-санитарной помощью, предоставляя объективную и регулярную информацию о всех крупных программах в области здравоохранения для учета в циклах планирования в странах. Resumen Control de la prestación de servicios para la cobertura universal de salud: evaluación de la disponibilidad y preparación de los servicios Objetivo Describir la evaluación de la disponibilidad y preparación de los servicios (SARA), así como los resultados de su aplicación en seis países de tres continentes. Métodos La evaluación de la disponibilidad y preparación de los servicios es un enfoque integral que tiene como objeto evaluar y realizar un control de la disponibilidad de servicios de salud y la preparación de las instalaciones para realizar intervenciones de atención sanitaria, y que incluye un conjunto estandarizado de indicadores que abarcan todos los programas principales. Se emplean instrumentos estandarizados de recolección de datos para recopilar información sobre un conjunto definido de indicadores seleccionados a través de un censo o encuesta muestral sobre las instalaciones de los servicios de salud públicos y privados. 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