Quantifying health facility service readiness for small and sick newborn care: comparing standards-based and WHO level-2 + scoring for 64 hospitals implementing with NEST360 in Kenya, Malawi, Nigeria, and Tanzania.

BACKGROUND: Service readiness tools are important for assessing hospital capacity to provide quality small and sick newborn care (SSNC). Lack of summary scoring approaches for SSNC service readiness means we are unable to track national targets such as the Every Newborn Action Plan targets. METHODS: A health facility assessment (HFA) tool was co-designed by Newborn Essential Solutions and Technologies (NEST360) and UNICEF with four African governments. Data were collected in 68 NEST360-implementing neonatal units in Kenya, Malawi, Nigeria, and Tanzania (September 2019-March 2021). Two summary scoring approaches were developed: a) standards-based, including items for SSNC service readiness by health system building block (HSBB), and scored on availability and functionality, and b) level-2 + , scoring items on readiness to provide WHO level-2 + clinical interventions. For each scoring approach, scores were aggregated and summarised as a percentage and equally weighted to obtain an overall score by hospital, HSBB, and clinical intervention. RESULTS: Of 1508 HFA items, 1043 (69%) were included in standards-based and 309 (20%) in level-2 + scoring. Sixty-eight neonatal units across four countries had median standards-based scores of 51% [IQR 48-57%] at baseline, with variation by country: 62% [IQR 59-66%] in Kenya, 49% [IQR 46-51%] in Malawi, 50% [IQR 42-58%] in Nigeria, and 55% [IQR 53-62%] in Tanzania. The lowest scoring was family-centred care [27%, IQR 18-40%] with governance highest scoring [76%, IQR 71-82%]. For level-2 + scores, the overall median score was 41% [IQR 35-51%] with variation by country: 50% [IQR 44-53%] in Kenya, 41% [IQR 35-50%] in Malawi, 33% [IQR 27-37%] in Nigeria, and 41% [IQR 32-52%] in Tanzania. Readiness to provide antibiotics by culture report was the highest-scoring intervention [58%, IQR 50-75%] and neonatal encephalopathy management was the lowest-scoring [21%, IQR 8-42%]. In both methods, overall scores were low (< 50%) for 27 neonatal units in standards-based scoring and 48 neonatal units in level-2 + scoring. No neonatal unit achieved high scores of > 75%. DISCUSSION: Two scoring approaches reveal gaps in SSNC readiness with no neonatal units achieving high scores (> 75%). Government-led quality improvement teams can use these summary scores to identify areas for health systems change. Future analyses could determine which items are most directly linked with quality SSNC and newborn outcomes.

Health facility assessment of small and sick newborn care in low- and middle-income countries: systematic tool development and operationalisation with NEST360 and UNICEF.

BACKGROUND: Each year an estimated 2.3 million newborns die in the first 28 days of life. Most of these deaths are preventable, and high-quality neonatal care is fundamental for surviving and thriving. Service readiness is used to assess the capacity of hospitals to provide care, but current health facility assessment (HFA) tools do not fully evaluate inpatient small and sick newborn care (SSNC). METHODS: Health systems ingredients for SSNC were identified from international guidelines, notably World Health Organization (WHO), and other standards for SSNC. Existing global and national service readiness tools were identified and mapped against this ingredients list. A novel HFA tool was co-designed according to a priori considerations determined by policymakers from four African governments, including that the HFA be completed in one day and assess readiness across the health system. The tool was reviewed by > 150 global experts, and refined and operationalised in 64 hospitals in Kenya, Malawi, Nigeria, and Tanzania between September 2019 and March 2021. RESULTS: Eight hundred and sixty-six key health systems ingredients for service readiness for inpatient SSNC were identified and mapped against four global and eight national tools measuring SSNC service readiness. Tools revealed major content gaps particularly for devices and consumables, care guidelines, and facility infrastructure, with a mean of 13.2% (n = 866, range 2.2-34.4%) of ingredients included. Two tools covered 32.7% and 34.4% (n = 866) of ingredients and were used as inputs for the new HFA tool, which included ten modules organised by adapted WHO health system building blocks, including: infrastructure, pharmacy and laboratory, medical devices and supplies, biomedical technician workshop, human resources, information systems, leadership and governance, family-centred care, and infection prevention and control. This HFA tool can be conducted at a hospital by seven assessors in one day and has been used in 64 hospitals in Kenya, Malawi, Nigeria, and Tanzania. CONCLUSION: This HFA tool is available open-access to adapt for use to comprehensively measure service readiness for level-2 SSNC, including respiratory support. The resulting facility-level data enable comparable tracking for Every Newborn Action Plan coverage target four within and between countries, identifying facility and national-level health systems gaps for action.

Assessment of vaccination service delivery and quality: a cross-sectional survey of over 1300 health facilities from 29 districts in Sindh, Pakistan conducted between 2017-18.

BACKGROUND: Routine childhood immunization coverage in Pakistan remains sub-par, in part, due to suboptimal utilization of existing vaccination services. Quality of vaccine delivery can affect both supply and demand for immunization, but data for immunization center quality in Pakistan is sparse and in Sindh province in Southern Pakistan, no comprehensive health facility assessment has ever been conducted at a provincial level. We assessed health facilities, specifically immunization centers, and their associated health workers throughout the province to summarize quality of immunization centers.  METHODS: An exhaustive list of health facilities obtained from Sindh's provincial government was included in our analysis, comprising a total of 1396 public, private, and public-private health facilities. We adapted a health facility and health worker assessment survey developed by BASICS and EPI-Sindh to record indicators pertaining to health facility infrastructure, processes and human resources. Using expert panel ranking, we developed critical criteria (the presence of a cold box/refrigerator, vaccinator and vaccination equipment at the immunization center) to indicate the bare minimum items required by immunization centers to vaccinate children. We also categorized other infrastructure, process, and human resource items to determine high, low and moderate function requirements to ascertain quality. We evaluated presence of critical criteria, calculated scores for high, moderate and low function requirements, and displayed frequencies of infrastructure, process and human resource indicators for all immunization centers across Sindh. We analyzed results at the division level and utilized a two-sample independent clustered t-test to test differences in average function requirement scores between facilities that met critical criteria and those that did not. RESULTS: Out of the 1396 health facilities assessed across Sindh province from October 2017 to January 2018, 1236 (88.5%) were operational while 1209 (86.6%) offered vaccination services (immunization centers). Only 793 (65.6%; 793/1209) immunization centers met the critical criteria of having all the following items: vaccinator, a cold box or refrigerator and vaccine supplies. Of the 416 (34.4%; 416/1209) immunization centers that did not meet the critical criteria, most of the centers did not have a cold box or refrigerator (28.3%; 342/1209), followed by lack of vaccines (19.9%; 240/1209), and a vaccinator (13.0%; 157/1209). Of the 2153 healthcare workers interviewed, 1875 (87.1%) were vaccinators, of which 1745 (81.0%; 1745/2153) were male, and had an average of 12.4 years of schooling. A total of 1805 (96.3%; 1805/1875), 1655 (88.3%; 1655/1875) and 1387 (74.0%; 1387/1875) of the vaccinators were trained in vaccination, cold chain and inventory management respectively. CONCLUSION: One out of three immunization centers in Sindh lack the critical components essential for quality vaccination services. While the majority of health workers (>80%) were trained on vaccination and cold chain management, the proportion trained on inventory management was comparatively low. Our findings therefore suggest that suboptimal immunization center quality is partly due to inadequate infrastructure and inefficient processes contributed to an extent, by low levels of inventory management training among vaccinators. Our study presents critical research findings with high-impact policy implications for identifying and addressing gaps to improve vaccination uptake within a low-middle income country setting.

Exploring approaches to weighting estimates of facility readiness to provide health services used for estimating input-adjusted effective coverage: a case study using data from Tanzania.

The ideal approach for calculating effective coverage of health services using ecological linking requires accounting for variability in facility readiness to provide health services and patient volume by incorporating adjustments for facility type into estimates of facility readiness and weighting facility readiness estimates by service-specific caseload. The aim of this study is to compare the ideal caseload-weighted facility readiness approach to two alternative approaches: (1) facility-weighted readiness and (2) observation-weighted readiness to assess the suitability of each as a proxy for caseload-weighted facility readiness. We utilised the 2014-2015 Tanzania Service Provision Assessment along with routine health information system data to calculate facility readiness estimates using the three approaches. We then conducted equivalence testing, using the caseload-weighted estimates as the ideal approach and comparing with the facility-weighted estimates and observation-weighted estimates to test for equivalence. Comparing the facility-weighted readiness estimates to the caseload-weighted readiness estimates, we found that 58% of the estimates met the requirements for equivalence. In addition, the facility-weighted readiness estimates consistently underestimated, by a small percentage, facility readiness as compared to the caseload-weighted readiness estimates. Comparing the observation-weighted readiness estimates to the caseload-weighted readiness estimates, we found that 64% of the estimates met the requirements for equivalence. We found that, in this setting, both facility-weighted readiness and observation-weighted readiness may be reasonable proxies for caseload-weighted readiness. However, in a setting with more variability in facility readiness or larger differences in facility readiness between low caseload and high caseload facilities, the observation-weighted approach would be a better option than the facility-weighted approach. While the methods compared showed equivalence, our results suggest that selecting the best method for weighting readiness estimates will require assessing data availability alongside knowledge of the country context.

An assessment of facility readiness for comprehensive abortion care in 12 districts of Pakistan using the WHO Service Availability and Readiness Assessment tool.

Although Pakistan's Essential Package of Health Services was recently updated to include therapeutic and post-abortion care, little is known about current health facility readiness for these services. This study assessed the availability of comprehensive abortion care, and readiness of health facilities to deliver these services, within the public sector in 12 districts of Pakistan. A facility inventory was completed in 2020-2021 using the WHO Service Availability and Readiness Assessment, with a newly developed abortion module. A composite readiness indicator was developed based on national clinical guidelines and previous studies. Just 8.4% of facilities reported offering therapeutic abortion, while 14.3% offered post-abortion care. Misoprostol (75.2%) was the most common method provided by facilities that offer therapeutic abortion, followed by vacuum aspiration (60.7%) and dilatation and curettage (D&C) (59%). Few facilities had all the readiness components required to deliver pharmacological or surgical therapeutic abortion, or post-abortion care (<1%), but readiness was higher in tertiary (22.2%) facilities. Readiness scores were lowest for "guidelines and personnel" (4.1%), and slightly higher for medicines and products (14.3-17.1%), equipment (16.3%) and laboratory services (7.4%). This assessment highlights the potential to increase the availability of comprehensive abortion care in Pakistan, particularly in primary care and in rural areas, to improve the readiness of health facilities to deliver these services, and to phase out non-recommended methods of abortion (D&C). The study also demonstrates the feasibility and utility of adding an abortion module to routine health facility assessments, which can inform efforts to strengthen sexual and reproductive health and rights.

Methodological reflections on health system-oriented assessment of maternity care in 16 hospitals in sub-Saharan Africa: an embedded case study.

Health facility assessments (HFAs) assessing facilities' readiness to provide services are well-established. However, HFA questionnaires are typically quantitative and lack depth to understand systems in which health facilities operate-crucial to designing context-oriented interventions. We report lessons from a multiple embedded case study exploring the experiences of HFA data collectors in implementing a novel HFA tool developed using systems thinking approach. We assessed 16 hospitals in four countries (Benin, Malawi, Tanzania and Uganda) as part of a quality improvement implementation research. Our tool was organized in 17 sections and included dimensions of hospital governance, leadership and financing; maternity care standards and procedures; ongoing quality improvement practices; interactions with communities and mapping of the areas related to maternal care. Data for this study were collected using in-depth interviews with senior experts who conducted the HFA in the countries 1-3 months after completion of the HFAs. Data were analysed using the inductive thematic analysis approach. Our HFA faced challenges in logistics (accessing key hospital-based respondents, high turnover of managerial staff and difficulty accessing information considered sensitive in the context) and methodology (response bias, lack of data quality and data entry into an electronic platform). Data elements of governance, leadership and financing were the most affected. Opportunities and strategies adopted aimed at enhancing data collection (building on prior partnerships and understanding local and institutional bureaucracies) and enhancing data richness (identifying respondents with institutional memory, learning from experience and conducting observations at various times). Moreover, HFA data collectors conducted abstraction of records and interviews in a flexible and adaptive way to enhance data quality. Lessons and new skills learned from our HFA could be used as inputs to respond to the growing need of integrating the systems thinking approach in HFA to improve the contextual understanding of operations and structure.

Readiness of emergency obstetric and newborn care in public health facilities in Afghanistan between 2010 and 2016.

OBJECTIVE: To assess changes in readiness to provide emergency obstetric and newborn care (EmONC) in health facilities in Afghanistan between 2010 and 2016. METHODS: A secondary analysis was performed of a subset of data from cross-sectional health facility assessments conducted in December 2009 to February 2010 and May 2016 to January 2017. Interviews with health providers, facility inventory, and record review were conducted in both assessments. Descriptive statistics and χ2 tests were used to compare readiness of EmONC at 59 public health facilities expected to provide comprehensive EmONC. RESULTS: The proportion of facilities reporting provision of uterotonic drugs, anticonvulsants, parenteral antibiotics, newborn resuscitation, and cesarean delivery did not change significantly between 2010 and 2016. Provision of assisted vaginal deliveries increased from 78% in 2010 to 98% in 2016 (P<0.001). Fewer health facilities had amoxicillin (61% in 2016 vs 90% in 2010; P<0.001) and gentamicin (74% in 2016 vs 95% in 2010; P<0.002). The number of facilities with at least one midwife on duty 24 hours a day/7 days a week significantly declined (88% in 2016 vs 98% in 2010; P=0.028). CONCLUSION: Despite a few positive changes, readiness of EmONC services in Afghanistan in 2016 had declined from 2010 levels.

Competence of health workers in emergency obstetric care: an assessment using clinical vignettes in Brong Ahafo region, Ghana.

OBJECTIVES: To assess health worker competence in emergency obstetric care using clinical vignettes, to link competence to availability of infrastructure in facilities, and to average annual delivery workload in facilities. DESIGN: Cross-sectional Health Facility Assessment linked to population-based surveillance data. SETTING: 7 districts in Brong Ahafo region, Ghana. PARTICIPANTS: Most experienced delivery care providers in all 64 delivery facilities in the 7 districts. PRIMARY OUTCOME MEASURES: Health worker competence in clinical vignette actions by cadre of delivery care provider and by type of facility. Competence was also compared with availability of relevant drugs and equipment, and to average annual workload per skilled birth attendant. RESULTS: Vignette scores were moderate overall, and differed significantly by respondent cadre ranging from a median of 70% correct among doctors, via 55% among midwives, to 25% among other cadres such as health assistants and health extension workers (p<0.001). Competence varied significantly by facility type: hospital respondents, who were mainly doctors and midwives, achieved highest scores (70% correct) and clinic respondents scored lowest (45% correct). There was a lack of inexpensive key drugs and equipment to carry out vignette actions, and more often, lack of competence to use available items in clinical situations. The average annual workload was very unevenly distributed among facilities, ranging from 0 to 184 deliveries per skilled birth attendant, with higher workload associated with higher vignette scores. CONCLUSIONS: Lack of competence might limit clinical practice even more than lack of relevant drugs and equipment. Cadres other than midwives and doctors might not be able to diagnose and manage delivery complications. Checking clinical competence through vignettes in addition to checklist items could contribute to a more comprehensive approach to evaluate quality of care. TRIAL REGISTRATION NUMBER: NCT00623337.

Evaluation of resources for contact lens practice in private contact lens clinics of Muscat, Oman.

BACKGROUND: The integration of the contact lens (CL) practice with the VISION 2020 initiative is important. We assessed the facilities at the private CL clinics of Muscat. Accordingly, we suggested the appropriate eye care for CL wearers in Oman. STUDY DESIGN: This was a descriptive study. MATERIALS AND METHODS: This study was conducted between May and July 2006. A team of optometrists and health inspectors visited clinics and collected information about the infrastructure, available human resources, and materials used in the CL practice. We used a pre-tested close-ended questionnaire to collect responses of the practitioners and observations of the field staff. STATISTICAL METHOD: Univariate parametric type of analysis. RESULTS: The team visited 67 CL clinics and interviewed 75 CL practitioners. Proper hand washing facility was available at 61 clinics. Thirty-nine practitioners had >10 years of experience in dispensing contact lenses. Only 13 clinics had a bio-microscope. None of the clinics had legal documents signed by both providers and end users of the contact lens. CONCLUSIONS: Contact lens has received less attention in areas outside the developed world. The CL practice in the private sectors of Oman needs to be strengthened. Minimum standards, standard operating procedures for CL practice, and its periodic supervision would be useful.