DHS Data Users: Insights on Health System Quality from the Service Provision Assessments

This new blog series, DHS Data Users, captures examples of how you, the data user, have incorporated data from DHS, MIS, and/or SPA surveys into your analyses, at your institution, or to influence policies or programs. If you are interested in being featured in the ‘DHS Data Users’ blog series, let us know here by submitting your example of DHS Program data use.

The year 2018 saw an upswell of interest in health system quality with the publication of three global reports highlighting critical deficits in quality in health systems in low- and middle-income countries [1,2,3]. Much of the empirical basis for these reports was drawn from the Service Provision Assessments (SPA), the lesser-known surveys conducted by The Demographic and Health Surveys (DHS) Program, which provide comprehensive assessments of health systems in low-resource settings from Haiti to Nepal.

These surveys include a detailed audit of facility resources, provider interviews, direct observations of primary care services, and exit interviews with patients or caretakers. Each assessment is a sample of the complete health system (public and private) or in some cases a complete census. The resulting wealth of data enables assessment of structural inputs to quality of care, the care process – both competent care and user experience – and some outcomes from care, primarily user confidence in the health system. A small but increasing number of researchers is delving into all the SPA data have to offer. Among the insights the SPA surveys have yielded just from my own research are:

Most health systems assessed are not fully prepared for basic health care.
A comparative study of 8,443 facilities in 9 countries based on SPA surveys between 2007 and 2015 found that hospitals averaged between 69% (Senegal 2012-2014) and 82% (Tanzania 2015, Namibia 2009) on the service readiness index defined by the World Health Organization for primary health facilities. Non-hospitals achieved at best 68% readiness (Namibia 2009) and at worst only 41% (Uganda 2007, Bangladesh 2014) [4]. Within primary care services – antenatal care, family planning, and sick child care – service-specific service readiness is not highly predictive of competent care being delivered.
Across facilities with a similar level of readiness, provider adherence to clinical guidelines varied widely. Correlation between readiness and observed clinical quality was more consistent for observations of labor and delivery, though only two SPA surveys include these data [5].
In Kenya , where the 2010 SPA did include direct observation of labor and delivery, both structural quality of maternity care and observed clinical quality was higher in facilities in wealthier areas than facilities in poorer areas, with women in the poorest areas receiving care that complied with only half of recommended clinical guidelines on average [6].
Across 8 countries, adherence to clinical guidelines was lower in sick child care, where providers completed only 38% of the standard Integrated Management of Childhood Illness (IMCI) items, than in family planning (46%) and antenatal care (57%) [7]. The median sick child consultation lasted only 8 minutes [8]. Focusing specifically on Malawi, where the survey team conducted a limited re-examination of sick children, providers diagnosed pneumonia in only 1 in 5 children who showed symptoms of pneumonia per the IMCI guidelines [9].
Analysis of the 2013-2014 Malawi SPA survey with a simultaneous household survey suggested that poor quality care may contribute to avertable neonatal mortality, with a predicted prevalence of neonatal mortality of 28.3 deaths per 1,000 in lower quality facilities and 5.2 deaths per 1,000 in higher quality facilities, among women who would choose higher quality if it were more accessible to them [10].

As attention shifts from describing health system quality to improving it at scale, robust and ongoing measurement will be an essential tool for governments and researchers alike, particularly the direct observation of care delivery and perspective from patients themselves that makes the SPA such a unique and valuable resource.

References

Written by Dr. Hannah Leslie

Dr. Hannah Leslie is a Research Associate at the Harvard Chan School of Public Health; she served as the Measurement Research Lead for the Lancet Global Health Commission on High-Quality Health Systems in the SDG Era. She received her MPH and Ph.D. in Epidemiology from the University of California, Berkeley. Her research has made extensive use of the Service Provision Assessment surveys to 1) develop metrics of structure and process quality in LMICs, 2) describe current quality of care, and 3) assess predictors and effects of poor quality. Her recent work focuses on effective coverage calculations, patient experience measurement, and quality of care as a driver of HIV testing and treatment retention.

International Women’s Day 2019

The DHS Program is now in its 35^th year with a long history of helping to collect, analyze, and disseminate data on women’s empowerment, gender equality, men’s engagement, and gender-based violence within the context of health and development. Historically, The DHS Program has integrated attention to gender in all its activities and aspects of its operations, from the types of data collected and disaggregated and analyses conducted, and the “how” and the “who” of data collection, capacity strengthening, dissemination, and use.

Over the coming five years, The DHS Program will continue its cross-cutting approach to gender integration into its work and surveys. In particular, The Program will endeavor to help achieve the agency-wide commitments mandated by USAID’s Gender Equality and Female Empowerment Policy. The DHS Program supports USAID’s objectives and has adopted an updated Gender Integration Strategy with the following priorities:

Continued collection of high-quality data for gender indicators and sex disaggregation: The project will continue to contribute to evidence-based, gender-integrated health programming by providing the data necessary for understanding gender disparities related to health, including disparities in wealth, access to resources, and decision making power. Similarly, it will continue to collect data on domestic violence; early marriage and skewed sex ratio; household headship; women’s relative earnings and control of their earnings; women’s ownership of a house, of land of a bank account, and of a mobile phone; as well as female genital cutting and fistula.

The DHS Program will monitor and respond to emerging needs for gender data important for women’s health and demographic behavior. The DHS Program is soliciting public feedback through March 15, 2019, on potential new areas/indicators/questions, including on the measurement of gender equality, male engagement, women’s empowerment, decision making, and domestic violence. This feedback will help identify some of the current gender-related data gaps.
Increased focus of dissemination efforts to highlight gender disparities in health and resource and opportunity access: Data collected on gender and women’s empowerment are widely disseminated using digital, print, and other means. Most indicators are readily available on the STATcompiler, The DHS Program’s Mobile App, and the DHS API. The DHS Program website also maintains a “Gender” topic page, which provides a one-stop shop for gender indicators from DHS surveys.
Enabling gender equality in access to opportunities, capabilities, learning, and resources: The DHS Program will continue its efforts to ensure that there is no discrimination by sex, pregnancy status, sexual orientation, or gender identity in access to opportunities for training, employment, and learning all along the survey continuum.
By maintaining confidentiality and gender-sensitive protections. The DHS Program has strict ethical guidelines to protect respondents and interviewers and ensure confidentiality of respondents, their families, and of the data. While these guidelines apply to all respondents, they also specifically recognize the need for special protections for women in certain circumstances.
By exploring technologies to ask highly sensitive questions: Several of the questions asked in DHS surveys are highly sensitive. While some of these sensitive questions are asked of both women and men, such as number of sexual partners, some others are mainly asked of women, including questions on experience of sexual violence. Improving the validity of responses to these questions remains a challenge for any survey program, and it is important to look for ways to both improve reporting and also provide respondents with a more secure platform to disclose sensitive information, such as audio computer assisted self-interviewing (ACASI).
By continuing to integrate gender into the research agenda: The DHS Program’s research agenda continues to include innovative studies that shed light on the linkages between gender and health. The DHS Program will undertake many new research projects that will contribute to a better understanding of the level and changes in women’s empowerment and the interface between gender and health outcomes as well as gender disparities in health, while also applying a gender lens to analyses that do not directly involve gender indicators. In the meantime, read the latest gender analytical publications.

For International Women’s Day 2019, The DHS Program invites you to explore the wealth of gender-related resources and publications available at dhsprogram.com. Learn more about Sustainable Development Goal #5, Gender Equality indicators available in DHS surveys in the infographic below.