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Salud Mesoamérica 2015 Initiative: Data for Better Health

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SM2015 is an ambitious project with the Ministry of Health and local support. This presentation outlines the design and activities around the data collection and analysis of the evaluation, as well as the results, conclusions, and future activities.

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Salud Mesoamérica 2015 Initiative: Data for Better Health

  1. 1. 1 Salud Mesoamérica Initiative: Data for Better Health November 11, 2014 Ali H. Mokdad, Ph.D. Director, Middle Eastern Initiatives Professor, Global Health
  2. 2. 2 Outline Introduction Design and activities Results Conclusions and future activities
  3. 3. 3 Outline Introduction Design and activities Results Conclusions and future activities
  4. 4. 4 Introduction • SMI is an ambitious project with MOH and local support • Baseline and 18-month follow-up completed • Indicators developed by the MOH and IDB • IHME serves as an independent evaluator
  5. 5. 5 Outline Introduction Design and activities Results Conclusions and future activities
  6. 6. 6 Activity flowchart Study and survey design (IHME) • Fact-finding visits • Instrument design • CAPI (Real-time data collection) • Training and pilots • Sampling • Quality checks Data collection (in-country agencies) • Community census • Household survey • Health facility survey • Supervision by IHME Analysis (IHME)
  7. 7. 7 Household survey • Household characteristics • Expenditure and health expenditure • Health services utilization (women and children) • Family planning, reproductive history • Child health, breastfeeding and immunization Physical measures Dried blood spots (DBS) Water quality (Panama)
  8. 8. 8 Facility survey • Questionnaire administered to facility manager • Physical observation ─ Equipment and inputs ─ Review of registries to detect stock-outs • Medical record review ─ Record quota according to the characteristics of the unit » Antenatal care » Deliveries » Maternal and neonatal complications • Selection of medical records from MoH records when possible
  9. 9. 9 Effective coverage of measles immunization • Immunization history from health card and caregiver recall for 6,204 children under five in Mexico and Nicaragua • DBS samples from 1,134 children, 12-23 months • ELISA test of DBS samples for presence of measles antibodies •Comparison of survey-based and biomarker-based estimates of measles immunization coverage •Validation study in Chiapas to adjust cut-off point
  10. 10. 10 SMI evaluation innovations • Integrated surveillance approach: data collected from different sources on the same variable • Ability to link information • Identification of health facilities visited by households • Large samples in high-risk populations • Census for denominator • Electronic data capture on Netbooks • Rapid, automated quality check process with prompt feedback • Detailed health facility observation and medical record review • Dried blood spot analysis Medical record review and electronic data capture
  11. 11. 11 Outline Introduction Design and activities Results Conclusions and future activities
  12. 12. 12 Sample Households Women Children Belize * 351 311 Costa Rica 41 schools El Salvador 3,625 4,730 3,328 Guatemala 4,420 5,899 5,282 Honduras 2,971 3,342 3,144 Mexico 5,428 6,988 6,462 Nicaragua 2,071 2,823 2,225 Panama 1,710 2,453 2,253 *LQAS
  13. 13. 13 Reasons for non-use of contraception
  14. 14. 14
  15. 15. 15
  16. 16. 16 Costa Rica SMI Intervention Regions
  17. 17. 17 Costa Rica Indicators Indicator N Prevalence 95% CI Knowledge of contraception availability at EBAIS facilities 881 30.5% (21.5 - 39.5%) Receipt of sexual and reproductive health counseling 560 24.5% (19.2 - 29.8%) Correct identification of STI symptoms 912 12.2% (8.2 - 16.1%) Correct identification of methods to reduce the risk of STIs 909 22.4% (16.3 - 28.4%)
  18. 18. 18 Sexually active students Grade Gender Percent sexually active (95% CI) 7th grade All 4.5% (1.0 -8.1%) Male 3.0% (0.0 -6.2%) Female 5.7% (0.0 - 11.3%) 8th grade All 11.9% (3.7 - 20.1%) Male 8.0% (0.0 - 16.8%) Female 16.0% (3.6 - 28.3%) 9th grade All 27.3% (14.0 - 40.7%) Male 26.4% (8.2 - 44.6%) Female 27.6% (6.8 - 48.4%) 10th grade All 21.3% (12.5 - 30.0%) Male 19.9% (5.2 - 34.7%) Female 21.9% (9.1 - 34.6%) 11th grade All 40.6% (23.2 - 58.0%) Male 70.5% (27.3 - 100%) Female 9.3% (0.0 - 26.5%)
  19. 19. 19 Mexico
  20. 20. 20 Denominator is Equally Important
  21. 21. 21 Comparison of SMI and ENSANUT 2012 Indicator Prevalence SMI Prevalence ENSANUT 2012, rural Chiapas Prevalence ENSANUT 2012, national Institutional deliveries* 47% (N=4538) Segments: 0.0%-100% Municipalities: 1.6%-99.2% 45% (N=139) 94% (N=5738) Anemia in children, age 12-59 months 25% (N=4474) Segments: 0.0%-100% Municipalities: 3.0-51.5% 31% (N=207) 23% (N=7570) MMR immunization coverage, age 0-59 mos** 79% (N=6003) Segments: 32.7%-100% Municipalities: 33.7%-100% 90% (N=344) 92% (N=13160) Wasting (<-2SD weight for height), age 0-59 mos 1.4% (N=5771) Segments: 0.0%-11.1% Municipalities: 0.0%-5.4% 2.6% (N=326) 1.6% (N=10658) *For most recent birth in the past 5 years ; **Based on recall and vaccination card
  22. 22. 22 Challenging Environment • Lots of disparities • Remote areas • Logisitical challenges • Indigenous population • Culture and expectations
  23. 23. 23 DBS Results
  24. 24. 24 Mexico: measles immunization coverage
  25. 25. 25 Where are the gaps? Proportion of card-positive children lacking antibodies
  26. 26. 26 Odds of lacking antibodies by facility characteristics Characteristic Odds Ratio 95% CI lower 95% CI upper Basic facility 0.35 0.07 1.77 Complete facility 1.16 0.09 15.09 Facility has doctor 0.78 0.06 9.98 Electricity at all hours 2.72 0.28 26.91 Internet access 0.23 0.04 1.37 Routine staff meetings on medical topics 1.22 0.12 12.81 Any fridges with out-of-range temperature on day of survey **10.79 1.55 74.99 N = 101 This is a survey-weighed logistic regression * p <0.10 ** p <0.05 *** p <0.01 **** p <0.001
  27. 27. 27 Nicaragua: crude and effective coverage of measles immunization *Figure restricted to 299 children with all three sources, excluding children with DBS collection within 28 days of vaccination. Lines indicate 95% confidence intervals. Estimates are survey weighted.
  28. 28. 28 Crude and effective coverage of measles immunization *The number in each municipality indicates sample size. Estimates are survey weighted.
  29. 29. 29 Crude and adjusted odds ratios of likelihood that card- positive children lack antibodies Characteristic Odds Ratio 95% CI lower 95% CI upper Anemic 1.36 0.79 2.34 Underweight 7.99 1.66 38.51 Asset score 0.05 0.00 0.82 Urban area 0.27** 0.11 0.69 Matagalpa* 0.54 0.12 2.45 RAAN* 16.59** 2.21 124.53 Madriz* 4.73 0.90 24.80 1+ broken cold storage observed 7.82 0.68 90.14 N = 237. Survey weighted logistic regression * Jinotega reference category; * *p <0.05
  30. 30. 30 Sample sizes for HF surveys (intervention areas) Country Baseline 18-m follow-up Facilities Medical records Facilities Medical records Mexico 60 1,744 60 1,985 Guatemala 64 1,175 60 2,304 Belize 39 792 38 1,191 El Salvador 65 n/a 60 1,591 Honduras 59 1,293 60 1,519 Nicaragua 40 850 60 1,698 Panama 38 498 39 863 Total 365 6,352 377 11,151
  31. 31. 31 Mexico- Chiapas
  32. 32. 32 Mexico HF Performance Indicator Matrix Baseline 18-month 18-month target # Indicator description Percent (95% CI) Percent (95% CI) % One-sided Z- test p value* 7020** Health facilities with permanent availability of inputs and equipment necessary for prenatal and postpartum care 3.6% (0.4 – 12.5%) 45.8% (32.7 – 59.2%) 80% < 0.00001 7040 Health facilities with permanent availability of inputs and equipment necessary for delivery and newborn care 0% (0 – 19.5%) 21.4% (4.7 – 50.8%) 80% < 0.00001 7030 Health facilities with permanent availability of inputs and equipment necessary for emergency obstetric and neonatal care 0% (0 - 24.7%) 14.3% (1.8 – 42.8%) 80% < 0.00001 7010 Health facilities with permanent availability of inputs and equipment necessary for pediatric, vaccination and nutrition care 3.6% (0.4 – 12.5%) 13.6% (6.0 – 25%) 80% < 0.00001 7050 Health facilities with modern family planning supplies (oral, injectable, barrier, IUD), according to the schedule (population under responsibility, time of year, rotation) 55.1% (40.2 – 69.3%) 62.7% (49.1 – 75.0%) 80% 0.0001 7000 Health facilities with cold chain that meets the standards 70.8% (48.9 – 87.4%) 77.8% (57.8 – 91.4%) 80% 0.3864 **The requirements for lab inputs at hospitals changed from the baseline to the 18-month evaluation, becoming more flexible with the allowance of rapid tests as an alternative to lab equipment. *One sided test of proportions comparing if the estimate is lower than the target
  33. 33. 33 7020: Health facilities with availability of inputs and equipment necessary for prenatal and postpartum care Baseline(%) 18-Month(%) Indicator 7020 3.6 45.8 Standing scales 70.9 98.3 Stadiometer/ tallimeter 72.7 100 Gynecological exam table 1 82 100 CLAP obstetric tape 29.1 100 Lamp gooseneck/ hand lamp 67.3 95.0 Sphygmomanometer 85.5 95.0 Stethoscope 85.5 100 Perinatal maternal medical history 90.9 91.7 Perinatal maternal card 90.9 88.3 IUD insertion kit2 62.0 84.3 All necessary equipment observed and functional 12.7 68.3 (Iron + Folic acid)/ Multivitamin 71.7 98.3 Erythromycin/Ampicillin/ Penicillin benzathine3 81.3 100 Tetanus vaccine2,4 28.6 85.7 Ayre palletes 2 28.6 78.4 Microscope slides2 49.0 86.3 Nitrofurantoin2 63.3 98.0 All pharmacy inputs observed on the day of survey 11.3 69.5 Continuous availability in previous three months 9.4 59.3 Rapid syphilis test kit / dark field microscope/ equipment for enzyme immunoassay 60 85.7 Rapid HIV/AIDS test kit / fluorescence microscope 53.3 100 Urine strips / urinalysis equipment 73.3 92.9 Blood glucose strips / glucose meter 80 100 Hemocue / automated cell counter 66.7 78.6 Pregnancy test5 100 100 Lab reagents (blood type + RH factor antibody) 93.3 92.9 All lab equipment observed on day of survey 13.3 35.7 Indicator 7020: Health facilities with availability of inputs and equipment necessary for prenatal and postpartum care Equipment Pharmacy inputs Laboratory inputs 1 Not applicable to mobile units 2 Not applicable to ambulatory without doctor 3 Only applies to Ambulatory facilities with doctor 4 Only applicable if facility stores vaccine 5 Only applicable to Basic facilities
  34. 34. 34 7020: Health facilities with availability of equipment necessary for prenatal and postpartum care Baseline 18-month follow-up *Gynecological exam tables not measured at mobile units Overall Standing scale Stadiometer Gyn. exam table/stretcher1 Gooseneck lamp CLAP obstetrical tape Blood pressure apparatus Perinatal maternal medical history Stethoscope Overall Standing scale Stadiometer Gyn. exam table/stretcher1 Gooseneck lamp CLAP obstetrical tape Blood pressure apparatus Perinatal maternal medical history Stethoscope
  35. 35. 35 7040: Health facilities with availability of inputs and equipment necessary for delivery and newborn care * Drug requirements dependent on facility EONC classification Baseline(%) 18-Month(%) Indicator 7040 0 21.4 Intravenous catheter sterile N ° 18 88.2 100 Metallic/Plastic Clamp or umbilical tape 100 100 Equipment p / serum c / macrogotero and microgotero 94.1 92.9 Nasogastric tube1 41.2 78.6 Sterile fields or sheltering for a baby 94.1 92.9 All necessary equipment observed and functoinal 35.3 71.4 Hyoscine bromide / Butilioscina 53.3 85.7 Ergonovine maleate / Ergometrine / Oxytocin 46.7 100 Drops of chloramphenicol ophatlmology / 1% silver nitrate /oxytetracycline ophthalmic 46.7 92.9 Iodopovidona 20 92.9 Ringer lactate / Hartman solution / saline solution 33.3 100 S lidocaine /S epinephrine 40 100 C / mounted needle syringe (syringe insulin) 40 85.7 Vitamin K 40 100 All pharmacy inputs observed on the day of the survey 0 64.3 Continuous availability in previous three months 0 28.6 Indicator 7040: Health facilities with availability of inputs and equipment necessary for delivery and newborn care Equipment Pharmacy inputs 1 Nasogastric tube K 33 measured at baseline, but any nasogastric tube accepted at 18-months
  36. 36. 36 7040: Health facilities with permanent availability of pharmacy inputs necessary for delivery and newborn care *Uterotonics = Ergonovine maleate/Egometrine/Oxytocin • Stock-outs are an issue at 18-month evaluation, but consistently better in most recent months • 60% of basic and complete EONC had all drugs available on the day of survey, but only 27% also had continuous availability in previous three months of uterotonics and vitamin K
  37. 37. 37 7030: Availability of inputs and equipment necessary for emergency obstetric and neonatal care Baseline(%) 18-Month(%) Indicator 7030 0 14.3 Anesthesia equipment1 100.0 85.7 Autoclave (or dry heat sterilizer) 46.2 85.7 Blood pressure apparatus 38.5 85.7 Kit for C-sections1 100.0 85.7 Laryngoscope 61.5 85.7 MVA kit 30.8 42.9 Neonatal/ pediatric stethoscope1 75 71.4 Oxygen tank 61.5 92.9 Portable doppler (or Pinard stethoscope) 61.5 85.7 Reanimation resuscitation bag for adult 53.8 78.6 Neonatal resuscitation bag 69.2 78.6 Stethoscope 69.2 78.6 All necessary equipment observed and functional 0 35.7 Amikacin /Amikacin sulfate1 25 100 Penicillin crystals /IV ampicillin /Amoxicillin 66.7 100 Ceftriaxone1 25 100 Cloramphenicol/ Metronidazole1 25 100 Dexamethasone / Betamethasone 25 100 Diazepam / Midazolam Chlorhydrate1 25 100 Furosemide1 50 100 Hidralazine / Hidrazaline chloral hidrate1 25 100 Magnesium sulfate 41.7 85.7 Nifedipine1 50 100 Oxytocin / Ergometrine 58.3 100 Sevoflurane 1 100 100 Succinylcholine chloride1 25 71.4 Gentamicin2 0 100 All pharmacy inputs observed on the day of survey 0 71.4 Continuous availability in previous three months 0 28.6 2 Only applies to Basic facilities Indicator 7030: Health facilities with availability of inputs and equipment necessary for emergency obstetric and neonatal care Equipment Pharmacy inputs 1 Only applies to Complete facilities
  38. 38. 38 7010: Health facilities with availability of inputs and equipment necessary for pediatric, vaccination and nutrition care Baseline(%) 18-Month(%) Indicator 7010 3.6 13.6 Pediatric balance or scale 70.9 81.7 Standing balance or scale for children 52.7 98.3 Tallimeter or stadiometer 69.1 100.0 Stethoscope 60 100.0 Oral/axillary thermometer1 97.3 95.6 Growth card 89.1 96.7 Pediatric tensiometer2 16.7 50.0 Pediatric stethoscope 2 33.3 50.0 Packets/ Envelopes of ORS 75 100 Ferrous sulfate drops 57.7 90 Albendazol/Mebendazol 76.9 100 Antibiotics3 76.6 98.0 Ringer lactate/ Hartman solution/ Saline solution 2 31.3 100 Pentavalent 74.1 57.1 MMR 81.5 85.7 Rotavirus 74.1 78.6 Pneumococcal conjugate 37.0 42.9 BCG 70.4 50 1 Only applicable at Ambulatory facilities 2 Only applicable at Basic & Complete facilities 3 Not applicable to Ambulatory facilities without doctor 4 Only applies to facilities that store vaccines Indicator 7010: Health facilities with availability of inputs and equipment necessary for pediatric, vaccination and nutrition care Equipment Pharmacy inputs Vaccines 4
  39. 39. 39 7010: Health facilities with availability of equipment necessary for pediatric, vaccination and nutrition care Overall 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 83 83 83 83 83 83 83 83 83 83 80 80 67 60 Infant scale 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 1 0 0 0 0 0 0 0 1 0 1 0 Child scale 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 Tallimeter 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Stethoscope 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Card 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 1 0 1 Baseline 18-month follow-up Overall 100 100 100 100 100 100 100 100 100 100 100 100 100 83 83 83 83 83 83 83 83 80 80 80 80 80 80 80 67 67 67 67 67 67 67 67 67 67 60 60 60 50 50 50 40 40 40 40 33 33 33 33 33 20 20 Infant scale 1 Child scale 1 Tallimeter 1 Stethoscope 1 Card 1
  40. 40. 40 7050: Availability of modern contraceptive methods on the day of the survey *Only applies to Basic and Complete facilities **Only applies to Complete facilities 0 10 20 30 40 50 60 70 80 90 100 Male Condom Any pill Any injectable IUD* IUD insertion kit* Doctor trained to perform tubal ligation & vasectomy** Baseline 18-Month
  41. 41. 41 7000: Cold chain according to the standards* *Among facilities that had at least one observed refrigerator for storing vaccines 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0 Temperature was 2-8 C on the day of the survey Temperature monitoring chart observed for each fridge Temperature was recorded twice daily during the last 30 days Temperature range was 2-8C for each fridge in the last 30 days or if temperature wasn’t 2-8 C, there is a record of action Baseline 18-Month
  42. 42. 42 Nicaragua
  43. 43. 43 Nicaragua HF Performance Indicator Matrix Baseline 18-month 18-month target # Indicator description Percent (95% CI) Percent (95% CI) % One-sided Z- test p value* 7000 Health facilities with cold chain according to standards 28.6% (13.2-48.7%) 88.9% (70.8-97.6%) 85% 0.7143 7010 Health facilities that have the necessary inputs to provide child health care according to the norms 0% (0 – 9.5%) 71.7% (57.7-83.2%) 85% 0.0033 7020 Health facilities that have the necessary inputs for providing pre- and post natal care according to the norms 10.8% (3.0-25.4%) 76.8% (63.6-87.0%) 85% 0.0426 7030 Health facilities that have the necessary inputs for providing emergency obstetric and neonatal care according to the norms 60% (14.7-94.7%) 90.9% (58.7-99.8%) 85% 0.7084 7050 Health facilities that have continuous supplies of modern family planning methods 59.5% (42.1 – 75.2%) 87.5% (75.9-94.8%) 85% 0.6998 *One sided test of proportions comparing if the estimate is lower than the target
  44. 44. 44 Nicaragua HF Performance Indicator Matrix 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0% 7000 7010 7020 7030 7050 Baseline 18-Month
  45. 45. 45 7000: Health facilities with cold chain according to standards Baseline(%) 18-Month(%) Indicator 7000 28.6 88.9 A temperature monitoring chart on each functioning refrigerator 57.1 92.6 Monitoring chart filled out twice each working day in the last 30 days1 28.6 88.9 Requirements 1At baseline, every day in previous all 30 days was considered
  46. 46. 46 7010: Health facilities that have necessary inputs to provide child health care according to the norms • 86.8% of facilities met equipment component • 88.8% of facilities met pharmacy component • 84.9% of facilities met vaccine component • 71.7% of facilities met all three components of the indicator. • Facilities doing well and missing very few requirements 1 Health posts not required to have pediatric stethoscopes 2 Data missing for pediatric scale & growth and development card in 4 units at 18 months 3 Not applicable in health posts 4 Hib not evaluated due to survey programming
  47. 47. 47 7020: Health facilities that have necessary inputs to provide prenatal and post-natal care according to the norms Baseline(%) 18-Month(%) Indicator 7020 10.8 76.8 Scale and tallimeter 86.5 98.2 Gynecological exam table 91.9 98.2 CLAP or metric tape 75.7 100 Gooseneck lamp or hand lamp 54.1 83.9 Blood pressure apparatus 89.2 98.2 Stethoscope 86.5 98.2 Gestogram 73.0 96.4 IUD insertion kit1 0 100 HIV rapid test n/a 100 Serological mixer/Syphilis rapid test/R.P.R.(syphilis)/Rapid plasma reagent n/a 90.9 Qualitative urinalysis strip n/a 100 Glucose strips/glucometer n/a 100 Standard hemoglobin TED/spectrophotometer/Diagnostico 500/Stax Fax/ Climar Junior/Microhematocrit centrifuge n/a 100 Microscope n/a 100 Cell counter n/a 100 Blood glucose strips/ glucose meter 100 n/a Hemocue/ automated cell counter 100 n/a Rapid HIV/AIDS test/ flourescence microscope 60 n/a Rapid syphilis test/ dark field microscope/ equipment for enzyme immunoassay 60 n/a Urine protein strips/ urinalysis equipment 100 n/a 1 Not applicable in health posts 2 Only applies to Basic facilities Indicator 7020: Health facilities that have necessary inputs to provide prenatal and post-natal care according to the norms Equipment Laoratory inputs 2
  48. 48. 48 7050: Health facilities with availability of modern contraceptive methods on the day of the survey 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0 Condoms Contraceptive pills Injectables Intrauterine device Baseline 18-Month
  49. 49. 49 Belize SMI Intervention Regions
  50. 50. 50 Belize HF Performance Indicator Matrix Baseline 18-month 18-month target # Indicator description Percent (95% CI) Percent (95% CI) % One-sided Z- test p value* 7030 Health facilities that have the necessary inputs for providing emergency obstetric and neonatal care according to the norms 0% (0 - 60.2%) 0%(0-60.2%) 75% 0.0003 7020 Health facilities that have the necessary inputs for providing pre- and post natal care according to the norms 2.9% (0.0 - 14.9%) 17.2% (5.8-35.8%) 85% <0.00001 7010 Health facilities that have the necessary inputs to provide child health care according to the norms 0% (0 - 9.5%) 0% (0-9.5%) 85% <0.00001 7050 Health facilities that have permanent availability of modern family planning methods 73.7%(48.8 - 90.9%) 90%(68.3-98.8%) 85% 0.7344 7460 Health facilities with a mechanism in place for carrying out patient satisfaction surveys 0%** 55.3% (38.3-71.4%) 85% <0.00001 7410 Health facilities that have implemented Quality of Care job aid tools for reproductive health 0%** 55.3% (38.3-71.4%) 85% <0.00001 7465 Health facilities that can submit and receive data from the Belize Health Information System (BHIS) 0%** 30% (6.7-65.2%) 85% <0.00001 7420 Health facilities that have sexual and reproductive health (SRH) educational materials specifically targeted at adolescents 0%** 62.2% (44.8-77.5%) 85% 0.0001 **New intervention: baseline assumed to be 0% * One-side test of proportions comparing if the estimate is lower than the target
  51. 51. 51 7020: Health facilities with availability of equipment necessary for prenatal and postpartum care 1Missing data for 1 ambulatory facility 2Not required for ambulatory facilities 3Only facilities that stored vaccines reported on Tetanus availability at follow-up 4Rapid test not asked at baseline 5Only required in basic facilities Baseline (%) 18-Month (%) Indicator 7020 2.9% 17.2% Pharmacy inputs (Iron + Folic acid)/ Multivitamin 65.2 93.3 Nitrofurantoin 30.4 53.3 Cephalexin 43.5 53.3 Tetanus vaccine3 70 100 Ayre palettes/swabs 26.1 73.3 Pap smear slides n/a 76.7 Laboratory inputs Rapid Syphillis test/dark field microscope/ equipment for enzyme immunoassay 4 75 100 Rapid HIV/AIDS test/fluorescence microscope4 50 100 Urine protein strips/urinalysis equipment 100 100 Blood glucose strips/glucose meter 0 75 Hemocue/automated cell counter 50 100 Microcuvettes 5 100 50 Pregnancy test kit5 100 100 Baseline (%) 18-Month (%) Indicator 7020 2.9% 17.2% Equipment Scale with measuring rod 60.0 79.3 Gynecological exam table 60.0 100 CLAP obstetric tape 54.3 96.6 Gestogram 34.3 100 Lamp 48.6 96.6 Sphygmomanometer1 48.6 100 Stethoscope 57.1 100 Fetoscope 22.9 93.1 Thermometer 31.4 100 Reflex Hammer 8.6 65.5 Perinatal maternal medical history 60 96.6 Perinatal maternal card 60 96.6 Referral forms 34.3 96.6 Robes or sheets for patients 40 89.7 Set for IUD Insertion2 25 100 Equipment cart 2 0 100
  52. 52. 52 7020: Health facilities with availability of inputs and equipment necessary for prenatal and postpartum care • Heat map detailing equipment and drugs by facility • Facilities doing well and missing very few requirements Indicator value 17% Reflex hammer Nitrofurantoin, Cephalexin
  53. 53. 53 7020: Health facilities with availability of equipment necessary for prenatal and postpartum care • Indicator value increases to 41% when excluding just these three issue inputs • Facilities are generally missing just one or two of the requirements Indicator increases by 24%
  54. 54. 54 7020: Health facilities with availability of pharmacy inputs and vaccines necessary for prenatal and postpartum care 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0 Baseline 18-Month
  55. 55. 55 7010: Health facilities with availability of inputs and equipment necessary for pediatric, vaccination and nutrition care Interviewers commented that physicians generally own personal stethoscope & ophthalmoscopes Adult stethoscopes and blood pressure apparatus can be used for children as well Seasonal vaccine Baseline 18-Month Indicator 7010 0 0 Pediatric scales or salter scales 62.2 100 Measuring Tape 59.5 97.2 Height rod 56.8 100 Stethoscope 57.6 100 Pediatric stethoscope 13.5 13.9 Pantascope/oto-ophthalmoscope 5.4 8.3 Hand Lamp 16.2 81 Examination table or stretcher 62.2 89 Pediatric blood pressure apparatus 25 100 Neonatal tensiometer 0 0 Binaural stethoscope for newborns 25 0 Reflex hammer 25 75 Negatoscope 0 100 Packets/envelopes of oral rehydration salt 52 94.6 Ferrous sulfate drops/multivitamins 60 83.8 Albendazole/Mebendazole 64 94.6 Zinc sulfate/zinc gluconate 28 83.8 Antibiotics 100 88.9 Saline solutions 100 100 IV Set 50 100 Pentavalent 100 100 MMR 100 100 Polio 100 100 Influenza 90 52.9 BCG 100 100 Indicator 7010: Health facilities with availability of inputs and equipment necessary for pediatric, vaccination and nutrition care Equipment Pharmacy inputs Vaccines
  56. 56. 56 7010: Health facilities with availability of inputs and equipment necessary for pediatric, vaccination and nutrition care The picture looks different if we consider the following: • Pediatric and neonatal stethoscopes can be substituted with a normal stethoscope • Pediatricians often own personal ophthalmoscopes & pediatric stethoscopes • Influenza vaccine may not be stored during all times of the year Excluding these requirements, the indicator value increases almost 38% Baseline 18-Month Indicator 7010 0 0 Pediatric scales or salter scales 62.2 100 Measuring Tape 59.5 97.2 Height rod 56.8 100 Stethoscope 57.6 100 Hand Lamp 16.2 81 Examination table or stretcher 62.2 89 Binaural stethoscope for newborns 25 0 Reflex hammer 25 75 Negatoscope 0 100 Packets/envelopes of oral rehydration salt 52 94.6 Ferrous sulfate drops/multivitamins 60 83.8 Albendazole/Mebendazole 64 94.6 Zinc sulfate/zinc gluconate 28 83.8 Antibiotics 100 88.9 Saline solutions 100 100 IV Set 50 100 Pentavalent 100 100 MMR 100 100 Polio 100 100 BCG 100 100 Indicator 7010: Health facilities with availability of inputs and equipment necessary for pediatric, vaccination and nutrition care Equipment Pharmacy inputs Vaccines
  57. 57. 57 7010: Health facilities with availability of inputs and equipment necessary for pediatric, vaccination and nutrition care 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0 Baseline 18-Month
  58. 58. 58 7050: Health facilities with availability of modern contraceptive methods on the day of the survey 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0 Male Condom Any pill Any injectable IUD Training for doctors to perform tubal ligation & vasectomy Baseline 18-Month
  59. 59. 59 El Salvador SMI Intervention Regions
  60. 60. 60 El Salvador 18-M HF Performance Indicators Baseline 18-month 18-month target # Indicator description Percent (95% CI) Percent (95% CI) % One-sided Z-test p value* 7001 Health facilities with availability of refrigerator 42.6% (29.2 – 56.8%) 78.4% (64.7 – 88.7%) 84.4% 0.119 7010 Health facilities with availability of supplies and equipment needed for child 36.2% (24 – 49.9%) 92.2% (81.1 – 97.8%) 75.3% 0.997 7020 Health facilities with continuous availability of supplies and equipment needed for prenatal care 48.3% (35 – 61.8%) 98% (89.6 – 100%) 88.3% 0.985 7050 Health facilities have supplies of modern family planning methods (oral pill, injectable, barrier, IUD) 19% (9.9 – 31.4%) 92.2% (81.1 – 97.8%) 84.4% 0.936 7193 Health facilities with availability of staff 69.8% (55.7 – 81.7%) 76.8% (63.6 – 87%) 83.3% 0.004 3041 First prenatal care visit within 12 weeks of gestation, with doctor or nurse n/a 64.9% (58.8 – 70.6%) 77% <0.00001 4106 Enrollment of children in ECOS Familiares within 8 days of birth n/a 90.1% (86.6 – 92.9%) 61% 1 * One-side test of proportions comparing if the estimate is lower than the target
  61. 61. 61 El Salvador HF Performance Indicator Matrix 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0% 7001 7010 7020 7050 7193 Baseline 18-month
  62. 62. 62 7010: Health facilities with availability of supplies and equipment needed for child care 1Baseline only captures Albendazole, while 18-month includes Albendazole or Mebendazole. Baseline (%) 18-Month (%) Indicator 7010 36.2 92.2 Equipment Infant scale 87.9 96.1 Child scale 86.2 100 Thermometer 96.6 100 Pharmacy inputs Oral rehydration salts 89.7 98.0 Zinc 86.2 98.0 Antihelmentics1 48.3 100
  63. 63. 63 7010: Health facilities with availability of supplies and equipment needed for child care 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0 Baseline 18-Month 1Baseline only captures Albendazole, while 18-month includes Albendazole or Mebendazole.
  64. 64. 64 Guatemala SMI Intervention and Control Regions
  65. 65. 65 Guatemala HF Performance Indicator Matrix Baseline 18-month 18-month target # Indicator description Percent (95% CI) Percent (95% CI) % One-sided Z- test p value* 7020** Health facilities with permanent availability of inputs and equipment necessary for prenatal and postpartum care 14.1% (6.6 – 25.0%) 10.7% (4.0 – 21.9%) 50% < 0.00001 7030 Health facilities with permanent availability of inputs and equipment necessary for emergency obstetric and neonatal care 0% (0-19.5%) 8.3% (0.2 – 38.5%) 50% 0.0019 7010 Health facilities with permanent availability of inputs and equipment necessary for pediatric, vaccination and nutrition care 3.2% (0.4 – 11.0%) 3.6% (0.4 – 12.5%) 50% < 0.00001 7050 Health facilities with stock-out of modern family planning supplies (oral, injectable, barrier, IUD), 40.3% (28.1 – 53.6%) 33.9% (21.8 – 47.8%) 30% 0.2606 7160 Municipal Health Districts that can access data and generate regular reports in immunization, maternal, newborn, and child care n/a 92.9% (66.1 – 99.8%) 70% 0.969 8610 Children aged 0-23 months who received growth monitoring according to their age in their most recent visit n/a 81.3% (77.9 – 84.5%) 6% 1 **The requirements for lab inputs at hospitals changed from the baseline to the 18-month evaluation, becoming more flexible with the allowance of rapid tests as an alternative to lab equipment. * One-side test of proportions comparing if the estimate is lower than the target
  66. 66. 66 7010: Ambulatory health facilities with availability of equipment necessary for pediatric, vaccination and nutrition care Baseline 18-month follow-up Overall 100 100 100 100 100 75 75 75 75 75 75 75 75 75 75 75 75 75 75 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 25 25 25 25 25 25 25 20 Child scale Tallimeter Stethoscope Thermometer Overall 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 75 75 Child scale Tallimeter Stethoscope Thermometer
  67. 67. 67 7020: Health facilities with availability of equipment necessary for antenatal and postpartum care Baseline 18-month follow-up Overall 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 86 86 86 86 86 86 86 86 86 86 86 86 86 86 86 86 86 86 86 71 71 71 71 71 71 71 71 57 57 57 57 57 57 57 57 57 57 57 57 57 57 57 43 43 43 43 29 Standing scale Gyn table Lamp Tape BP Stethoscope Med history Overall 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 86 86 86 86 86 86 86 86 86 86 86 86 86 86 86 86 86 86 86 86 86 86 83 71 71 71 71 71 71 71 71 67 Standing scale Gyn table Lamp Tape BP Stethoscope Med history
  68. 68. 68 Panama SMI Intervention Regions
  69. 69. 69 Panama HF Performance Indicator Matrix Baseline 18-month 18-month target # Indicator description Percent (95% CI) Percent (95% CI) % One-sided Z- test p value* 7010 Basic attention units (UBAs) with continuous availability of supplies needed for child care, immunization and nutrition 11.8% (1.5 - 36.4%) 84.2% (60.4 - 96.6%) 80% 0.6768 7020 Basic attention units (UBAs) with continuous availability of supplies and equipment needed for pre and postpartum care 17.6% (3.8 - 43.4%) 100% (82.4 - 100%) 80% 0.9854 7040 Basic EONC facilities with continuous availability of supplies and equipment needed for delivery care 7.1% (0.2 - 33.9%) 47.1% (23.0 - 72.2%) 80% < 0.00001 7050 Basic attention units (UBAs) that have supplies of modern family planning methods (oral, injectable, barrier, IUD) 7.1% (0.2 - 33.9%) 78.9% (54.4 - 93.9%) 80% 0.4543 7192 Facilities with 24/7 availability of a nurse or general physician at basic EONC level facilities 60.0% (32.3 - 83.7%) 76.5% (50.1 - 93.2%) 78% 0.4395 7710 UBA facilities that possess monthly AIN-C registries in which 80% of children under 24 months are registered with weight n/a 53.3% (26.6 - 78.7%) 80% 0.0049 7730** Population living in communities with a plan for better community sanitation and water quality n/a 100% (79.4 - 100%) 80% 0.9772 7740** UBAs with birthing plans for communities under their responsibility (which have been approved by the community) n/a 87.5% (61.7 – 98.4%) 80% 0.7734 **When considering actual observed availability of plans at health facilities, 56.3% of communities had sanitation plans and 37.5% of communities had birthing plans located at respective health facilities. * One-side test of proportions comparing if the estimate is lower than the target
  70. 70. 70 Panama HF Performance Indicator Matrix - Indicators 7730 and 7740: This is a new intervention, thus not evaluated at baseline. 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0% 7010¹ 7020 7040² 7050 7192³ 7710 7730⁴ 7740⁴ Baseline 18 months
  71. 71. 71 7040: Availability of inputs and equipment for delivery care by facility Baseline facilities (N =14 ) 18-month follow-up facilities (N= 17) Equipment p / serum c / macrogotero and microgotero Sterile fields or sheltering for a baby Intravenous catheter sterile N ° 18 Metallic clamp /umbilical tape / plastic clamp* Infusion equipment Urinary catheter Hyoscine bromide / Butylscopolamine Ergonovine maleate / Ergometrine / Oxytocin Ringer lactate / Hartmann solution / Saline solution Drops of chloramphenicol ophthalmic / 1% silver nitrate Vitamin K Equipment p / serum c / macrogotero and microgotero Sterile fields or sheltering for a baby Intravenous catheter sterile N ° 18 Metallic clamp /umbilical tape / plastic clamp* Infusion equipment Urinary catheter Hyoscine bromide / Butylscopolamine Ergonovine maleate / Ergometrine / Oxytocin Ringer lactate / Hartmann solution / Saline solution Drops of chloramphenicol ophthalmic / 1% silver nitrate Vitamin K
  72. 72. 72 7020: Health facilities with availability of inputs and equipment necessary for prenatal and postpartum care *Does not apply to ambulatory UBA facilities **Stock-out of ferrous sulfate was checked Baseline(%) 18- Month(%) Indicator 7020 17.6 100.0 Equipment CLAP obstetrical tape 60.0 100 Gynecological exam table* 66.7 100 Gooseneck lamp/hand lamp 40.0 100 Perinatal maternal card 100 100 Perinatal maternal medical history 100 100 Sphygmomanometer 80.0 100 Standing scales 80.0 100 Stethoscope 93.3 100 Tallimeter/stadiometer 53.3 100 All equipment observed on the day of survey 26.7 100 Pharmacy inputs Ayre palletes/swabs 76.5 100 Ferrous sulfate 100 100 Microscope slides 76.5 100 All inputs observed on day of survey 76.5 100 Continuous availability in previous 3 months** 52.9 100
  73. 73. 73 Honduras SMI Intervention and Control Regions
  74. 74. 74 Honduras 18-M HF Performance Indicators Baseline 18-month 18-month target # Indicator description Percent (95% CI) Percent (95% CI) % One-sided Z- test p value* 7030 Health facilities with permanent availability of inputs necessary for emergency obstetric and neonatal care in maternity clinics 62.5% (24.5 – 91.5%) 85.7% (42.1 – 99.6%) 80% 0.6473 7035 Health facilities with permanent availability of inputs necessary for emergency obstetric and neonatal care in hospitals 0% (0.0 – 45.9%) 50% (11.8 – 88.2%) 2 units 0.8068 7050 Health facilities with modern family planning supplies (oral, injectable, barrier, IUD), according to the schedule (population under responsibility, time of year, rotation) 86.4% (75.0 – 94.0%) 93% (83.0 – 98.1%) 90% 0.7735 7060 Health facilities with permanent availability of inputs and necessary for the treatment of pneumonia and diarrhea 0% (0.0 – 4.6%) 51.1% (35.8 – 66.3%) 80% <0.00001 7070 Continuous availability of powdered micronutrients n/a 93.5% (82.1 – 98.6%) 80% 0.9889 * One-side test of proportions comparing if the estimate is lower than the target
  75. 75. 75 Honduras HF Performance Indicator Matrix 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0% 7030 7035 7050 7060 7070* Baseline 18-month *This indicator is a new intervention, thus not evaluated at baseline
  76. 76. 76 7030: Basic EONC facilities with continuous availability of inputs for emergency obstetric and neonatal care in maternity clinics 1At baseline, oxytocin and ergometrine are counted. At 18-months, these two and ergobasine are counted.
  77. 77. 77 7035: Health facilities with availability of inputs for neonatal and obstetric emergencies in hospitals Baseline(%) 18-Month(%) Indicator 7035 0 50 Resuscitation bag for adults 83.3 100 Neonatal resuscitation bag 100 100 MVA kit 66.7 100 Stethoscope 66.7 100 Sphygmomanometer 83.3 100 Pinard stethoscope/portable doppler 100 100 Oxygen tank 83.3 100 Autoclave/dry heat sterilizer 66.7 83.3 Pediatric/neonatal stethoscope 0 83.3 Laryngoscope 100 83.3 Anesthesia kit 66.7 66.7 Uterotonics1 100 100 Tetracycline eye ointment 16.7 100 Saline wash 66.7 100 Saline solution or Ringer's lactate 83.3 100 Magnesium sulfate 100 100 Anti-hypertensives2 100 100 Naloxone hydrochloride 83.3 100 Furosemide 100 100 Phenobarbital sodium 100 100 Diazepam 100 100 Dextrose 66.7 100 Dexabethasone/ betamethasone3 66.7 100 Sodium bicarbonate 100 100 Antibiotics4 100 100 Adrenaline 100 100 Atropine/epinephrine 100 100 Equipment Pharmacy inputs 1Baseline measured oxytocin or ergometrine, while 18- months measured these two or ergobasine 2Hydralazine, hydralazine hydrochloride, alphamethyl dopa, propanolol, nifedipine 3At baseline, only dexamethasone is measured; at followup, betamethasone is also measured. Requirement for one of these two drugs only applies to follow-up 4Amoxicillin, ampicillin, amikacin sulfate, penicillin G, clindamycin, cephalexin, dicloxicillin, doxycycline, gentamicin, metronidazole
  78. 78. 78 7050: Availability of modern contraceptive methods on the day of the survey 0 10 20 30 40 50 60 70 80 90 100 Injectables Contraceptive pills Condoms Intrauterine device (IUD) Baseline 18-Month
  79. 79. 79 Outline Introduction Design and activities Results Conclusions and future activities
  80. 80. 80 WOW What a great SUCCESS
  81. 81. 81 Conclusions and future activities • Great support for SMI at all levels • Great support from the MoHs for the evaluation
  82. 82. 82 Future activities • Some of the requirements have to be reviewed • Seasionality has to be accounted for • Further assess facility’s ability to operate vs not • Comparative assessment and scoring is needed
  83. 83. 83 Future activities • Lessons learned have to be documented • Success and failure • A network for sharing information within and between countries • Lots to offer to other areas of the country • Lots to offer globally • Build upon the success and maintain it • Continue to engage the local Health officials • Continue to engage the communities
  84. 84. 84 Thank You For more information: mokdaa@uw.edu

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