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Health

History of the SDI Initiative

  • The SDI program began in 2008, through collaboration between the World Bank Group and African Economic Research Consortium and was supported by the Hewlett Foundation and the African Development Bank. As a direct response to the canonical World Development Report 2004: Making Services Work for Poor People,  the SDI initiative laid the groundwork for the innovative way of measuring the quality of health and education at the point where the service meets the citizen.  
  • The first SDI surveys were developed and piloted in 2010. The surveys introduced novel methodologies in measurement of quality of public service provision including innovations in assessing provider competency and measurement of absenteeism in health facilities. The first full SDI survey was completed in 2012 and quickly ramped up in the Africa region.
  • Between 2012 and 2018, almost a dozen surveys were completed in the Africa region, and the surveys focused on maternal and child health, communicable diseases, inputs and infrastructure.
  • 2018 marked a watershed moment in global health with the introduction of three global reports that emphasized the importance of improving quality of care in health care facilities to realize the Sustainable Development Goals (SDGs). The SDI Health Survey Team undertook a comprehensive revamp (described below) to ensure that the survey tools responded to the latest.

 

SDI Health Survey Revamp: Assessment Methods

SDI Health Surveys are in-person, facility-based surveys with questionnaires capturing health facility characteristics, health care provider information, and patient experience. The survey takes place over the course of two days (one pre-announced facility visit and one unannounced surprise facility visit) and is typically administered by field teams of 2-6 enumerators depending on the size of the facility.

Three questionnaires were developed, each distinguished by who the intended respondent was –facility manager, health care providers, patients –for clarity and ease of administration. The domains and subdomains in the framework are covered across the three questionnaires.

Health Survey

What does the refreshed SDI health survey measure?

Facilities

Health Care Providers

Patients

  • Measure facility-level indicators of service delivery and quality of primary care
  • In-person interview with facility manager
  • Direct observation of amenities, infrastructure, equipment and supplies
  • Paper or digital record and inventory review
  • Measure provider-level indicators of effort, clinical knowledge and competence, and work environment
  • In-person interview with health care providers
  • Clinical case simulations (vignettes) → Surprise (unannounced) visit

Click here for Vignette Demonstration Video

Click here for Vignette Factsheet

  • Measure patient experience and satisfaction with care
  • In-person patient exit interview with patient or his/her proxy
  • Anchoring vignettes to measure expectations and satisfaction with care

 

Methodology used prior to SDI Health Survey Revamp

Definition of core indicators

Below, you can find brief definitions of core indicators collected for health SDI surveys.

  • Provider absenteeism

    Share of a maximum of 10 randomly-selected providers absent from the facility during an unannounced visit.

    Number of health professionals who are absent from the facility on an unannounced visit as a share of ten randomly sampled workers who should be on-duty. Health professionals doing outreach are counted as present.

  • Caseload per health provider

    Number of outpatient visits per clinician per day.

    Caseload is calculated as the number of outpatient visits recorded in outpatient records in the three months prior to the survey, divided by the number of days the facility was open during the three-month period and the number of health professionals who conduct patient consultations.

     

    This indicator is adjusted for the average absenteeism at the facility-level. For example, if a facility reports having 10 healthcare providers who conduct outpatient consultations, but that facility’s absenteeism on an unannounced visit is found to be 40%, then the number of healthcare providers will be adjusted down by 40% and only 6 healthcare providers will be counted as available for patient care.

  • Diagnostic accuracy

    Percent of correct diagnoses provided in the five clinical vignettes.

    The SDI includes five core vignettes: (i) acute diarrhea w/ dehydration; (ii) pneumonia; (iii) diabetes mellitus; (iv) pulmonary tuberculosis; (v) malaria w/ anemia. Healthcare providers are scored on their ability to provide correct diagnosis on each of those vignettes and their overall score is calculated as the percent of vignettes answered correctly.

  • Treatment accuracy

    Percent of correct treatments provided in the five clinical vignettes.

    The SDI includes five core vignettes: (i) acute diarrhea w/ dehydration; (ii) pneumonia; (iii) diabetes mellitus; (iv) pulmonary tuberculosis; (v) malaria w/ anemia. Healthcare providers are scored on their ability to provide correct treatment on each of those vignettes and their overall score is calculated as the percent of vignettes answered correctly.

  • Management of maternal and neonatal complications

    Number of relevant treatment actions proposed by the clinician.

    The SDI includes two vignettes to assess maternal and neonatal complications. Providers are scored on the number of relevant treatment actions that they propose out of five specific actions for post-partum hemorrhage and seven specific actions for neonatal asphyxia. 

  • Medicine availability

    Percent of 14 basic medicines which were available and in-stock at the time of the survey.

    Medicine availability is calculated as the percent of 14 medicines available and in-stock at the time of the survey. The list of medicines included for the SDI is based on a subset of the WHO Essential Medicines list. The medicines included are:

     

    1. Amitriptyline (anti-depressant)
    2. Amoxicillin (antibiotic)
    3. Atenolol (beta blocker)
    4. Captopril (ACE inhibitor)
    5. Ceftriaxone (antibiotic)
    6. Ciprofloxacin (antibiotic)
    7. Cotrimoxazole (antibiotic)
    8. Diazepam (anti-seizure)
    9. Diclofenac (nonsteroidal anti-inflammatory)
    10. Glibenclamide (anti-diabetic)
    11. Omeprazole (proton pump inhibitor)
    12. Paracetamol (analgesic)
    13. Salbutamol (bronchodilator)
    14. Simvastatin (statin)

     

    The list of medicines in the SDI is adapted based on country standards. Thus, some of these medicines were not included in the surveys in Kenya, Nigeria and Uganda, so these countries have been omitted from this indicator.  

  • Equipment availability

    Availability and functioning thermometer, stethoscope, sphygmomanometer and weighing scale.

    Equipment availability is calculated as the availability and functioning of a thermometer, a stethoscope, a sphygmomanometer and a weighing scale (adult, child or infant). Credit is given if all four components are available. 

     

    Thermometer: Credit is given if a facility reports and the enumerator observes that the facility has one or more functioning thermometers (used for measuring patient body temperature).

     

    Stethoscope: Credit is given if a facility reports and the enumerator observes that the facility has one or more functioning stethoscopes.

     

    Sphygmomanometer: Credit is given if a facility reports and the enumerator observes that the facility has one or more functioning sphygmomanometers.

     

    Weighing Scale: Credit is given if a facility reports and the enumerator observes that the facility has one or more functioning adult, child or infant weighing scale.

  • Infrastructure availability

    Availability of an improved water source, an improved toilet and electricity.

    Infrastructure availability is calculated as the availability of three components: improved water source, improved toilet and electricity. Credit is given if all three components are available.

     

    Improved toilet: Credit is given if facility reports and enumerator confirms facility has one or more functioning flush toilets or ventilated improved pit (VIP) latrines, or covered pit latrine (with slab).

     

    Improved water source: Credit is given if facility reports their main source of water is piped into the facility, piped onto facility grounds or comes from a public tap/standpipe, tubewell/borehole, a protected dug well, a protected spring, bottled water or a tanker truck. This definition is based on the WHO/UNICEF Joint Monitoring Program for Water Supply, Sanitation and Hygiene.

     

    Electricity: Credit is given if facility reports using electric power grid, fuel-operated generator, battery-operated generator, or a solar powered system as their main source of electricity.