Salud Mesoamérica 2015 Initiative: Data for Better Health

1

Salud Mesoamérica Initiative: Data for Better Health

November 11, 2014

Ali H. Mokdad, Ph.D.

Director, Middle Eastern Initiatives

Professor, Global Health

2

Outline

Introduction

Design and activities

Results

Conclusions and future activities

3

Outline

Introduction


Results


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

Outline

Introduction


Results


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)

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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

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

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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

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

Outline

Introduction


Results


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

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Reasons for non-use of contraception

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15

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Costa Rica

SMI Intervention Regions

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Costa Rica Indicators

Indicator N Prevalence 95% CI

Knowledge of contraception

availability at EBAIS facilities881 30.5% (21.5 - 39.5%)

Receipt of sexual and reproductive

health counseling560 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 STIs909 22.4% (16.3 - 28.4%)

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Sexually active studentsGrade 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%)

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Mexico

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Denominator is Equally Important

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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

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Challenging Environment

• Lots of disparities

• Remote areas

• Logisitical challenges

• Indigenous population

• Culture and expectations

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DBS Results

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Mexico: measles immunization coverage

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Where are the gaps?

Proportion of card-positive children lacking antibodies

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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

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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.

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Crude and effective coverage of measles immunization

*The number in each municipality indicates sample size. Estimates are survey weighted.

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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

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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

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Mexico- Chiapas

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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

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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 table1 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 palletes2

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

1Not applicable to mobile units2Not applicable to ambulatory without doctor3Only applies to Ambulatory facilities with doctor 4Only applicable if facility stores vaccine5Only applicable to Basic facilities

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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

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equipment necessary for delivery and newborn care

* Drug requirements dependent on facility EONC classification


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

1Nasogastric tube K 33 measured at baseline, but any nasogastric tube accepted at 18-months

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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

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7030: Availability of inputs and equipment necessary for

emergency obstetric and neonatal care


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

Sevoflurane1

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

2Only applies to Basic facilities

Indicator 7030: Health facilities with availability of inputs and equipment necessary

for emergency obstetric and neonatal care

Equipment

Pharmacy inputs

1Only applies to Complete facilities

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7010: Health facilities with availability of inputs and equipment

necessary for pediatric, vaccination and nutrition care


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 stethoscope2 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 solution2

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 501Only applicable at Ambulatory facilities2Only applicable at Basic & Complete facilities3Not applicable to Ambulatory facilities without doctor 4Only 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

Vaccines4

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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

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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

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

Nicaragua

43

Nicaragua HF Performance Indicator Matrix


# 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

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

7000: Health facilities with cold chain according to standards


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

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

requirements1Health posts not required to have pediatric stethoscopes2Data missing for pediatric scale & growth and development card in 4 units at 18 months3Not applicable in health posts4Hib not evaluated due to survey programming

47

7020: Health facilities that have necessary inputs to provide

prenatal and post-natal care according to the norms


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/a1Not applicable in health posts2Only 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 inputs2

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

Belize


50

Belize HF Performance Indicator MatrixBaseline 18-month 18-month target


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


for prenatal and postpartum care

1Missing data for 1 ambulatory facility2Not required for ambulatory facilities3Only facilities that stored vaccines reported on Tetanus availability at follow-up4Rapid test not asked at baseline5Only 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 immunoassay4

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

Microcuvettes5

100 50

Pregnancy test kit5 100 100


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


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 cart2

0 100

52


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


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

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



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


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



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


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



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

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

El Salvador


60

El Salvador 18-M HF Performance IndicatorsBaseline 18-month 18-month target

# Indicator description Percent (95% CI) Percent (95% CI) % One-sidedZ-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


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

7010: Health facilities with availability of supplies and

equipment needed for child care

1Baseline only captures Albendazole, while 18-month includes Albendazole or Mebendazole.


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

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

Guatemala

SMI Intervention and Control Regions

65

Guatemala HF Performance Indicator Matrix



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.


66

7010: Ambulatory health facilities with availability of equipment


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


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 tableLampTape

BPStethoscopeMed 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 tableLampTape

BPStethoscopeMed history

68

Panama


69

Panama HF Performance Indicator MatrixBaseline 18-month 18-month target


test p value*

7010Basic attention units (UBAs) with continuous

availability of supplies needed for child care,

immunization and nutrition11.8% (1.5 - 36.4%) 84.2% (60.4 - 96.6%) 80% 0.6768

7020Basic attention units (UBAs) with continuous

availability of supplies and equipment needed for

pre and postpartum care17.6% (3.8 - 43.4%) 100% (82.4 - 100%) 80% 0.9854

7040Basic EONC facilities with continuous

availability of supplies and equipment needed for

delivery care7.1% (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 facilities60.0% (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 weightn/a 53.3% (26.6 - 78.7%) 80% 0.0049

7730** Population living in communities with a plan for

better community sanitation and water qualityn/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.


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

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


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 17.6 100.0Equipment

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


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

Honduras

SMI Intervention and Control Regions

74

Honduras 18-M HF Performance Indicators


# 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%) 2units

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


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

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

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


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

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

Outline

Introduction


Results


80

WOWWhat a great SUCCESS

81


• Great support for SMI at all levels

• Great support from the MoHs for the evaluation

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

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

Thank You

For more information:

[email protected]

Health & Medicine

Salud Mesoamérica 2015 Initiative: Data for Better Health