Quantitative Service Delivery Survey in Health 2000 - Uganda

Abstract
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This study examines various dimensions of primary health care delivery in Uganda, using a baseline survey of public and private dispensaries, the most common lower level health facilities in the country.

The survey was designed and implemented by the World Bank in collaboration with the Makerere Institute for Social Research and the Ugandan Ministries of Health and of Finance, Planning and Economic Development. It was carried out in October - December 2000 and covered 155 local health facilities and seven district administrations in ten districts. In addition, 1617 patients exiting health facilities were interviewed. Three types of dispensaries (both with and without maternity units) were included: those run by the government, by private for-profit providers, and by private nonprofit providers, mainly religious.

This research is a Quantitative Service Delivery Survey (QSDS). It collected microlevel data on service provision and analyzed health service delivery from a public expenditure perspective with a view to informing expenditure and budget decision-making, as well as sector policy.

Objectives of the study included:
1) Measuring and explaining the variation in cost-efficiency across health units in Uganda, with a focus on the flow and use of resources at the facility level;
2) Diagnosing problems with facility performance, including the extent of drug leakage, as well as staff performance and availability;
3) Providing information on pricing and user fee policies and assessing the types of service actually provided;
4) Shedding light on the quality of service across the three categories of service provider - government, for-profit, and nonprofit;
5) Examining the patterns of remuneration, pay structure, and oversight and monitoring and their effects on health unit performance;
6) Assessing the private-public partnership, particularly the program of financial aid to nonprofits.

Geographic coverage
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The study districts were Mpigi, Mukono, and Masaka in the central region; Mbale, Iganga, and Soroti in the east; Arua and Apac in the north; and Mbarara and Bushenyi in the west.

Analysis unit
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- local dispensary with or without maternity unit

Universe
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The survey covered government, for-profit and nonprofit private dispensaries with or without maternity units in ten Ugandan districts.

Kind of data
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Sample survey data [ssd]

Sampling procedure
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The survey covered government, for-profit and nonprofit private dispensaries with or without maternity units in ten Ugandan districts.

The sample design was governed by three principles. First, to ensure a degree of homogeneity across sampled facilities, attention was restricted to dispensaries, with and without maternity units (that is, to the health center III level). Second, subject to security constraints, the sample was intended to capture regional differences. Finally, the sample had to include facilities in the main ownership categories: government, private for-profit, and private nonprofit (religious organizations and NGOs). The sample of government and nonprofit facilities was based on the Ministry of Health facility register for 1999. Since no nationwide census of for-profit facilities was available, these facilities were chosen by asking sampled government facilities to identify the closest private dispensary.

Of the 155 health facilities surveyed, 81 were government facilities, 30 were private for-profit facilities, and 44 were nonprofit facilities. An exit poll of clients covered 1,617 individuals.

The final sample consisted of 155 primary health care facilities drawn from ten districts in the central, eastern, northern, and western regions of the country. It included government, private for-profit, and private nonprofit facilities. The nonprofit sector includes facilities owned and operated by religious organizations and NGOs. Approximately one third of the surveyed facilities were dispensaries without maternity units; the rest provided maternity care. The facilities varied considerably in size, from units run by a single individual to facilities with as many as 19 staff members.

Ministry of Health facility register for 1999 was used to design the sampling frame. Ten districts were randomly selected. From the selected districts, a sample of government and private nonprofit facilities and a reserve list of replacement facilities were randomly drawn. Because of the unreliability of the register for private for-profit facilities, it was decided that for-profit facilities would be identified on the basis of information from the government facilities sampled. The administrative records for facilities in the original sample were first reviewed at the district headquarters, where some facilities that did not meet selection criteria and data collection requirements were dropped from the sample. These were replaced by facilities from the reserve list. Overall, 30 facilities were replaced.

The sample was designed in such a way that the proportion of facilities drawn from different regions and ownership categories broadly mirrors that of the universe of facilities. Because no nationwide census of for-profit health facilities is available, it is difficult to assess the extent to which the sample is representative of this category. A census of health care facilities in selected districts, carried out in the context of the Delivery of Improved Services for Health (DISH) project supported by the U.S. Agency for International Development (USAID), suggests that about 63 percent of all facilities operate on a for-profit basis, while government and nonprofit providers run 26 and 11 percent of facilities, respectively. This would suggest an undersampling of private providers in the survey. It is not clear, however, whether the DISH districts are representative of other districts in Uganda in terms of the market for health care.

For the exit poll, 10 interviews per facility were carried out in approximately 85 percent of the facilities. In the remaining facilities the target of 10 interviews was not met, as a result of low activity levels.

Sampling deviation
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In the first stage in the sampling process, eight districts (out of 45) had to be dropped from the sample frame due to security concerns. These districts were Bundibugyo, Gulu, Kabarole, Kasese, Kibaale, Kitgum, Kotido, and Moroto.

Mode of data collection
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Face-to-face [f2f]

Research instrument
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The following survey instruments are available:

- District Health Team Questionnaire;
- District Facility Data Sheets;
- Uganda Health Facility Survey Questionnaire;
- Facility Data Sheets;
- Facility Patient Exit Poll Questionnaire.

The survey collected data at three levels: district administration, health facility, and client. In this way it was possible to capture central elements of the relationships between the provider organization, the frontline facility, and the user. In addition, comparison of data from different levels (triangulation) permitted cross-validation of information.

At the district level, a District Health Team Questionnaire was administered to the district director of health services (DDHS), who was interviewed on the role of the DDHS office in health service delivery. Specifically, the questionnaire collected data on health infrastructure, staff training, support and supervision arrangements, and sources of financing.

The District Facility Data Sheet was used at the district level to collect more detailed information on the sampled health units for fiscal 1999-2000, including data on staffing and the related salary structures, vaccine supplies and immunization activity, and basic and supplementary supplies of drugs to the facilities. In addition, patient data, including monthly returns from facilities on total numbers of outpatients, inpatients, immunizations, and deliveries, were reviewed for the period April-June 2000.

At the facility level, the Uganda Health Facility Survey Questionnaire collected a broad range of information related to the facility and its activities. The questionnaire, which was administered to the in-charge, covered characteristics of the facility (location, type, level, ownership, catchment area, organization, and services); inputs (staff, drugs, vaccines, medical and nonmedical consumables, and capital inputs); outputs (facility utilization and referrals); financing (user charges, cost of services by category, expenditures, and financial and in-kind support); and institutional support (supervision, reporting, performance assessment, and procurement). Each health facility questionnaire was supplemented by a Facility Data Sheet (FDS). The FDS was designed to obtain data from the health unit records on staffing and the related salary structure; daily patient records for fiscal 1999-2000; the type of patients using the facility; vaccinations offered; and drug supply and use at the facility.

Finally, at the facility level, an exit poll was used to interview about 10 patients per facility on the cost of treatment, drugs received, perceived quality of services, and reasons for using that unit instead of alternative sources of health care.

Cleaning operations
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Detailed information about data editing procedures is available in "Data Cleaning Guide for PETS/QSDS Surveys" in external resources.

STATA cleaning do-files and the data quality reports on the datasets can also be found in external resources.

摘要
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本研究旨在探讨乌干达初级卫生保健服务的多个维度，通过一项针对公立和私立诊所的基线调查，这些诊所是国家最常见的基层卫生机构。

该调查由世界银行与 Makerere 社会研究学院以及乌干达卫生部、财政部和计划经济部合作设计和实施。调查于2000年10月至12月进行，涵盖了十个区内的155个地方卫生机构和七个区的七个区行政机构。此外，还对1617名离开卫生机构的患者进行了访谈。

调查包括了三种类型的诊所（包括和不包括产科单元）：由政府运营的、由私营盈利性供应商运营的，以及由私营非盈利性供应商运营的，主要是宗教组织。

本研究是一项定量服务交付调查（QSDS）。它收集了关于服务提供的微观层面数据，并从公共支出的角度分析了卫生服务交付，旨在为支出和预算决策以及行业政策提供信息。

研究目标包括：
1) 衡量和解释乌干达各卫生单位成本效益的差异，重点关注设施层面的资源流动和使用情况；
2) 诊断设施性能问题，包括药物泄漏的程度，以及员工的表现和可用性；
3) 提供有关定价和用户费政策的信息，并评估实际提供的服务类型；
4) 阐明政府、盈利性和非盈利性三种服务提供者类别（政府、盈利性和非盈利性）的服务质量；
5) 探讨薪酬模式、薪酬结构和监督与监测及其对卫生单位绩效的影响；
6) 评估公私合作，特别是对非盈利组织的财务援助计划。

地理覆盖范围
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研究区包括中部的姆皮吉、穆科诺和马萨卡；东部的姆巴莱、伊甘加和索托蒂；北部的阿鲁阿和阿帕克；以及西部的姆巴拉拉和布什尼。

分析单元
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- 带或不带产科单位的当地诊所

总体
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调查涵盖了十个乌干达区内带或不带产科单位的政府、盈利性和非盈利性私人诊所。

数据类型
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样本调查数据 [ssd]

抽样程序
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调查涵盖了十个乌干达区内带或不带产科单位的政府、盈利性和非盈利性私人诊所。

抽样设计受三个原则的指导。首先，为了确保样本设施之间的一致性，抽样范围限于带或不带产科单位的诊所（即健康中心III级）。其次，在安全限制条件下，样本旨在捕捉区域差异。最后，样本必须包括主要所有权类别的设施：政府、私营盈利性和私营非盈利性（宗教组织和非政府组织）。政府和非盈利性设施的样本基于1999年卫生部的设施登记册。由于没有盈利性设施的全国性普查，因此通过要求样本政府设施识别最近的私人诊所来选择这些设施。

在155个调查的卫生机构中，81个是政府设施，30个是私营盈利性设施，44个是非盈利性设施。对客户的出口调查涵盖了1,617人。

最终样本包括来自国家中部、东部、北部和西部十个区的155个初级卫生保健设施。它包括政府、私营盈利性和私营非盈利性设施。非盈利部门包括由宗教组织和非政府组织拥有和运营的设施。大约三分之一的调查设施是不带产科单位的诊所；其余设施提供产科护理。设施的大小差异很大，从由单个个体运营的单位到拥有多达19名员工的设施。

1999年卫生部的设施登记册用于设计抽样框架。随机选择了十个区。从选定的区中，随机抽取了政府和私营非盈利性设施，并随机抽取了备用设施名单。由于私营盈利性设施登记册的不可靠性，决定基于政府设施样本的信息来识别盈利性设施。首先在区总部审查了原始样本中设施的行政记录，其中一些不符合选择标准和数据收集要求的设施被从样本中删除。这些设施被备用名单中的设施所取代。总的来说，替换了30个设施。

样本设计得如此之好，以至于从不同地区和所有权类别抽取的设施比例大致反映了设施总体的情况。由于没有盈利性卫生设施的全国性普查，因此很难评估样本在多大程度上代表了这一类别。美国国际开发署（USAID）支持的“改善卫生服务交付”（DISH）项目在选定区进行的卫生机构普查表明，大约63%的设施以盈利性为基础运营，而政府和非盈利性供应商分别运营了26%和11%的设施。这表明在调查中对私人供应商进行了抽样不足。然而，不清楚DISH区是否在医疗保健市场方面代表了乌干达的其他区。

对于出口调查，在约85%的设施中，每个设施进行了大约10次访谈。在剩余的设施中，由于活动水平低，未能达到10次访谈的目标。

抽样偏差
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在抽样过程的第一个阶段，由于安全问题，不得不从样本框架中删除了八个区（45个区中的八个）：邦迪布吉奥、古卢、卡巴罗勒、卡塞塞、基巴莱、基图姆、科蒂多和莫罗托。

数据收集方式
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面对面 [f2f]

研究工具
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以下调查工具可供使用：
- 区卫生团队问卷；
- 区设施数据表；
- 乌干达卫生设施调查问卷；
- 设施数据表；
- 设施患者出口调查问卷。

调查在三个层面收集数据：区行政、卫生设施和客户。通过这种方式，可以捕捉到提供组织、一线设施和用户之间关系的基本要素。此外，比较不同层面的数据（三角测量）允许交叉验证信息。

在区级，对卫生服务区主任（DDHS）进行了区卫生团队问卷的调查，对DDHS办公室在卫生服务交付中的作用进行了访谈。具体而言，问卷收集了有关卫生基础设施、员工培训、支持和监督安排以及融资来源的数据。

在区级，使用区设施数据表收集了有关1999-2000财年样本卫生单位的更详细信息，包括有关人员配备和相关的薪酬结构、疫苗供应和免疫活动以及设施的基本和补充药物供应的数据。此外，还审查了2000年4月至6月期间设施对总门诊、住院、免疫和分娩数量的月度报告。

在设施层面，乌干达卫生设施调查问卷收集了与设施及其活动相关的广泛信息。对负责人进行的问卷涵盖了设施的特征（位置、类型、级别、所有权、服务范围、组织和服务）；投入（人员、药物、疫苗、医疗和非医疗消耗品以及资本投入）；产出（设施利用和转诊）；融资（用户收费、按类别服务的成本、支出以及财务和非财务支持）；以及制度支持（监督、报告、绩效评估和采购）。每个卫生设施问卷都辅以设施数据表（FDS）。FDS旨在从卫生单位记录中获得有关人员配备和相关的薪酬结构；1999-2000财年的每日患者记录；使用设施的患者类型；提供的疫苗接种；以及设施中的药物供应和使用。

最后，在设施层面，使用出口调查对每个设施的大约10名患者进行了访谈，以了解治疗成本、收到的药物、对服务质量的感觉以及选择该单位而不是其他医疗保健来源的原因。

数据清理操作
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有关数据编辑程序的详细信息可在“PETS/QSDS调查数据清理指南”中找到，位于外部资源。

STATA清理do文件和数据集的数据质量报告也可在外部资源中找到。