Assessing the quality of care in a new nation: South

Tropical Medicine and International Health

doi:10.1111/tmi.12363

volume 00 no 00

Assessing the quality of care in a new nation: South Sudan’s first national health facility assessment Sima Berendes1, Richard L. Lako2, Donald Whitson1, Simon Gould1 and Joseph J. Valadez1 1 Liverpool School of Tropical Medicine, International Public Health Department, Liverpool, UK 2 Ministry of Health of the Republic of South Sudan, Juba, Sudan

Abstract

objectives We adapted a rapid quality of care monitoring method to a fragile state with two aims: to assess the delivery of child health services in South Sudan at the time of independence and to strengthen local capacity to perform regular rapid health facility assessments. methods Using a two-stage lot quality assurance sampling (LQAS) design, we conducted a national cross-sectional survey among 156 randomly selected health facilities in 10 states. In each of these facilities, we obtained information on a range of access, input, process and performance indicators during structured interviews and observations. results Quality of care was poor with all states failing to achieve the 80% target for 14 of 19 indicators. For example, only 12% of facilities were classified as acceptable for their adequate utilisation by the population for sick-child consultations, 16% for staffing, 3% for having infection control supplies available and 0% for having all child care guidelines. Health worker performance was categorised as acceptable in only 6% of cases related to sick-child assessments, 38% related to medical treatment for the given diagnosis and 33% related to patient counselling on how to administer the prescribed drugs. Best performance was recorded for availability of in-service training and supervision, for seven and ten states, respectively. conclusions Despite ongoing instability, the Ministry of Health developed capacity to use LQAS for measuring quality of care nationally and state-by-state, which will support efficient and equitable resource allocation. Overall, our data revealed a desperate need for improving the quality of care in all states. keywords quality of care, capacity building, monitoring and evaluation, national survey, lot quality assurance sampling, Africa, South Sudan, fragile state

Introduction The Republic of South Sudan (RSS), the world’s newest country, is in urgent need of an inexpensive, decentralised method to assess and recurrently monitor the quality of its healthcare services. South Sudan became independent in July 2011 after the 2005 peace agreement ended Africa’s longest civil war, which claimed >2.5 million lives. The prolonged Sudan–South Sudan conflict, domestic conflicts, frequent droughts, the influx of refugees from Sudan and internal displacement have deprived the population of basic needs and put pressure on the country’s essential services. Currently, >70% of the population is illiterate, the maternal mortality ratio (2050 deaths/100 000 live-births) is the highest in the world, and under-five mortality (106 deaths/1000 live-births) is one of the highest (Wakabi 2011; MOH 2012).

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At the time of independence, South Sudan still suffered from chronically intermittent insecurity due to border conflicts with Sudan, intertribal cattle raiding, other ethnic conflicts and activities of rebel militia groups (WFP 2012; BBC 2014). However, it was stable enough to start moving from a fragmented humanitarian to a coordinated developmental approach to health service delivery. Among the priority strategic objectives in the nation’s first Health-Sector Development Plan was establishing a strong monitoring and evaluation (M&E) system for evidence-based decision-making (MOH 2011b). Currently, no peer-reviewed scientific publications exist about the quality of health care (QoC) in South Sudan. The results of a health facility mapping (HFM) survey (2010–2011) documented the dire state of the country’s health infrastructure (MOH 2011a). The HFM mapped the physical location of health facilities (HFs) and measured access and input indicators. Being a census it was

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Tropical Medicine and International Health

volume 00 no 00

S. Berendes et al. South Sudan’s first national health facility assessment

time-consuming and expensive. At the time, the MOH recognised the need for a complementary, more rapid survey to regularly assess process and output indicators in addition to access and inputs. RSS decided to use the Lot Quality Assurance Sampling (LQAS) method for QoC assessments as it is relatively inexpensive, rapid, uses small samples of HFs and patients and produces data appropriate for statistical inferences on both national and state levels. LQAS is a classification method originally developed for industrial quality control (Dodge & Romig 1929) and subsequently adapted to health sciences (Valadez 1991). It has been applied in different health arenas (Robertson & Valadez 2006), including for quality assurance of health programmes (Valadez et al. 1996, 1997). Recently, we used LQAS for the rapid assessment of public and private HFs in Nigeria (Berendes et al. 2012; Oladele et al. 2012). Here, we adapt a similar LQAS design to a fragile state to rapidly assess the quality of health delivery services at the time of independence and to strengthen the MOH’s capacity to perform regular rapid assessments.

Methods Overall study design and eligibility This rapid health facility assessment (r-HFA) is a national cross-sectional survey among a sample of 14–16 HFs in each of 10 states totalling 156 randomly selected functioning facilities. We included public and private not-forprofit facilities from all levels [hospitals, primary healthcare centres (PHCC) and primary healthcare units (PHCU)]. Facilities were eligible if they were accessible, open for service, had a physical building, equipment and drugs, and ≥1 technical staff (Table 1). In each facility, we assessed infrastructure, equipment, material and supplies, interviewed health workers (HW) and reviewed patient records. In addition, we observed six consecutive consultations of sick children