Knowledge Brief Health, Nutrition and Population Global Practice UNLOCKING SDG 3 SUCCESS: THE ROLE OF THE THE POWER OF DATA PRIVATE SECTOR COLLECTION ON HEALTH IN REPRODUCTIVE SERVICE DELIVERY HEALTH SERVICES IN BANGLADESH Kathryn Andrews AhmedSharma Jigyasa Al-Sabir, Bushra Binte Alam, and Sameh El-Saharty May 20142023 November Source: WB Flickr KEY MESSAGE: To accelerate progress toward global goals such as Universal Health Coverage and to overhaul primary health care, we must harness high-quality data on system performance vis-à-vis an average citizen’s experience of receiving care; the World Bank's revamped Service Delivery Indicators Health Survey is stepping up to meet this crucial need. INTRODUCTION accountable. Furthermore, when done right, using a framework to guide domains of measurement induces This year holds special significance as the midpoint in accountability in the measurement processes by ensuring implementation of the Sustainable Development Goals that measurement priorities are driven by an evidence- (SDGs). With each step closer to the end of the SDG based common understanding of theories of change. implementation window, efforts to measure progress and achievement toward these goals will only intensify. While MEASUREMENT FOR CATALYZING IMPROVEMENT rhetoric often emphasizes the importance of data for IN QUALITY OF CARE development, the global community has yet to fully translate this discourse into substantial investments in In 2018, three global reports released on the quality of care high-quality data for evidence-based decision-making. emphasized the role of measurement of care quality and Beyond just financial commitments to robust data service delivery in accelerating progress toward collection, there is a pressing need for greater political and Sustainable Development Goal 3 and related global scientific dedication. objectives like Universal Health Coverage (Berwick et al. 2018). Measurement continues to stay in the spotlight Measurement should serve as a catalyst for action and since the era of the Millennium Development Goals, with accountability, but in turn, there must be accountability in substantial investments over the last two decades in health measurement processes. Choices regarding what to system performance measurement and information measure, how to measure it, what remains unmeasured, systems (WHO 2018). and to whom findings are disseminated reflect political decisions and underlying conceptualization of “problems� Global efforts have concentrated on improving routine data and “solutions,� and can profoundly impact policy collection through health management information directions. systems (HMIS), which serve important reporting and auditing purposes, but are inherently limited in Comprehensive, framework-driven measurement activities comprehensively assessing quality of care or performance are crucial to provide an unbiased and holistic platform for of health systems in delivering services to their users. decision-making and for holding leaders and institutions Routine administrative data, important in their own right, Page 1 HNPGP Knowledge Brief • often lack essential clinical details required to evaluate care FIGURE 1: Theoretical Framework Guiding the quality, such as patient experiences, provider adherence to Revamped Content of the World Bank’s Service guidelines, and treatment appropriateness, and may be Delivery Indicators Health Survey subject to biases, inaccuracies, and gaps. To surmount these weaknesses, survey data and complementary sources are crucial in providing a more holistic, patient-centered perspective on quality of care, which is essential for achieving improved health outcomes. Given the critical role of robust and reliable measurement in accelerating progress toward global goals, it is now imperative that the global development community aligns both its rhetoric and its actions with unwavering clarity and audacity to drive meaningful advancements in measuring quality of care. OPPORTUNITIES AND DEFICITS IN HEALTH SYSTEM MEASUREMENT There are several large-scale health facility survey Source: World Bank programs already in existence to help shed light on service availability and quality. Specifically, the United States IMPROVED MEASUREMENT FOR ACTION AND Agency for International Development’s (USAID’s) Service ACCOUNTABILITY Provision Assessment (SPA) Surveys, the World Health Organization’s (WHO’s) Service Availability and Readiness To address these widely recognized limitations, the World Assessments (SARAs), and the World Bank’s Service Bank’s SDI Health Survey team has undertaken a Delivery Indicators (SDI) Health Surveys are all designed comprehensive revamp of the SDI Health Survey (Andrews to collect nationally representative data on health care and Sharma 2021). Leveraging a decade's worth of services.1, 2, 3 However, there are crucial shortcomings, insights and grounded in a fresh theoretical framework both in terms of the quantity and quality of these data. drawn from the latest literature, the survey uses a systems- based approach to measuring quality of care (Figure 1) On the quantity side, limited investment in these types of (Kruk et al. 2018). data collection efforts has meant limited data availability. As an indication of the relative prioritization of these two The survey content is also responsive to evolving global types of data, the Demographic and Health Surveys (DHS) priorities (including pandemic preparedness and response, Program has conducted over 450 population-based climate resilience, human resources retention and burnout, surveys and just over 30 facility-based surveys since its supply chain challenges, and a growing burden of inception.4 On the quality side, historically, the content and noncommunicable diseases) (Sharma, Andrews, and methodologies of SPA, SARA, and SDI have suffered from Bhatia 2022; Bhatia, Andrews, and Sharma 2022). This key shortcomings, including an emphasis on infectious and new generation of SDI Health Surveys, introduced since maternal and child health conditions, a focus on physical 2021, represent a leap forward in the quality of primary data inputs and infrastructure, and outdated survey on service delivery (Andrews and Sharma 2021). methodologies relating to questionnaire design and sampling. For example, the SDI Health Survey used The revamped SDI surveys feature comprehensive methodologies that were cutting-edge upon program measurement of the foundations, processes, and person- inception over a decade ago, including in measuring centered outcomes of primary care and employ best presence/absence of health care providers at the facility practices in survey question design. This efficiently during a surprise visit by enumerators, provider captures the national and subnational patient experience competency assessments using simulation cases known (including in both public and private facilities), while robust as “clinical vignettes,� and direct observation of availability quality assurance mechanisms improve data quality and and functioning of key equipment and supplies. However, interpretability. The clinical vignettes have undergone a notable limitations included lack of a guiding theoretical meticulous revision process to rectify previous framework, a unidimensional approach to measurement inaccuracies, align with the latest global and national relating to health care providers, absence of any data guidelines for correct diagnosis and treatment of common collection from patients, and outmoded question design conditions, and capture the drivers behind incorrect and sampling methodologies. diagnoses and treatments. Page 2 HNPGP Knowledge Brief • Shifting away from the notion of health care providers as approaches. This approach empowers decision-making, inputs into (or worse, cogs in) the system, the SDI Health facilitates result monitoring, and enhances impact Survey tools now more appropriately spotlight providers as evaluation, thereby ensuring a more comprehensive and subjects of the system whose retention and well-being are effective assessment of health system quality. key measures of a healthy service delivery system (Bhatia, Andrews, and Sharma 2022). Perhaps most notably, the A CALL TO ACTION new generation of SDI Health Surveys now include patient interviews (Figure 2), conducted using an innovative The global community must recognize the imperative of sampling methodology to mitigate bias. strategic investments in primary data collection on service FIGURE 2: Content and Structure of World Bank’s Revamped Service Delivery Indicators Health Survey Source: World Bank SITUATING SDI HEALTH SURVEYS IN THE BROADER delivery—an essential cornerstone for informed diagonal MEASUREMENT LANDSCAPE decision-making. While SDI surveys are independent and reliable tools, While substantial resources are mobilized to reform health other tools such as routine data collection platforms and systems, a pronounced gap exists in prioritizing primary rapid phone surveys play a complementary role. Periodic data collection that can and should accompany the reform surveys play a vital role in validating both HMIS and rapid process. To holistically assess progress, pinpoint areas for phone survey data while also bridging gaps that extend intervention, and promote effective learning and beyond the scope of these individual sources. accountability, this critical element must not be relegated to the periphery. Moreover, their collective use enables a process of data triangulation, enhancing the overall understanding of Amidst the rhetoric surrounding evidence-based policy, health system quality. This synergy enables health substantive investments in primary data collection are systems to strategically plan interventions, adapt to diverse indispensable. It is incumbent upon us to realize that contexts, and continually improve the delivery of care. evidence generation extends far beyond specialized or bespoke research initiatives; it embodies a global public The paramount challenge and opportunity in health system good and the ethical responsibility inherent in our quality measurement lies in optimizing the “what,� “when,� commitment to effective implementation and development and “how� of data collection. It entails a shift from isolated activities. considerations of tools and methodologies to a strategic emphasis on selecting the most appropriate blend of Page 3 HNPGP Knowledge Brief • References Andrews, K., and J. Sharma. 2021. Service Delivery Indicators (SDI) This HNP Knowledge Note highlights the key innovations of the Health Survey Refresh Fact Sheet. Washington, DC: World revamped Service Delivery Indicators (SDI) Health Survey. For more Bank. information, please visit: www.worldbank.org/en/programs/service- delivery-indicators/health. Andrews, K., and J. Sharma. 2021. “A Revolution in Health Service Delivery Measurement.� World Bank Blogs. The authors are grateful to Jumana Qamruddin, Senior Health https://blogs.worldbank.org/health/revolution-health-service- Specialist, World Bank, and Victoria Fan, Senior Fellow, Center for delivery-measurement. Global Development for their thoughtful review and feedback on the content of this knowledge brief. Berwick, D. M., E. Kelley, M. E. Kruk, S. Nishtar, and M. A. Pate. 2018. “Three Global Health-Care Quality Reports in 2018.� Lancet 392: 194–95. Bhatia, R., K. Andrews, and J. Sharma. 2022. “Putting People First: Innovations in Measuring Health Care Worker Job Satisfaction.� World Bank Blogs. https://blogs.worldbank.org/health/putting- people-first-innovations-measuring-health-care-worker-job- satisfaction. Kruk, M. E., A. D. Gage, C. Arsenault, K. Jordan, H. H. Leslie, S. Roder- DeWan, O. Adeyi, et al. 2018. “High-Quality Health Systems in the Sustainable Development Goals Era: Time for a Revolution.� Lancet Global Health 6: E1196–E1252. Sharma, J., K. Andrews, and R. Bhatia. 2022. “Responding Better in Emergencies: Innovations in Measuring Health Facility Resilience for Pandemics and Other Disasters.� World Bank Blogs. https://blogs.worldbank.org/health/responding-better- emergencies-innovations-measuring-health-facility-resilience- pandemics-and. WHO (World Health Organization). 2018. Global Efforts in Measuring Quality of Care. Geneva. Endnotes 1 The DHS program. The DHS Program—Quality Information to Plan, Monitor and Improve Population, Health, and Nutrition Programs. https://dhsprogram.com/Methodology/Survey-Types/SPA.cfm. 2 WHO (World Health Organization). Service Availability and Readiness Assessment (SARA). https://www.who.int/data/data-collection- tools/service-availability-and-readiness-assessment- (sara)#:~:text=The%20Service%20Availability%20and%20Readiness,m anaging%20of%20a%20health%20system. 3 World Bank. Health Service Delivery Indicators. https://www.worldbank.org/en/programs/service-delivery- indicators/health. 4 The DHS Program. The DHS Program—Survey Types. https://dhsprogram.com/Methodology/Survey-Types/index.cfm. Page 4