Service Provision Assessment Survey 2004

Data were collected from a representative sample of facilities; a sample of health service providers at each facility; and a sample of sick child, family planning, antenatal, and STI clients. In addition, a sample of children receiving injections was selected.

• Sample of facilities: The sample was selected to provide national and regional-level representation of the health facilities offering maternal, child, and reproductive health services. These included a variety of types of hospitals, health centers, and health units managed by the government (public) or by nongovernmental organizations (NGOs). Private pharmacies and private clinics were not included in the sample. Facilities in the Frontier Governorates were also not included in the survey.

Among public sector facilities, the sample covered hospitals, maternal and child health and urban health units (MCH/urban HUs), rural health units (rural HUs), mobile units, and health offices. General/district and integrated hospitals were selected to represent general service (GS) hospitals. In addition, fever hospitals were also sampled. Although they do not provide the range of services covered by the ESPA 2004, fever hospitals provide health services for sick children and some services for infectious diseases that are of interest to the ESPA 2004 and policymakers. At the request of USAID and MOHP, 7 governorates (Cairo, Alexandria, Fayoum, Beni Suef, Menya, Qena, and Aswan) that are part of a USAID-supported pilot project were oversampled to provide key indicators for these areas.

The total sample size was determined on the basis of funding and logistic considerations, as well as the minimum sample size required for the levels of analysis desired. Using a list of facilities supplied by the MOHP, all facilities of interest were listed by facility type and region-stratifying by governorate-and then systematically selected. The selection was made separately for public and for NGO facilities. The number of facilities in the sample for each region was determined to ensure adequate regional representation of facilities as well as national representation of public and NGO facilities. The final sample contained 659 health facilities, among which 559 were MOHP facilities, with the remainder divided between facilities managed by various NGOs and private, nonprofit facilities.

During data collection, 15 facilities were found to be of different classifications from that indicated on the sampling frame. During data analysis, these facilities were reclassified to reflect their correct facility type. Data were weighted during analysis to account for the differentials caused by oversampling.

• Sample of Health Service Providers: The sample of health service providers was selected from providers who were present in the facility on the day of the survey and who provided services that were assessed by the ESPA 2004. In facilities with fewer than eight health service providers, all of the providers present on the day of the visit to the unit were interviewed. In facilities with more than eight providers, all providers whose work was observed were interviewed, and a random selection of the providers who were not observed when providing services were interviewed to compile a minimum of eight provider interviews. The selection was carried out to ensure that, if available, at least one provider from each assessed service was interviewed, even if no observation was conducted for that service.

• Sample for Observations and Exit Interviews: The sample for observations was opportunistic, meaning that clients were selected for observation as they arrived because there was no way to know how many eligible clients would attend the facility the day of the survey. Where numerous clients were eligible for observation, the rule was to observe a maximum of five clients for each provider of the service, with a maximum of 15 observations in any given facility for each service. In practice, fewer clients than were eligible were observed in some facilities. This occurred primarily where multiple services were provided to clients at the same time in different locations in a facility. Any family planning or ANC client who was also assessed for symptoms of RTI/STIs was observed both for elements related to STI services and for elements related to either family planning or ANC, whichever one was relevant. An attempt was made to interview the caretaker for all observed sick children before leaving the facility and to interview all family planning, ANC, and RTI/STI clients before leaving the facility.

In addition, observers were instructed to complete an observation checklist for five injections (either therapeutic or immunization) in all facilities where curative care for children was being provided. They were to attempt to observe therapeutic injections for children, but if clients receiving injections were not readily available, injections for vaccinations as well as injections for adults were accepted.

With regard to child health consultations, when there were several eligible children waiting for service, an effort was made to ensure that children with some illness (rather than injury or skin or eye infections) were selected for observation. When there were several eligible ANC or family planning clients waiting, observers were instructed to select clients for observation, attempting to achieve a ratio of "two new for every one follow-up case." The day's caseload and logistics of organizing observations did not always allow this objective to be met.

The total number of eligible clients who attended the facility on the day a service was observed was also collected to provide information on the proportion of all eligible clients who were observed. In total, among all eligible clients who received services the day of the survey, 30 percent of the sick children were observed, 70 percent of the family planning clients were observed, 80 percent of the ANC clients were observed, and 92 percent of the RTI/STI clients were observed.