DHS METHODOLOGICAL 

REPORTS 29

PROPOSAL OF A QUALITY OF 

CARE INDEX (QOCI)

AUGUST 2020

This publication was produced for review by the United States Agency for International Development. It was prepared by

Lindsay Mallick, Rukundo K. Benedict, Courtney Allen, and Bradley Janocha.

DHS Methodological Report No. 29

Proposal of a Quality of Care Index (QOCI)

Lindsay Mallick1,2

Rukundo K. Benedict1,3

Courtney Allen1,3

Bradley Janocha1,3

ICF

Rockville, Maryland, USA

August 2020

1 The DHS Program

2 Avenir Health

3

ICF

Corresponding author: Lindsay Mallick, International Health and Development, ICF, 530 Gaither Road, 

Suite 500, Rockville, MD 20850, USA; phone: +1 301-572-0211; fax: +1 301-407-6501; email: 

lmallick@avenirhealth.org
Acknowledgments: 

Editor: Kerry Aradhya

Document Production: Natalie Shattuck

This study was carried out with support provided by the United States Agency for International Development (USAID) 

through The DHS Program (#720-OAA-18C-00083). The views expressed are those of the authors and do not 

necessarily reflect the views of USAID or the United States Government.

The DHS Program assists countries worldwide in the collection and use of data to monitor and evaluate population, 

health, and nutrition programs. Additional information about The DHS Program can be obtained from ICF, 530 

Gaither Road, Suite 500, Rockville, MD 20850, USA; phone: +1 301-407-6500; fax: +1 301-407-6501; email: 

info@DHSprogram.com; internet: www.DHSprogram.com.

Recommended citation:

Mallick, Lindsay, Rukundo K. Benedict, Courtney Allen, and Bradley Janocha. 2020. Proposal of a Quality of Care 

Index (QOCI). DHS Methodological Report No. 29. Rockville, Maryland, USA: ICF.
iii

CONTENTS

TABLES........................................................................................................................................................ v

FIGURES .................................................................................................................................................... vii

PREFACE.................................................................................................................................................... ix

ACKNOWLEDGMENTS.............................................................................................................................. xi

ABSTRACT................................................................................................................................................ xiii

ACRONYMS AND ABBREVIATIONS ....................................................................................................... xv

1 INTRODUCTION.............................................................................................................................. 1

2 LITERATURE REVIEW AND INDICATOR SELECTION ............................................................... 5

2.1 Literature Review ................................................................................................................ 7

2.1.1 Family planning...................................................................................................... 7

2.1.2 Maternal and newborn health ................................................................................ 8

2.1.3 Child health .......................................................................................................... 10

2.1.4 Malaria ................................................................................................................. 12

2.1.5 Nutrition................................................................................................................ 13

2.1.6 Water, sanitation, and hygiene ............................................................................ 14

2.2 Indicators........................................................................................................................... 15

3 DATA AND METHODS ................................................................................................................. 19

3.1 Data................................................................................................................................... 19

3.2 Methods ............................................................................................................................ 21

4 RESULTS ...................................................................................................................................... 23

4.1 Bangladesh ....................................................................................................................... 23

4.2 Democratic Republic of the Congo ................................................................................... 26

4.3 Haiti ................................................................................................................................... 30

4.4 Malawi ............................................................................................................................... 33

4.5 Nepal................................................................................................................................. 36

4.6 Senegal ............................................................................................................................. 39

4.7 Tanzania ........................................................................................................................... 42

5 DISCUSSION................................................................................................................................. 47

5.1 Overview of Findings......................................................................................................... 47

5.2 Limitations of the Index and Broad Recommendations .................................................... 48

5.3 Limitations of the Indicators and Related Recommendations .......................................... 50

5.3.1 Family planning.................................................................................................... 51

5.3.2 Antenatal care...................................................................................................... 52

5.3.3 Delivery care ........................................................................................................ 52

5.3.4 Immunization........................................................................................................ 53

5.3.5 Child curative care ............................................................................................... 53

5.3.6 Water, sanitation, and hygiene ............................................................................ 55

5.4 Conclusion and Next Steps............................................................................................... 56

REFERENCES............................................................................................................................................ 57

APPENDIX.................................................................................................................................................. 69

v

TABLES

Table 1 Definitions of indicators and considerations ............................................................ 16

Table 2 Surveys and samples of facilities and clients .......................................................... 20

Table 3 Summary indicators of quality of care: subnational and national percentages and 

averages of facility availability of services and service provision among observed 

clients, Bangladesh SPA 2017 ................................................................................ 25

Table 4 Summary indicators of quality of care: subnational and national percentages and 

averages of facility availability of services and service provision among observed 

clients, Democratic Republic of the Congo SPA 2017-18 ....................................... 28

Table 5 Summary indicators of quality of care: subnational and national percentages and 

averages of facility availability of services and service provision among observed 

clients, Haiti SPA 2017-18 ....................................................................................... 32

Table 6 Summary indicators of quality of care: subnational and national percentages and 

averages of facility availability of services and service provision among observed 

clients, Malawi SPA 2013-14 ................................................................................... 35

Table 7 Summary indicators of quality of care: subnational and national percentages and 

averages of facility availability of services and service provision among observed 

clients, Nepal SPA 2015 .......................................................................................... 38

Table 8 Summary indicators of quality of care: subnational and national percentages and 

averages of facility availability of services and service provision among observed 

clients, Senegal SPA 2016 and 2017 ...................................................................... 41

Table 9 Summary indicators of quality of care: subnational and national percentages and 

averages of facility availability of services and service provision among observed 

clients, Tanzania SPA 2014-15 ............................................................................... 44

Table 10 Limitations and broad recommendations to improve the index and SPA surveys .. 48

Table 11 Summary of limitations and recommendations........................................................ 50

Appendix Table 1 Original set of indicators for consideration for inclusion in the quality of 

care index ................................................................................................................ 69

Appendix Table 2 Facility categories by country .................................................................................. 70

Appendix Table 3 Subnational and national weighted (and unweighted) samples of facilities and 

clients analyzed for each indicator, Bangladesh SPA 2017 .................................... 71

Appendix Table 4 Subnational and national weighted (and unweighted) samples of facilities and 

clients analyzed for each indicator, Democratic Republic of the Congo SPA 

2017-18.................................................................................................................... 72

Appendix Table 5 Subnational and national weighted (and unweighted) samples of facilities and 

clients analyzed for each indicator, Haiti SPA 2017-18........................................... 74

Appendix Table 6 Subnational and national weighted (and unweighted) samples of facilities and 

clients analyzed for each indicator, Malawi SPA 2013-14....................................... 75
vi

Appendix Table 7 Subnational and national weighted (and unweighted) samples of facilities and 

clients analyzed for each indicator, Nepal SPA 2015.............................................. 76

Appendix Table 8 Subnational and national weighted (and unweighted) samples of facilities and 

clients analyzed for each indicator, Senegal SPA 2016 and 2017.......................... 77

Appendix Table 9 Subnational and national weighted (and unweighted) samples of facilities and 

clients analyzed for each indicator, Tanzania SPA 2014-15 ................................... 78
vii

FIGURES

Figure 1 Health services along the continuum of care during the reproductive life cycle........ 5

Figure 2 Process of selecting indicators for the quality of care index...................................... 7

Figure 3 WHO 2016 framework for the quality of maternal and newborn health care........... 10

Figure 4 QOCI results in the divisions of Bangladesh ........................................................... 23

Figure 5 National average score, service scores, and highest- and lowest-scoring 

indicators, Bangladesh 2017 ................................................................................... 24

Figure 6 QOCI results in the provinces of the Democratic Republic of the Congo................ 26

Figure 7 National average score, service scores, and highest- and lowest-scoring 

indicators, Democratic Republic of the Congo 2017-18 .......................................... 27

Figure 8 QOCI results in the departments of Haiti................................................................. 30

Figure 9 National average score, service scores, and highest- and lowest-scoring 

indicators, Haiti 2017-18 .......................................................................................... 31

Figure 10 QOCI results in the regions of Malawi ..................................................................... 33

Figure 11 National average score, service scores, and highest- and lowest-scoring 

indicators, Malawi 2013-14 ...................................................................................... 34

Figure 12 QOCI results in the regions of Nepal ....................................................................... 36

Figure 13 National average score, service scores, and highest- and lowest-scoring 

indicators, Nepal 2015 ............................................................................................. 37

Figure 14 QOCI results in the regions of Senegal ................................................................... 39

Figure 15 National average score, service scores, and highest- and lowest-scoring 

indicators, Senegal 2016 and 2017 ......................................................................... 40

Figure 16 QOCI results in the regions of Tanzania.................................................................. 42

Figure 17 National average score, service scores, and highest- and lowest-scoring 

indicators, Tanzania 2014-15 .................................................................................. 43

ix

PREFACE 

The Demographic and Health Surveys (DHS) Program is one of the principal sources of international data 

on fertility, family planning, maternal and child health, nutrition, mortality, environmental health, 

HIV/AIDS, malaria, and provision of health services. 

One of the objectives of The DHS Program is to continually assess and improve the methodology and 

procedures used to carry out national-level surveys as well as to offer additional tools for analysis. 

Improvements in methods used will enhance the accuracy and depth of information collected by The DHS 

Program and relied on by policymakers and program managers in low- and middle-income countries.

While data quality is a main topic of the DHS Methodological Reports series, the reports also examine 

issues of sampling, questionnaire comparability, survey procedures, and methodological approaches. The 

topics explored in this series are selected by The DHS Program in consultation with the U.S. Agency for 

International Development.

It is hoped that the DHS Methodological Reports will be useful to researchers, policymakers, and survey 

specialists, particularly those engaged in work in low- and middle-income countries, and will be used to 

enhance the quality and analysis of survey data.

Sunita Kishor

Director, The DHS Program

xi

ACKNOWLEDGMENTS

We are grateful to the experts at the United States Agency for International Development who advised in 

the design of this research concept and the selection of meaningful indicators: Misun Choi, Robert Cohen, 

Troy Jacobs, Apoorva Jadhav, Ryan Mahoney, Erin Milner, Elizabeth Noonan, Pavani Ram, Vanessa 

Vassall, Kristen Wares, and William Weiss. To Ruilin Ren, our DHS sampling statistician, thank you for 

engaging with us during this process and sharing your advice on our sampling-related concerns. The authors 

of this report also wish to thank Wenjuan Wang for her guidance and leadership during the early phases of 

research for this report as well as her persistent mentorship on quality of care research. We are enormously 

grateful to Cameron Taylor for her support with malaria-related content, feedback related to quality of care, 

and review of the report. To Hamdy Moussa, we thank you for your review, encouragement, and 

recommendations for improving the report. We also offer our gratitude to Erica Nybro for designing and 

preparing both creative data visuals for this report and a summary brief. We thank Thomas Pullum and 

Sunita Kishor for their mentorship and support throughout the development of this report. And, finally, to 

Hannah Leslie, we cannot thank you enough for taking the time to thoughtfully reflect on the content of 

this report, which vastly improved its quality. 

xiii

ABSTRACT

As the use of health facilities along the continuum of care for women and children increases, focus must 

turn toward the provision of effective, high-quality care across services to end preventable maternal and 

child death. While health management information systems continue to develop, periodic health facility

surveys like the Service Provision Assessment (SPA) provide information to monitor progress and target 

interventions. However, these surveys are complex, and consensus around key indicators or summary 

measures is lacking. The authors of this report have identified a short list of indicators that measure 

readiness for and provision of highly effective interventions and propose a quality of care index (QOCI)

that spans reproductive, maternal, newborn, and child health and nutrition (RMNCHN) as well as water, 

sanitation, and hygiene (WASH).

To select the indicators, we conducted a preliminary literature review; an initial set of indicators was then 

refined following feedback from a group of subject-matter experts associated with the United States Agency 

for International Development. The agreed-upon indicators reflected international guidelines, had

demonstrated relationships with relevant health outcomes, were measurable with current SPA data, and 

informed readiness to provide services (e.g., availability of medications) as well as observed delivery of 

services (e.g., providing counseling or appropriately assessing conditions). The QOCI was composed of 17 

indicators across six health areas: family planning, antenatal care, delivery care, immunization, child 

curative care, and WASH. We used a weighted average approach to calculate the index. 

Quality could not be directly compared across countries given the differences in indicators and timing of 

surveys; thus, the findings are reported separately for each country. Within many countries, the QOCI 

showed geographic differences in total scores. Where comparable items were available across countries, 

we found that nutritional status was rarely assessed during child curative care visits. Conversely, availability 

of oral rehydration salts or zinc for diarrhea, WASH resources, immunizations, and blood pressure

measurements during antenatal care were common. 

This analysis revealed several limitations, both within the index and within the SPA questionnaires. These 

limitations are discussed in detail in this report, alongside actionable recommendations. In summary, the 

proposed indicators should undergo additional scrutiny to ensure that they hold the highest construct 

validity, and the SPA questionnaires should be revised accordingly. The SPA instruments should also align

with other tools to more widely monitor progress toward global goals for universal coverage of high-quality 

health care. 

KEY WORDS: quality of care, service readiness, health facility, service provision assessment surveys

xv

ACRONYMS AND ABBREVIATIONS

ACT artemisinin-based combination therapy

ANC antenatal care

ARI acute respiratory infection

BCG bacillus Calmette-Guérin 

BEmOC basic emergency obstetric care

CCI composite coverage index

CEmOC comprehensive emergency obstetric care

CH child health

DEL delivery

DHS Demographic and Health Survey(s)

DPT diphtheria-pertussis-tetanus 

DRC Democratic Republic of the Congo

ETAT emergency triage assessment and treatment

FP family planning

IM immunization

IMCI integrated management of childhood illness 

KMC kangaroo mother care

LiST Lives Saved Tool

ORS oral rehydration salts

QOCI quality of care index

RDT rapid diagnostic test

RMNCH reproductive, maternal, newborn, and child health

RMNCHN reproductive, maternal, newborn, and child health and nutrition

SARA Service Availability and Readiness Assessment

SDG Sustainable Development Goal

SPA Service Provision Assessment

UNICEF United Nations Children’s Fund

USAID United States Agency for International Development
xvi

WASH water, sanitation, and hygiene

WHO World Health Organization
1

1 INTRODUCTION 

In many low- and middle-income countries, primary health-care facilities provide essential preventive and 

lifesaving services for communities. In the era of the Sustainable Development Goals (SDGs), the role of 

primary health care in achieving universal health coverage and quality health services has become 

increasingly important (WHO 2017b). Under SDG 3 is target 3.8: Achieve universal health coverage, 

including financial risk protection, access to quality essential health-care services and access to safe, 

effective, quality and affordable essential medicines and vaccines for all (United Nations 2015). The Lancet 

Global Health Commission on High-Quality Health Systems in the SDG Era asserts that high quality of 

care is central to the tenet that health is a human right; it is also essential to the improvement of health 

systems (Kruk et al. 2018). With access to and use of health facilities increasing, focus must turn toward 

the provision of effective, high-quality care across services, with attention given to the continuum of 

services for women and children to end preventable maternal and child morbidity and mortality (WHO 

2018). It is no longer enough to measure the coverage of reproductive, maternal, newborn, and child health 

(RMNCH) and reproductive, maternal, newborn, and child health and nutrition (RMNCHN) interventions 

without considering whether the services provided by facilities are adequate (Leslie et al. 2017; Marsh et 

al. 2020).

Effective coverage—the product of crude coverage (i.e., the proportion of the population in need that uses

a service)—and measures of quality can be used to more comprehensively understand progress within the 

health system (Kruk et al. 2018; Ng et al. 2014). Although the concept of effective coverage has existed for 

decades, it has recently gained the spotlight among global health researchers and stakeholders who want to

better monitor progress toward SDG targets (Leslie and Gage 2020). The Effective Coverage Think Tank 

Group, hosted by the World Health Organization (WHO) and the United Nations Children’s Fund 

(UNICEF) in 2019, supported a standardized framework proposed by Amouzou and colleagues (2019) 

(Marsh et al. 2020). In this framework, effective coverage is represented along a cascade that moves from 

crude coverage through input-adjusted coverage, quality-adjusted coverage, and outcome-adjusted 

coverage (Amouzou et al. 2019). 

Although critiqued for being complex or their data being difficult to use, periodically conducted Service 

Provision Assessment (SPA) surveys, or similar national health facility surveys that include observation of 

services, are critical sources of information on quality of care. They can be used to glean information not 

only about quality of care within health facilities, nationally or subnationally, but also about qualityadjusted effective coverage. Provision of care and select services can be captured through health

management information systems at lower administrative levels, even at the facility level, and at more 

frequent intervals. However, these systems are still under development and are often limited by lack of 

representativeness, incomplete reporting, and not typically being publicly available (Mallick et al. 2020; 

MCSP 2018; WHO 2019a). Periodic health facility surveys with observation of services provide 

information about whether structural inputs are available, whether they are being used, whether providers 

are adhering to standards, and how clients perceive their visits (Kruk et al. 2018; Leslie and Gage 2020).

Through the measurement of quality of care, decision makers and stakeholders can identify weakness within 

the health system and address gaps through targeted improvement efforts (Kruk et al. 2018; WHO 2017b; 

WHO 2015b), although advancements in measurement of quality of care are needed. With an abundance of 
2

measures available, developing summary measures or quality indexes can be useful for more broadly 

assessing and monitoring progress, benchmarking within and across countries, and targeting areas for 

improvement (Kruk et al. 2018; WHO 2017b; Wilhelm et al. 2019)—for example, the Countdown to 2030 

tracks RMNCH intervention coverage for preventive and curative ailments using a composite coverage 

index (CCI) (Wehrmeister et al. 2016; WHO 2017b). The index is a weighted average of eight RMNCH 

indicators that lie along the continuum of maternal and child health, and the index uses data from 

population-based surveys. However, although the CCI is straightforward, easy to calculate, and helpful in 

tracking trends over time or across countries (Wehrmeister et al. 2016), it measures RMNCH coverage and 

not RMNCH care—a critical aspect of the health system. Currently, there is a need to identify the most 

critical indicators of quality of care that can further serve in benchmarking progress (Brizuela et al. 2019). 

Although an index comprising indicators across many health areas can provide an overall summary of 

quality at national and subnational levels, examining key indicators can drive monitoring of specific 

services. These key indicators should encompass not only the availability of life-saving equipment, 

medication, and technologies, but also the process under which care is provided.

Quality of care is a multifaceted concept usually measured with indicators that cover multiple dimensions 

of quality typically based on the seminal 1988 framework of Donabedian, including structure (i.e., the 

setting of care), process (i.e., how the care is delivered), and outcome (i.e., the impact of care on individuals) 

(Akachi and Kruk 2017; Donabedian 1988; Wilhelm et al. 2019). Measures of quality of care from facilitybased studies have included the availability of essential medicines, equipment, and skilled staff (structure);

interpersonal and technical aspects of the provider-client interaction (process); and client satisfaction with 

care and other health outcomes (outcome) as seen, for example, in Brizuela et al. (2019); Gage et al. (2018); 

Leslie et al. (2017); Mallick, Temsah, and Wang (2019); Mallick, Temsah, and Benedict (2018); Sheffel et 

al. (2019); Taylor et al. (2018); Tessema et al. (2016); Tumlinson et al. (2015); and Wilhelm et al. (2019).

As demonstrated in the above-mentioned studies, measurements of quality of care are currently siloed 

within health areas; further, there is no agreement on a minimum set of standardized indicators for quality 

of care (Akachi and Kruk 2017; Wilhelm et al. 2019). However, multilateral actors and researchers are 

working on refining and building consensus on key indicators to improve the measurement of quality of 

care for RMNCHN, including the Network for Improving Quality of Care and WHO (WHO 2019c). For 

example, the Network for Improving Quality of Care developed a list of 15 common indicators for 

monitoring maternal and newborn health for countries in the network that use information from facility 

registers, surveys, and client questionnaires (WHO 2019c). This work was part of a larger monitoring 

framework for improving quality of care that aligns with WHO standards on maternal, newborn, child, and 

adolescent care in facilities and includes several facility indicators (WHO 2016b, 2018, 2019c). Consensus 

is also being built around family planning indicators, pediatric indicators, and nutrition indicators (Jain, 

Townsend, and RamaRao 2018; WHO 2018).

This report aims to build off the work of the Countdown team and others by documenting the development 

of a composite quality of care index (QOCI) for RMNCHN services in facilities. The QOCI is intended to 

complement the CCI and also highlight the cross-cutting importance of water, sanitation, and hygiene 

(WASH). This paper presents an initial attempt to select a list of core quality of care indicators and 

summarize these key components across RMNCHN services available in The DHS Program’s SPAto create 

one singular measure. The indicators are calculated among respective facility or client populations. For 

example, indicators representing family planning service availability are calculated only among facilities 
3

providing family planning services; likewise, care provided during family planning visits are calculated 

using family planning clients as the base. The index is therefore intended to be aggregated at national or 

subnational levels rather than for individual facilities. The development of the indicators used to create the 

index was based on the current SPA questionnaires and sampling processes (DHS Phase VII). The indicators

are not intended to be comprehensive of all health services or to include all important factors within each 

service; they focus solely on structural and process components of quality and omit the component 

reflecting the client experience of care, given the limitations of collecting such data in exit interviews (e.g., 

courtesy bias and selection bias) (Bessinger and Bertrand 2001; Chavane et al. 2017; Hameed et al. 2017). 

This report does not provide external validation for the index or the indicators. Rather, both the index and 

indicators were chosen to serve as tracers for quality of care—a starting point for launching a conversation 

about what areas need to be more holistically explored to improve quality of care. Ideally, the indicators 

could be assessed alongside health outcome data from population surveys or health management 

information systems to better understand stopgaps within the health system. This report describes the steps 

used to develop the index, illustrates how it can be used to report at the national and subnational levels, and 

discusses the strengths and limitations of the indicators and index with a focus on how SPA surveys can be 

enhanced for future quality of care research. 

5

2 LITERATURE REVIEW AND INDICATOR SELECTION

We employed a multistage process to select the indicators. We first identified the service areas within formal 

health-care facilities that addressed RMNCHN and WASH. Figure 1 demonstrates how we conceptualized 

the continuum of health-care services. This figure shows that WASH is critical and cross-cutting across 

each service or health need. Nutrition services are also cross-cutting, embedded within various stages of 

the continuum of care.

Figure 1 Health services along the continuum of care during the reproductive life cycle

We then performed a literature review to identify the most impactful components of care for each health 

area according to recent research and international guidelines. That is, within each health service, we sought 

to identify the aspects of quality of care that are critical for alleviating the most pressing health issues—the 

elements of services that are key for preventing or treating the diseases or illnesses that contribute the most

to adverse health outcomes such as mortality. We described the literature and aspects of quality using the 

Donabedian framework of quality of care, which comprises three components—structure, process, and 

outcome. 

To guide the literature review, we sought to answer several questions:

 What are the key frameworks or global guidelines on quality of care within these health service 

areas? 

 How have these frameworks been applied or translated into indicators?

 How have these indicators been prioritized, or what evidence exists about how the services 

measured by the key indicators have affected health outcomes (e.g., mortality)? 

Reproductive 

health

•Family planning 

services

Maternal 

health

•Antenatal care and 

nutrition services

•Delivery services

Newborn 

health

•Prenatal 

preparedness

•Care at birth

•Breastfeeding 

support

Child 

health

•Vaccination

•Nutrition monitoring

•Treatment of major 

illnesses

Water, sanitation, and hygiene
6

The selection of the indicators followed the process depicted in Figure 2. Following and based upon the 

literature review, we selected an initial set of indicators within each service area that 1) were recommended 

by international guidelines; 2) were related to relevant health outcomes; 3) were available in SPA surveys; 

and 4) reflected structural readiness or capacity to provide services as well as important components of 

service delivery (i.e., quality of care). After an initial list of indicators was proposed (Appendix Table 1), 

topical subject matter experts affiliated with the United States Agency for International Development 

(USAID) provided clarification and additional guidance for final indicator selection. The final indicators 

within each service area were intended to balance the breadth of aspects of care related to major burdens of 

disease or health conditions with the pragmatism of a short index. Although the initial literature review 

identified evidence-based aspects of care, the final selection of indicators was based on existing 

frameworks, guidelines, and global or USAID priorities within quality of care; thus, the process was not 

wholly empirical. 
7

Figure 2 Process of selecting indicators for the quality of care index

Notes:

1 Donabedian framework (1988); Bruce framework 1990 (family planning); Newborn Services Rapid Health Facility 

Assessment (2012); Gabrysch et al. (2012) (obstetric and newborn signal functions); WHO Service Availability and Service 

Readiness (SARA) (2015); WHO and Partnership for Maternal, Newborn, and Child Health (2013) (quality of care); WHO 

standards for quality of maternal and newborn care in health facilities (2016); WHO standards for quality of care for

children and young adolescents in health facilities (2018); Integrated Management of Childhood Illness guidelines; WHO

pediatric emergency triage, assessment, and treatment guidelines (2016); WHO Global Malaria Programme’s T3: Test, 

Treat, and Track initiative (2012); WHO and UNICEF core questions and indicators for monitoring WASH in health facilities 

(2018). 

2 Potential indicators were identified from the literature review.

3 USAID topic experts, led by the DHS management team, reviewed proposed indicators via written feedback and 

telephone consultations in two separate rounds.

2.1 Literature Review

2.1.1 Family planning

The Bruce framework is a foundational framework for understanding the quality of family planning services 

(Bruce 1990). The domains from the Bruce framework fit within Donabedian’s quality of care framework 

and describe the structure of the care program (i.e., method choice, technical competence of providers, and 

constellation of services) and the process of service (i.e., exchange of information, interpersonal 

relationships, and mechanisms for follow-up) (Bruce 1990; Jain, Townsend, and RamaRao 2018). Among 

the proposed indicators, there remains a need for consensus on the indicators that best reflect quality of 

Review of major frameworks and core 

documents on quality of RMNCHN care in 

health facilities1

N=12

Potential indicators in SPA surveys

N=176

Proposed indicators 

N=24

Potential indicators2

N=586

Expert review of proposed indicators3

(2 rounds, 11 experts)

Final selection of indicators for the QOCI 

N=17

Literature review
8

care. Various attempts to understand quality of care have often included many indicators within summary 

index measures (Bellows et al. 2016; Do and Koenig 2007; Hong, Montana, and Mishra 2006; Jain, 

Townsend, and RamaRao 2018; Jain et al. 2019; Jayachandran, Chapotera, and Stones 2016; Mallick, 

Temsah, and Wang 2019; Mensch, Arends-Kuenning, and Jain 1996; RamaRao et al. 2003; Tessema et al. 

2016; Tumlinson et al. 2015).

The three structural indicators in the Bruce framework are the availability of an array of contraceptive 

methods, the technical competence of providers to administer the methods, and the availability of other 

services such as antenatal care (ANC) or sick-child care. Method availability lacks consensus in definition, 

though studies have defined it as the availability of at least one short-acting method, one long-acting 

method, and one barrier method (Mallick, Temsah, and Wang 2019; Tumlinson et al. 2015; Wang and 

Mallick 2019); the availability of the three most commonly used methods in the country (Mpunga et al. 

2017); or even the availability of a client’s preferred method (Slater et al. 2018). There is evidence that the 

number of methods available is positively associated with contraceptive use (Ross and Stover 2013; Ross 

et al. 2002; Wang and Mallick 2019; Wang et al. 2012). Jain, Townsend, and RamaRao (2018) suggest that 

method availability is also a product of the technical competence in offering the method and the availability 

of the required equipment. This suggests that method availability also crosses into the process domain of 

quality of care to incorporate whether clients are being offered and receiving help choosing appropriate 

methods. 

The information offered to a client—another element in the Bruce framework—can include a provider 

helping a woman choose a method, instructions on using a method, or information about the side effects of 

a method. Provider counseling on method preference and selection, side effects, and good treatment of 

clients has been shown to be positively associated with modern contraceptive use (Tumlinson et al. 2015).

Recently, Jain et al. (2019) validated an index reflecting the process component of quality of care, finding 

that high quality of care was associated with contraceptive continuation. In this 10-item index, the primary 

factor was identified as “effective use of method selected,” which comprised three items related to 

counseling about side effects and warning signs associated with the method. Previous research has also

shown that women with concerns about side effects are more likely than those without concerns to 

discontinue method use and have unmet need (Bradley, Schwandt, and Khan 2009). This indicator is 

particularly useful because it is available from facility-based surveys that observe family planning visits or 

interview clients, as well as from household surveys in which women self-report receipt of counseling (Choi 

2018).

Measures of the outcome dimension of quality of care for family planning (e.g., contraceptive uptake or 

contraceptive continuation) are largely limited or unavailable in health facility surveys. Although client 

satisfaction could be an outcome measure, studies have found that family planning clients often have high 

satisfaction regardless of services received (Assaf, Wang, and Mallick 2015; Galle et al. 2018).

2.1.2 Maternal and newborn health

With the increased recognition of the importance of quality of care in preventing maternal and newborn 

deaths (Black et al. 2016), considerable effort has been made to develop quality of care frameworks and 

indicators that assess the quality of health services for mothers and newborns at health facilities. For 

example, the Newborn Indicators Technical Group developed indicators that measure the service 

availability, equipment, supplies, staff training, and supervision that are essential for newborn care 
9

(Newborn Indicators Technical Working Group 2012). Gabrysch and colleagues (2012) proposed obstetric 

and newborn signal functions that cover general health requirements, routine care for mothers and 

newborns, basic emergency care for mothers and babies with complications, and comprehensive emergency 

care functions. The WHO Service Availability and Readiness Assessment (SARA) Reference Manual 

includes indicators measuring readiness for a wide range of services including obstetric and newborn care 

provided at health facilities (WHO 2015b). In 2013, the WHO and Partnership for Maternal, Newborn, and 

Child Health went through a Delphi process that included extensive literature review, expert consultations, 

and achievement of consensus; the partnership identified 19 core indicators for measuring quality of care 

for mothers, newborns, and children at health facilities (WHO 2014a). Other criteria such as measurability, 

reliability, validity, and usefulness were also considered in the selection of indicators (WHO 2014a). 

The maternal indicators covered antenatal, intrapartum, and postpartum care, and most measured the 

process aspect of quality of care (WHO 2014a). For example, given the importance of the diagnosis and 

early management of hypertensive disorders in pregnancy, measuring blood pressure for women during 

ANC visits was identified as one core quality of care indicator. Other indicators such as magnesium sulfate 

treatment for women with severe preeclampsia or eclampsia and women’s receipt of oxytocin were also 

included. For newborn care, the availability of functional bags and masks in health facilities to prevent birth 

asphyxia and the availability of kangaroo mother care (KMC) were among the indicators included. 

In more recent efforts to improve quality of care, WHO defined standards for quality of maternal and 

newborn care in health facilities and developed a quality of care framework that contains eight domains of 

quality of care (Figure 3) (WHO 2016b). Standards of care were developed for each of the domains, with 

Standard 1 being that all women and newborns receive routine, evidence-based care during labor, during 

delivery, and in the immediate postpartum period. Within this standard, quality statements and measures 

were created to assess the structure, process, and outcome components of quality of care for labor, delivery, 

and postnatal care. The structural measures focus on the availability of basic essential equipment, supplies, 

up-to-date written protocols, staff training, and supervision for routine care for mothers and newborns to

detect and manage complications such as preeclampsia or eclampsia, postpartum hemorrhage, prolonged 

or obstructed labor, birth asphyxia, puerperal sepsis, and other infections. The process indicators focus on 

receipt of routine care or appropriate management of complications. The outcome indicators focus on 

institutional and population mortality estimates of pre-discharge maternal and neonatal death, prenatal 

mortality, early neonatal death, stillbirth, and the proportion of women with complications that are properly 

treated. Most recently, the Quality, Equity, Dignity Network has pared down this list of measures, 

identifying 15 common indicators for monitoring within and across countries (WHO 2019c).
10

Figure 3 WHO 2016 framework for the quality of maternal and newborn health care

Estimates of the effectiveness of interventions on maternal mortality and neonatal mortality can help 

prioritize indicators that measure quality of care for mothers and newborns. The Lives Saved Tool (LiST)

is a computer-based model that estimates the impact of various interventions on maternal and child 

mortality; while it was being updated, the effectiveness of various interventions in preventing maternal 

mortality was estimated (Pollard, Mathai, and Walker 2013). Comprehensive emergency obstetric care 

(CEmOC) was highly effective in preventing five major causes of maternal death (i.e., 

preeclampsia/eclampsia, puerperal sepsis, antepartum hemorrhage, obstructed labor, and postpartum 

hemorrhage); basic emergency obstetric care (BEmOC) was also highly effective at preventing 

preeclampsia/eclampsia, pregnancy-related sepsis, and postpartum hemorrhage (Pollard, Mathai, and 

Walker 2013). An analysis using LiST ranked the importance of interventions for mothers, newborns, and 

children based on the estimated number of deaths averted (stillbirth, neonatal, maternal) and attributed the 

most lives saved of any intervention to labor and delivery management (Marchant et al. 2016).

Although observation (as opposed to retrospective reports) is the gold standard for capturing the quality of 

delivery care, observation of delivery for the purpose of collecting data is hindered by the time needed and 

lengthy instruments that could result in measurement error (Tripathi et al. 2015). Some indicators related 

to the structural aspect of quality of care could be obtained from health facility surveys (Brizuela et al. 

2019). However, process indicators are more complex and difficult to measure, and most health facility 

surveys do not observe delivery.

2.1.3 Child health

Building on the WHO 2016 standards for quality of maternal and newborn care in health facilities, in 2018 

the WHO followed a similar process to develop a set of standards for pediatric quality of care (WHO 2018). 

These standards center around the eight domains of quality of care that were revised from the maternal and 

newborn quality of care framework specifically for children. For each standard, indicators of quality of care 

were identified to measure the structure, process, and outcome dimensions. 
11

Although all standards are important components of quality of care that contribute to child health, Standard 

1 is particularly critical for reducing child morbidity and mortality. It requires that every child receive 

evidence-based care and management of illness according to WHO guidelines. Standard 1 structural

indicators focus on the availability of basic essential equipment, supplies, up-to-date written protocols, staff 

training, and supervision for routine children’s health services such as vaccinations, for emergency care, 

for infant and young child feeding, and for management of conditions such as bacterial infections, 

respiratory infections, diarrhea, fever, acute malnutrition, chronic and infectious disease, and maltreatment 

(WHO 2018). The process indicators focus on children’s receipt of routine care or appropriate management 

of their conditions. The outcome indicators cover a range of outcomes including estimates of facility-related 

mortality and case fatality due to common childhood illnesses as well as treatment rates (WHO 2018).

Researchers have developed summary indices of quality of care for sick children that often reflect and 

demonstrate the importance of facility readiness (i.e., structure) and clinical quality of care (i.e., process) 

in improving health outcomes (Leslie, Sun, and Kruk 2017; Leslie et al. 2017; Liu et al. 2019). The 

readiness to treat children with two simple interventions—antibiotics for pneumonia and oral rehydration 

salts (ORS) for diarrhea—is an important input for the quality of care of high-impact interventions. If

universal coverage for providing these two interventions is achieved, 670,000 children’s lives could be 

saved by 2030 (Marchant et al. 2016). Treatment of diarrhea with zinc supplementation can further alleviate 

diarrheal disease burden by shortening the duration of diarrheal episodes (Lazzerini and Wanzira 2016).

Another high-impact intervention is basic vaccinations (Marchant et al. 2016), which can include

diphtheria-pertussis-tetanus (DPT), oral polio, measles, and bacillus Calmette-Guérin (BCG) to prevent 

tuberculosis; these are strongly associated with falling rates of mortality in children (McGovern and 

Canning 2015). These vaccines were the first included in the Expanded Programme on Immunization, 

which was launched in the 1970s. In addition to providing critical life-saving interventions, facility 

readiness can motivate individuals to seek care. In a study in Malawi, higher quality of care (reflecting both 

the readiness of the facility and the clinical process) was associated with higher utilization of sick-child 

health care (Liu et al. 2019). Caretakers may bypass facilities, traveling longer distances to attend facilities 

with more structural readiness (Kahabuka et al. 2011). Similarly, for vaccination, facility readiness was 

strongly associated with uptake of basic vaccinations in some areas (Gage et al. 2018). 

Another important dimension of the clinical process relies on appropriate diagnosis and treatment—aspects 

of the process component of quality of care. Adherence to integrated management of childhood illness 

(IMCI) guidelines should result in children being correctly diagnosed and treated for illness (WHO 2014b). 

The IMCI diagnostic guidelines ensure that providers correctly check a child for important symptoms that 

signify a diagnosis of diarrhea, pneumonia, or malaria (Krüger, Heinzel-Gutenbrunner, and Ali 2017). 

Although children are commonly prescribed antibiotics unnecessarily (Fink et al. 2020), missed diagnoses 

of pneumonia are also problematic (Uwemedimo et al. 2018). Indeed, research identified variable or low

adherence to IMCI diagnostic guidelines; however, providers with recent training performed better (Krüger, 

Heinzel-Gutenbrunner, and Ali 2017; Kruk et al. 2018). Further, the IMCI guidelines ensure that children 

receive the appropriate treatment, such as specific antibiotics for community-acquired bacterial pneumonia 

(Kogan et al. 2003). Although several antibiotics can be used to treat community-acquired bacterial 

pneumonia in children, the recommended first-line treatment is amoxicillin, as common pneumoniacausing bacteria are developing resistance to antibiotics such as co-trimoxazole (Fink et al. 2020; Ginsburg 

and Klugman 2017; Low, Pichichero, and Schaad 2004). 
12

Although IMCI applies to all children, the pediatric emergency triage assessment and treatment (ETAT) 

guidelines were written to ensure that very sick children are correctly identified and initiate treatment as 

soon as they arrive at the health facility (WHO 2016a). Given that most deaths occur within 24 hours of 

admission, it is critical to identify children in need of life-saving treatment (WHO 2016a). In a study in 

which adherence to ETAT was low, between 7% and 18% of health workers were unable to identify several 

emergent conditions such as convulsion (13%), central cyanosis (18%), and open fractures (18%); between 

6% and 45% of health workers failed to identify conditions requiring urgent treatment, including severe 

pallor (19%), severe visible wasting (41%), and edema in both feet (45%) (Gargamo, Fantahun, and Abiso 

2019). Several studies have demonstrated the benefits of ETAT, such as improvements in the performance 

of health workers after training (Hategekimana et al. 2016) and reductions in child mortality (Molyneux, 

Ahmad, and Robertson 2006; Ralston et al. 2013; Robison et al. 2012).

Aside from appropriate diagnosis and treatment, another important aspect of the process component of 

quality of care is counseling for caregivers during child health visits. During clinical interactions, parents 

should be counseled on diagnoses, danger signs of illness, feeding and drinking instructions for their 

children, and when to return for follow-up. These four items reflect provider communication with clients. 

Previous research found that poor communication is associated with lower levels of client satisfaction and 

intent to return for care (Larson, Leslie, and Kruk 2017).

Facility readiness and adherence to treatment guidelines cover important elements of quality of care, 

providing useful measures for assessing the quality of child health services and improving health outcomes.

Although process components can be found in periodic health facility surveys, information on outcome 

indicators (e.g., case fatality) is less readily available in health facilities. 

2.1.4 Malaria

Assessing the quality of malaria services at health facilities has been largely guided by the IMCI guidelines 

(WHO 2018) and the WHO Global Malaria Programme’s T3: Test, Treat, and Track initiative (WHO 2012). 

Both emphasize that every suspected malaria case in malaria-endemic regions should be tested by 

microscopy or rapid diagnosis test (RDT) and that every confirmed malaria case should be treated with 

antimalarial medicine. Given these guidelines, assessments of the quality of malaria services at health 

facilities have focused on structural indicators such as a facility’s readiness to provide malaria tests and 

treatment and process indicators such as provider adherence to guidelines when providing these services

(Davlantes et al. 2019; Millar et al. 2014; Steinhardt et al. 2015; Taylor, Ahmed, and Wang 2019; Taylor et 

al. 2018; Zurovac et al. 2014).

Malaria service readiness is usually measured with multiple indicators on the availability of supplies, 

equipment, and human resources that are essential for providing malaria diagnosis and treatment services. 

These indicators are assessed individually or are combined into composite indices for overall facility 

performance assessment and comparison across countries or over time (Ssempiira et al. 2018; Taylor et al. 

2018). In a study based on SPA data in Tanzania, Malawi, and Senegal, a facility was considered malariaservice ready if it had diagnostic capacity for malaria and had drugs available for artemisinin-based 

combination therapy (ACT) (Taylor et al. 2018). Malaria diagnostic capacity requires a facility to have the 

capacity to perform a malaria test with microscopy (i.e., trained personnel and microscopy supplies) or an

RDT (i.e., trained personnel, RDT supplies, and protocol) (WHO 2015a). ACT is the first-line antimalarial 

treatment recommended by the WHO; assessment of its availability needs to be country-specific, as 
13

countries often have different antimalarial drugs available at health facilities. Other structural indicators,

such as the availability of national guidelines and relevant training for providers, were also included in 

assessments of the quality of malaria services (Candrinho et al. 2019). Malaria service readiness is poor 

even in malaria-endemic countries (Candrinho et al. 2019; Macarayan, Papanicolas, and Jha 2020; Taylor, 

Ahmed, and Wang 2019); for example, only 18% of facilities in Tanzania and 25% in Malawi are considered 

ready to provide malaria services (Taylor et al. 2018). Although countries perform differently in individual 

components of service readiness, some components such as diagnostic capacity and personnel training are 

concerning across countries. Availability of ACT, however, is less of a problem (Taylor et al. 2018).

Although it is important that facilities are ready to provide malaria diagnosis and treatment services, the 

process component (i.e., the provider’s adherence to guidelines for managing suspected malaria cases) is 

even more critical. Studies have measured the process component of quality of care according to the 

national malaria control program or WHO guidelines (Millar et al. 2014; Rowe et al. 2009). In the study by 

Taylor and colleagues (2018), quality of case management was assessed by examining 1) if the provider 

asked about fever; 2) if a child was felt for a temperature, had his or her temperature taken with a 

thermometer, or was checked for pallor by looking at his or her palms; and 3) if the provider instructed the 

child to see another provider or laboratory for a finger or heel stick for blood testing. The authors found 

that a low proportion of children (34% in Malawi and 25% in Tanzania) received all three services. When 

data are available, studies can assess the quality of case management of suspected malaria. One study in 

Mozambique examined whether suspected malaria cases were tested with microscopy or RDT and were 

treated appropriately (given ACT only following a positive test); the study found that failure to test was the 

largest gap, and only about half or fewer of all cases were appropriately managed (Candrinho et al. 2019).

Both malaria service readiness and quality of case management are important for universal access to malaria 

diagnosis and treatment. Measuring the quality of malaria services should take both into consideration. 

2.1.5 Nutrition

Facility-based nutrition interventions primarily target pregnant and lactating women, newborns, and young 

children to prevent maternal and child undernutrition and their consequences (Black et al. 2013; UNICEF 

2015). Although there is growing literature on quality of care, the literature is sparse with respect to the 

quality of delivery of nutrition interventions. Only a handful of studies have described structural, process, 

or outcome indicators for essential nutrition interventions such as iron supplementation, growth monitoring, 

and breastfeeding counseling (Kanyangarara, Munos, and Walker 2017; Mallick, Temsah, and Benedict 

2018; Munos et al. 2017; Nguhiu, Barasa, and Chuma 2017; Winter et al. 2017). However, more recently, 

WHO guidance on standards to improve the quality of care for mothers, newborns, children, and 

adolescents has included several nutrition interventions (WHO 2016b, 2018). 

Structural indicators from the WHO quality of care standards (WHO 2016b, 2018) focus on infant feeding, 

treatment of acute malnutrition and anemia in children, and information and communication materials for 

women and their families. Indicators include the availability of basic equipment, supplies, job aids,

treatment protocols, staff training, and outpatient referrals. Researchers have incorporated structural 

indicators such as the availability of weighing scales and micronutrient supplements into their reporting on 

intervention coverage (Munos et al. 2017; Nguhiu, Barasa, and Chuma 2017). Among studies describing

facility readiness for maternal, newborn, and child nutrition services, indicators have included the 

availability of micronutrient supplements, functioning adult and child/infant weighing scales, stadiometers 
14

or height rods, and tape measures as well as provider training related to infant and young child feeding and 

assessing the nutritional status of pregnant women (Winter et al. 2017, Mallick et al. 2018). Often,

medications and equipment are more available than the human resource (training-related) indicators 

(Kanyangarara, Munos, and Walker 2017; Mallick, Temsah, and Benedict 2018; Winter et al. 2017).

Availability of medications is fundamental for health outcomes; for example, research in Haiti and Malawi

found that iron availability was associated with increased odds of adherence to iron consumption during 

pregnancy in both countries (Wang, Benedict, and Mallick 2019). 

The process indicators focus on adherence to feeding and growth monitoring guidelines and appropriate 

treatment and management of conditions, although these indicators are less represented in research related 

to nutrition quality of care. Nguhiu, Barasa, and Chuma (2017), in their study on effective coverage of 

maternal and child health services in Kenya, included only one process indicator from ANC—client recall 

of prescription of iron supplements. However, Mallick, Temsah, and Benedict (2018) and Joseph et al. 

(2020) identified several process indicators. For ANC, these included observation or client reports of iron 

supplementation, prescription, and counseling and physical examination of pregnant women including 

anemia testing, advice on nutrition during pregnancy, and breastfeeding counseling (Joseph et al. 2020; 

Mallick, Temsah, and Benedict 2018). Process indicators for child curative care included physical 

examination of child, growth monitoring, receipt of vitamin A supplementation, and infant feeding practices 

during illness (Mallick, Temsah, and Benedict 2018). Among the process indicators, the prescription 

component tended to be conducted more often than counseling-related components of care (Mallick, 

Temsah, and Benedict 2018). Process indicators such as counseling are important for maternal and child 

health outcomes; for example, a study of facility breastfeeding counseling during ANC showed that high 

levels of counseling were associated with early breastfeeding in urban Malawi (Mallick, Benedict, and 

Wang 2020). In facilities, breastfeeding counseling is recommended to support optimal breastfeeding 

practices that contribute to child growth, development, and survival (WHO 2017a). 

Outcome indicators are few and focus on estimates of institutional mortality such as case fatality rates from 

complicated severe malnutrition, receipt of counseling services, and satisfaction with care (WHO 2016b, 

2018). Very few nutrition outcome indicators on quality of care were identified in the literature—only those 

from the WHO standards described previously. 

Similar to child health, many elements of quality of care for delivery of nutrition interventions (particularly 

structural indicators) are available in health facility surveys. Process indicators are also available in health 

facility surveys but are limited to a few maternal health and child curative care services. Outcome indicators 

are rarely captured in health facility surveys. 

2.1.6 Water, sanitation, and hygiene

The importance of WASH for improving the quality of care in facilities is increasingly recognized (WHO 

and UNICEF 2018). In 2016, a WHO/UNICEF expert group finalized a set of five core indicators that cover 

basic WASH, waste management, and environmental cleaning services for health facilities (WHO and 

UNICEF 2018). Several of these indicators are included in the WHO standards for quality of care for 

mothers, newborns, children, and adolescents (WHO 2016b, 2018). Specifically, Standard 8 requires health 

facilities to have an appropriate physical environment with adequate water, sanitation, and energy supplies

and to have medicines, supplies, and equipment for routine maternal and newborn care, management of 
15

related complications (WHO 2016b), and routine care and management of common childhood illnesses

(WHO 2018). 

The structural indicators focus on the availability of basic essential equipment, WASH facilities, supplies, 

up-to-date written protocols, staff training, and sufficient funding for maternal, newborn, and child health 

care. They include functioning safe water sources, drinking water stations, hand hygiene stations, nappychanging stations, sanitation facilities, laundry facilities, and waste bins (WHO 2016b, 2018). The process 

indicators include the number of days in a quarter without water from an improved water source and without

soap/disinfectant, the number of days in a year with unsafe waste disposal or no waste treatment, and the 

proportion of providers and staff trained in WASH and infection prevention (WHO 2016b, 2018). The 

outcome indicators include patient, provider, and staff satisfaction and observations of provider 

handwashing or alcohol rubs before examination (WHO 2016b, 2018). 

Among studies examining WASH in facilities, structural indicators are most common (Maina et al. 2019; 

WHO and UNICEF 2019). A global study reported that more than 20% of health-care facilities had no basic 

water services, 10% had no basic sanitation services, and 15% did not have handwashing facilities at the 

point of care (WHO and UNICEF 2019). Another study evaluating WASH readiness against antimicrobial 

resistance in hospitals in Kenya found that readiness was lowest for hygiene at 57%, followed by sanitation 

(61%), and water (65%); the authors noted variation within the facilities based on location, which reflected 

differences in infrastructure (Maina 2019).

Handwashing with soap is a high-impact intervention that can reduce infection and could save more than

235,000 children’s lives by 2030 (Marchant et al. 2016). However, even when facilities and supplies are 

available, poor adherence to infection-control practices such as handwashing are common (Bedoya et al. 

2017; Seward et al. 2015); provider behaviors related to WASH adherence can also impact client satisfaction

(Bouzid, Cumming, and Hunter 2018). A review of WASH in facilities in low- and middle-income countries

found that poor WASH services were associated with low client satisfaction and impacted care-seeking 

behavior, although it did not fully deter it (Bouzid, Cumming, and Hunter 2018). 

Although health facility surveys provide some information on structural indicators, they rarely include 

process or outcome measures. WASH readiness and compliance with WASH protocols are important for 

reducing maternal, newborn, and child mortality. Thus, it is important to capture these measures as part of 

quality of care in health facilities. 

2.2 Indicators

Table 1 presents the agreed-upon indicators following the selection process described above. The table 

contains health areas, lists the short name of each indicator, and defines the numerator and denominator of 

each indicator. Additional considerations are presented in the right-hand column to clarify items that were 

used to calculate indicators, limitations of indicators, or specific instruments used (e.g., if an indicator 

represents data from the observation protocol or exit interview). This column also provides additional 

justification for selection of indicators, especially related to proxy indicators or indicators that are limited 

by the current SPA questionnaire design.
16

Table 1 Definitions of indicators and considerations

Service, indicator, and 

domain structure (S) or 

process (P) Numerator (N) and denominator (D) Considerations

Family planning (FP)

FP1-S: Method choice N: Number of facilities with at least one short-acting, one long-acting, 

and one barrier or fertility awareness method

D: Number of facilities that provide FP services

Specific methods vary by country. Short-acting methods include 

emergency contraceptive pills, monthly pills, and injectables. Longacting methods include implants, intrauterine devices, and male and 

female sterilization. Barrier and fertility awareness methods include 

male and female condoms, spermicides, diaphragms, and cycle 

beads. Commodities must be provided and available at the facility at 

the time of the survey, except for sterilization, which is based on a 

facility’s report of provision of the procedure alone.

FP2-P: Counseling on 

side effects

N: Number of clients who were counseled about side effects and health 

concerns about the method chosen or provided 

D: Number of clients who were given or prescribed a FP method

This could be calculated among new users, but the sample size may be 

too small.

Antenatal care (ANC)

ANC1-P: Blood pressure 

measurement

N: Number of ANC clients who were measured for blood pressure

D: Number of ANC clients

This is calculated according to observation of client visits.

ANC2-P: Counseling on 

iron

N: Number of ANC first-visit clients who were observed and reported 

receiving counseling on use or side effects of iron supplements

D: Number of ANC first-visit clients

This uses concordant responses between observation and the exit 

interview. However, iron counseling may occur during group 

counseling sessions.

ANC3-P: Breastfeeding 

counseling

N: Number of ANC clients who reported receiving breastfeeding 

counseling during ANC at this visit or prior visit

D: Number of ANC clients

This is based on the exit interview to capture counseling that occurs 

outside of the individual client visit (i.e., in group counseling sessions). 

It includes client reports of any breastfeeding-related counseling at the 

current or any prior visit during that pregnancy. Self-report in exit 

interviews can be biased toward overreporting of counseling. 

Delivery care (DEL)

DEL1-S: Basic 

emergency obstetric 

care (BEmOC)

N: Number of facilities that reported performing all of the BEmOC signal 

functions at least once during the last three months 

D: Number of facilities providing normal delivery services

BEmOC signal functions include parenteral administration of antibiotics, 

parenteral administration of uterotonic drugs/oxytocin, parenteral 

administration of anticonvulsants for hypertensive disorders of 

pregnancy, manual removal of placenta, assisted vaginal delivery, and 

removal of retained products.

DEL2-S: Essential drugs N: Number of facilities with a uterotonic and magnesium sulfate in stock

D: Number of facilities providing normal delivery services

DEL3-S: Newborn 

resuscitation

N: Number of facilities with a functional bag and masks

D: Number of facilities providing labor and delivery services

Two neonatal sizes are preferred although SPA questionnaires do not 

specify size. 

Immunization (IM)

IM1-S: Availability of 

viable vaccines and 

syringes

N: Number of facilities that have all age-appropriate primary vaccines 

available (per country schedule) and coupled with appropriate 

syringes and appropriate refrigeration (2-8 degrees)

D: Number of facilities that provide vaccination services, including 

outreach

Basic vaccination includes pentavalent (or DPT-containing vaccine), oral 

polio, measles, and BCG. Country-specific adaptations are possible. 

Child curative care (CH)

CH1-S: Antibiotics for 

pneumonia

N: Number of facilities that have first-line antibiotics

D: Number of facilities that provide child curative care services

Antibiotics include amoxicillin suspension or dispersible pediatric-dosed 

tablets.

CH2-S: Zinc/oral 

rehydration salts (ORS)

for diarrhea

N: Number of facilities that have ORS or zinc

D: Number of facilities that provide child curative care services

Although ORS and zinc are complementary in treating diarrhea, the 

indicator is coded with an “or” for a baseline assessment. Future 

iterations could reconsider this. 

Continues...
17

Table 1—Continued

Service, indicator, and 

domain structure (S) or 

process (P) Numerator (N) and denominator (D) Considerations

Child curative care (CH)

CH3-S: Malaria 

diagnostic and 

treatment capacity

N: Number of facilities that have diagnostic capacity (microscopy 

diagnostic capacity or malaria rapid diagnostic test capacity) and 

have ACT or first-line antimalarial available

D: Number of facilities that provide child curative care services

This indicator does not align with the global definition of malaria 

diagnostic and treatment capacity. That is, it does not capture having a 

trained provider. This is discussed in detail in the discussion section. 

CH4-P: Assessment for 

acute respiratory 

infection (ARI) 

N: Number of children whose breaths were counted 

D: Number of children whose caretaker reported and provider discussed 

symptoms of ARI

The denominator includes visits in which both the provider asked about 

signs of illness and the caretaker reported respective signs in order to 

capture the appropriate denominator of children presenting with 

symptoms. CH5-P: Assessment for 

diarrhea 

N: Number of children who were checked for signs of dehydration 

D: Number of children whose caretaker reported and provider discussed 

symptoms of diarrhea

CH6-P: Anemia 

assessment 

N: Number of children who were assessed for anemia

D: Number of sick-child visits

Assessment includes checking palms and conjunctiva.

CH7-P: Nutritional status 

assessment 

N: Number of children whose weight was taken, weight was plotted on a 

growth chart, and growth was discussed.

D: Number of sick-child visits

This does not include measurement of mid-upper arm circumference 

(only weight for height). However, height measurements are not 

recorded in the SPA protocol. 

Water, sanitation, and hygiene (WASH)

WASH1-S: Basic services 

for WASH

N: Number of facilities with improved water on premises, handwashing 

in general service area, and improved latrine for client use in 

outpatient area

D: All facilities

Improved water is piped into the facility or piped onto facility grounds; 

bottled water is available; or water is available from a public tap or 

standpipe, a tube well or borehole, a protected dug well, a protected 

spring, rainwater, a cart with a small tank or drum, or a tanker truck; 

and the outlet from this source is within 500 meters of the facility. An 

improved latrine is a functioning flush or pour-flush toilet, a ventilated 

improved pit latrine, or a composting toilet. 

19

3 DATA AND METHODS

3.1 Data 

This analysis used data from seven nationally representative SPA surveys conducted since 2013. SPA 

surveys are typically conducted among a nationally representative sample or through a census of formal 

sector health facilities in a country. These facilities include public, private, and mixed private-public 

facilities but exclude health service provision from informal outlets (e.g., pharmacies and mobile clinics). 

Appendix Table 2 lists the facilities that are sampled in each survey. 

The SPA instruments are designed to collect information about the facilities’ capacity to provide services. 

The interviewers assess basic infrastructure and availability of equipment, medicines, guidelines, and 

human resources at the facility. Health providers are interviewed about their routine duties as well as 

qualifications and training. SPA surveys are unique among health facility surveys, especially nationally 

representative health facility surveys, in that they include observation of health-care visits for select 

services: family planning, ANC, and child curative care. Interviewers observe up to 15 consultations per 

service per facility. After client observation, the client (or caretaker) has the opportunity to participate in an 

exit interview, during which information is solicited from the client about his or her perceptions of the visit.

Table 2 presents each survey’s country, year, number of facilities analyzed, and country-specific 

considerations. Several criteria guided the selection of countries for this analysis. We included countries 

that conducted a SPA survey following the most recent revision and standardization of the surveys (i.e., the 

most recent survey conducted in any country since 2013). Although a recent SPA survey was conducted in 

Afghanistan, this survey was not conducted among a nationally representative sample of all facilities; thus,

it was excluded from our study. 
20

Table 2 Surveys and samples of facilities and clients

Number of facilities

Number of family 

planning clients Number of ANC clients Number of child clients

Country and year 

of survey(s)

Subnational 

unit (N) N

Subnational 

median N

Subnational 

median N

Subnational 

median N

Subnational 

median Country-

Bangladesh

2017

Divisions

(8)

1,524 190 na na na na na na The survey did not include 

thus, the score calculatio

countries. More informati

section.

Democratic 

Republic of the 

Congo (DRC)

2017-18

Provinces

(26)

1,380 42 273 na 4,512 113 2,660 99 Very few family planning cl

indicator based on this po

index in this country.

Haiti

2017-18

Departments

(11)

1,007 78 1,107 76 1,526 115 2,166 128

Malawi

2013-14

Regions

(3)

977 362 1,482 597 2,068 884 3,329 1,161

Nepal

2015

Regions

(5)

940 202 754 104 1,509 232 2,186 313 Stand-alone HIV testing an

excluded.

Senegal

2016 and 2017

Regions

(14)

1,249 89 639 38 849 44 1,064 61 Analysis combined survey 

continuous survey model 

clients from all three serv

planning, and child curati

Client-based indicators a

based on 2016 survey da

and child curative care se

2017 data. Facility-based 

both 2016 and 2017 surv

from analysis of client-ba

data were not collected fr

Tanzania

2014-2015

Regions

(30)

1,188 39 1,689 50 4,007 120 4,961 144
21

3.2 Methods

We created the QOCI using two types of indicators. The first type is a structural indicator, which is facilitybased (i.e., calculated using facilities as the unit of the analysis) and reflects the structural component of 

Donabedian’s quality of care framework. This represents the availability and readiness to provide services. 

The second type of indicator is client-based, using clients as the unit of analysis, and reflects Donabedian’s 

process component (i.e., service delivery). Each type of indicator is calculated as the percentage of facilities 

or clients that meet the criteria for the indicator among the facilities providing the service or clients 

receiving the service, with a possible range of 0 to 100. These percentages are calculated at national and 

subnational (e.g., regional, provincial) levels. Each percentage is calculated using appropriate facility or 

client weights. 

The index was created using an equal-weight (or weighted additive) approach as applied in prior RMNCH 

and quality of care indices (Jain et al. 2019; Mallick, Temsah, and Wang 2019; Shwartz et al. 2013; Wang 

et al. 2019; Wehrmeister et al. 2016; WHO 2015b). Each service area can have both types of indicators (i.e., 

facility- and client-based). In this approach, the indicators within each service are averaged, assigning an 

equal weight to each indicator within the service that is inversely proportional to the number of indicators 

within that service. That is, the more indicators in a service, the less weight those indicators carry; 

conversely, indicators in services with fewer indicators carry greater weight in the overall index. The service

scores are then averaged to obtain a total score; thus, each service is weighted equally. Assuming equal 

weights in this way ignores the sample size for each indicator, as the samples size varies based on the type 

of service and whether the indicator is facility-based or client-based.

Given that each indicator has a range of 0 to 100, the index also has a potential range of 0 to 100. The 

formula for calculating the index is: 

(

FP1 + FP2

2

) + (

ANC1 + ANC2 + ANC3

3

) + (

DEL1 + DEL2 + DEL3

3

) + (

IM1

1

) + (

(CH1 + CH2 + CH3 + CH4 + CH5 + CH6 + CH7)

7

) + (

WASH1

1

)

6

x 100

Table 1 defines each indicator, where FP is family planning, ANC is antenatal care, DEL is delivery care, 

IM is immunization, CH is child curative care (including diarrhea, pneumonia/ARI, malaria, and general 

nutrition), and WASH is water, sanitation, and hygiene. The index includes 17 indicators.

In countries that do not have observation data from which to calculate client-based indicators or do not 

collect malaria data (e.g., Bangladesh), the calculation can be adjusted by removing the unavailable 

indicators and calibrating the denominator for the service-specific and overall averages. An index such as 

this can be used with data from health facility surveys that do not collect client-based indicators, such as 

the SARA survey: 

(

FP1

1

) + (

DEL1 + DEL2 + DEL3

3

) + (

IM1

1

) + (

(CH1 + CH2)

2

) + (

WASH1

1

)

5

x 100
22

We calculated the score at national and subnational levels. Given differences in the calculation of the index 

across countries (e.g., exemption of all client-based indicators in Bangladesh, exemption of client-based 

family planning indicators in the DRC) and the varying data collection times among the surveys (ranging 

from 2014-15 in Tanzania to 2017-18 in the DRC and Haiti), scores are not directly comparable across 

countries. For each country, we present the percentage of facilities or clients meeting the criteria for each 

indicator, the service area scores, and the overall scores. Appendix tables are included for each country to 

detail the number of facilities or clients analyzed for each indicator, overall, by service, and by indicator. 

Analyses were conducted using Stata 16.0 and Microsoft Excel 2016. 
23

4 RESULTS

In the following sections, we discuss the results for each country separately. Figures 4 to 10 are maps 

reflecting subnational variation in overall quality of care. Tables 3 to 9 show the subnational and national 

scores for each country, by indicator, service area, and total score. Appendix Tables 3 to 9 show the weighted 

(and unweighted) sample sizes for each indicator at subnational and national levels; sample sizes are 

important considerations when drawing conclusions about quality of care, especially at subnational levels 

where the number of facilities or clients can be quite small. 

4.1 Bangladesh

Bangladesh received a quality score of 40 out of 100 (Figure 4); scores ranged only 8 points across 

divisions, from 34 in Mymensingh to 42 in Khulna. As mentioned earlier, although the client-based 

indicators presented in Table 1 are included in the other country indices, they are not included in the index 

for Bangladesh. It is, therefore, difficult to compare this country’s composite score with the scores of the 

other countries in this study. Comparison can be made, however, among the divisions of Bangladesh and 

among the services that comprise its QOCI.

Figure 4 QOCI results in the divisions of Bangladesh
24

Nationally, the two highest-scoring service areas were child curative care and basic WASH services, which 

scored 78 and 66, respectively (Figure 5 and Table 3). Immunization received the lowest score, with only 

3% of facilities in Bangladesh providing viable vaccines and syringes. The other two services, delivery care

and family planning, had scores of 28 and 24, respectively. The ANC service was not included in the index,

as this service includes only client-based indicators. Although most of the services varied little between 

administrative divisions, basic WASH services had a notable variety of results. In Khulna, 83% of facilities 

had basic WASH services. In Mymensingh, however, only 39% of facilities provided basic WASH services.

Figure 5 National average score, service scores, and highest- and lowest-scoring indicators, Bangladesh

2017

In additional, two indicators in the delivery care service area had large disparities among divisions. In 

Rangpur, 42% of facilities were counted as having performed BEmOC signal functions in the past three

months, while only 3% of facilities in Sylhet performed these functions—a difference of 39 percentage 

points. The neonatal resuscitation indicator had slightly less variation. Although 73% of facilities in Sylhet 

had equipment for neonatal resuscitation, only 44% of facilities in Rangpur had these items—a difference 

of 29 percentage points.
25

Table 3 Summary indicators of quality of care: subnational and national percentages and averages of facility avai

services and service provision among observed clients, Bangladesh SPA 2017

Unit* Service or indicator Barishal Chattogram Dhaka Khulna Rajshahi Rangpur Sylhet Mymen

Family planning

F Method availability 20.5 25.3 26.5 24.8 23.7 21.1 19.3 20

C Counseling on side effects na na na na na na na n

Family planning average 20.5 25.3 26.5 24.8 23.7 21.1 19.3 20

Antenatal care

C Blood pressure measurement na na na na na na na n

C Counseling on iron na na na na na na na n

C Counseling on breastfeeding na na na na na na na n

Antenatal care average na na na na na na na n

Delivery care

F BEmOC signal functions performed 6.1 10.5 9.6 10.3 6.0 41.7 3.4 5

F Essential drugs 6.1 19.4 10.5 8.7 9.2 13.0 14.7 6

F Neonatal resuscitation 57.3 61.7 62.5 59.1 55.2 43.6 72.8 59

Delivery care average 23.2 30.5 27.5 26.0 23.5 32.8 30.3 23

Immunization

F Availability of viable vaccines and 

syringes

2.4 2.6 4.2 2.3 2.5 2.6 2.5 1

Child curative care

F Antibiotics for children 79.6 78.0 67.6 64.9 75.9 73.6 78.2 79

F ORS/Zinc for diarrhea 87.2 78.7 81.9 85.0 81.6 83.7 83.8 88

F Malaria diagnosis and treatment capacity na na na na na na na n

C ARI assessment na na na na na na na n

C Diarrhea assessment na na na na na na na n

C Anemia assessment na na na na na na na n

C Nutritional status assessment

Child curative care average 83.4 78.4 74.8 75.0 78.8 78.7 81.0 84

WASH

F Basic services for WASH 50.5 70.3 66.1 83.1 71.2 68.3 57.2 38

Total 36.0 41.4 39.8 42.2 39.9 40.7 38.1 33

Notes: 

*Unit of analysis: F = facility; C = client.

ARI = acute respiratory infection; BEmOC = basic emergency obstetric care; na = not applicable; ORS = oral rehydration salts; WASH = water, sanitation, and hygiene.

Scale: 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0
26

4.2 Democratic Republic of the Congo

In the DRC, the overall quality of care score was 37 out of 100 maximum possible points. As shown in

Figure 6, quality of care varied greatly across provinces in the DRC, from 19 in Sankuru to 55 in NordKivu. Of the seven countries in this study, the DRC had the second-most administrative divisions and the 

highest range of quality of care scores—36 points.

Figure 6 QOCI results in the provinces of the Democratic Republic of the Congo

Table 4 and Figure 7 show, at the national level, that the services varied in level of quality, from a score of 

21 for delivery care to a score of 52 for child curative care. These, too, fluctuated widely across provinces 

and within services. For delivery care, which included facility report of recent provision of BEmOC signal 

functions, availability of essential drugs, and equipment for neonatal resuscitation, Equateur had a score of 

only 3. Kasaï-Central and Nord-Kivu were more equipped, each scoring an average of 38 for the three 

indicators. Child curative care scores were higher, ranging from 31 in Sankuru to 62 in Nord-Ubangi and 

Nord-Kivu. 
27

Figure 7 National average score, service scores, and highest- and lowest-scoring indicators, Democratic 

Republic of the Congo 2017-18

Within services, however, the indicator scores also varied substantially, particularly within the child curative 

care service. That is, provision of care related to nutritional status assessment was very uncommon or 

nonexistent in some regions (ranging from 0% to 17%), while availability of ORS or zinc was much more 

common, available at nearly all facilities in Nord-Kivu and Sud-Kivu. For family planning, only one 

indicator (based on facilities) was included, as there were too few clients to include a client-based indicator;

the indicator that was included varied greatly. In both Sud-Ubangi and Haut-Uélé, 6% of facilities had a 

mix of short-acting, long-acting, and barrier methods or fertility awareness methods (cycle beads), while 

77% of facilities met these criteria in Bas-Uélé. However, very few facilities provided family planning 

services in some regions (e.g., only 11 facilities, unweighted, in Bas-Uélé and Tanganyika). Blood pressure 

measurement was 78% nationally but was as low as 29% in one province (Sankuru). Across provinces, only 

7% to 61% had all four basic vaccinations available and properly stored. Additionally, 4% to 67% of 

facilities had basic services for WASH (i.e., improved water, handwashing resources, and an improved 

latrine for clients).
28

Table 4 Summary indicators of quality of care: subnational and national percentages and averages of facility availability o

provision among observed clients, Democratic Republic of the Congo SPA 2017-18

Unit* Service or indicator Sud-Kivu Kinshasa

KongoCentralMaiNdombe Kwilu Kwango EquateurSudUbangiNordUbangi Mongala Tshuapa 

Family planning

F Method availability 38.8 63.7 40.8 39.9 18.6 61.4 40.9 6.2 59.5 26.0 15.4 

C Counseling on side effects na na na na na na na na na na na 

Family planning average 38.8 63.7 40.8 39.9 18.6 61.4 40.9 6.2 59.5 26.0 15.4 

Antenatal care

C Blood pressure measurement 84.4 78.4 96.7 49.8 86.1 74.8 86.1 84.8 88.3 78.6 84.8 

C Counseling on iron 68.7 35.4 61.9 12.4 27.3 52.4 2.0 34.2 44.2 30.7 27.7 

C Counseling on breastfeeding 35.3 32.3 8.4 22.6 32.9 46.2 39.8 16.1 44.4 17.1 36.4 

Antenatal care average 62.8 48.7 55.7 28.3 48.8 57.8 42.6 45.0 59.0 42.1 49.6 

Delivery care

F BEmOC signal functions performed 12.9 22.9 16.0 4.8 11.1 7.2 6.2 20.2 2.2 6.0 12.7 

F Essential drugs 14.7 29.4 22.5 7.4 13.5 6.6 0.6 5.0 12.2 0.0 0.0 

F Neonatal resuscitation 43.6 45.3 37.7 5.1 12.8 19.6 2.2 21.7 34.8 5.3 7.0 

Delivery care average 23.7 32.5 25.4 5.8 12.5 11.1 3.0 15.6 16.4 3.8 6.6 

Immunization

F Availability of viable vaccines and 

syringes

7.2 10.3 22.8 18.3 15.7 21.4 31.4 27.2 49.4 14.1 15.0 

Child curative care

F Antibiotics for children 45.4 47.3 72.3 55.2 52.2 63.2 37.4 29.8 83.1 11.1 61.4 

F ORS/Zinc for diarrhea 96.1 64.4 68.1 94.0 90.9 88.3 89.3 72.8 82.4 81.8 58.7 

F Malaria diagnosis and treatment 

capacity

61.5 43.3 68.0 55.5 36.6 56.8 69.4 53.5 81.3 58.0 64.8 

C ARI assessment 60.5 47.5 47.0 31.2 31.1 38.4 5.7 33.4 24.4 13.8 7.2 

C Diarrhea assessment 63.6 91.8 80.2 48.5 93.7 76.1 37.5 63.4 83.4 38.1 67.1 

C Anemia assessment 72.5 70.1 85.7 71.6 83.4 88.5 81.3 76.9 74.4 51.8 73.8 

C Nutritional status assessment 4.5 0.0 0.0 1.0 0.0 4.0 0.0 0.1 0.3 0.2 7.5 

Child curative care average 57.7 52.1 60.2 51.0 55.4 59.3 45.8 47.1 61.3 36.4 48.6 

WASH

F Basic services for WASH 57.1 66.6 27.1 30.4 4.0 4.8 23.4 7.5 6.9 7.3 2.6 

Total 41.4 45.8 38.8 29.1 26.0 36.1 31.2 25.4 42.2 22.1 23.2 

Notes: 

*Unit of analysis: F = facility; C = client.

ARI = acute respiratory infection; BEmOC = basic emergency obstetric care; na = not applicable; ORS = oral rehydration salts; WASH = water, sanitation, and hygiene.

Scale: 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0
29

Table 4—Continued

Unit* Service or indicator Ituri Nord-Kivu

HautKatanga LualabaHautLomami TanganyikaKasaïOriental Sankuru Lomami Kasaï

Family planning

F Method availability 22.5 60.1 40.9 37.5 15.3 49.3 57.2 28.5 49.9 42.5 

C Counseling on side effects na na na na na na na na na na 

Family planning average 22.5 60.1 40.9 37.5 15.3 49.3 57.2 28.5 49.9 42.5 

Antenatal care

C Blood pressure measurement 86.8 89.7 98.4 84.5 37.6 83.6 78.5 28.5 60.7 49.6 

C Counseling on iron 41.7 52.1 39.5 27.5 13.6 50.3 15.2 6.5 17.9 17.5 

C Counseling on breastfeeding 55.7 41.8 22.6 16.7 36.1 3.1 24.5 16.8 32.9 26.0 

Antenatal care average 61.4 61.2 53.5 42.9 29.1 45.7 39.4 17.3 37.2 31.0 

Delivery care

F BEmOC signal functions performed 16.5 30.1 9.9 9.1 1.7 10.6 1.4 5.6 1.2 14.7 

F Essential drugs 8.9 31.7 48.7 28.5 30.7 6.0 7.3 6.0 10.5 19.6 

F Neonatal resuscitation 12.5 50.8 43.9 58.4 57.7 25.7 37.1 34.4 16.1 22.5 

Delivery care average 12.6 37.5 34.2 32.0 30.0 14.1 15.3 15.3 9.3 18.9 

Immunization

F Availability of viable vaccines and 

syringes

30.7 55.8 27.7 11.2 25.5 5.2 20.9 15.1 52.2 21.3 

Child curative care

F Antibiotics for children 24.8 53.3 44.9 36.0 23.2 27.7 42.3 6.0 30.7 84.1 

F ORS/Zinc for diarrhea 84.7 99.9 83.2 78.3 67.5 67.1 50.0 35.1 83.1 80.4 

F Malaria diagnosis and treatment 

capacity

37.9 67.8 52.0 67.8 31.7 36.1 48.3 17.2 66.5 46.0 

C ARI assessment 50.3 65.3 53.5 51.7 22.9 35.1 57.7 17.4 46.9 9.4 

C Diarrhea assessment 65.0 70.2 71.9 68.4 76.5 68.8 29.3 60.9 46.5 83.2 

C Anemia assessment 82.2 62.1 83.0 94.3 56.1 70.7 95.6 71.8 67.4 48.6 

C Nutritional status assessment 1.2 2.8 0.7 17.3 0.2 0.0 0.8 0.0 2.3 2.9 

Child curative care average 49.4 60.2 55.6 59.1 39.7 43.6 46.3 29.8 49.1 50.7 

WASH

F Basic services for WASH 25.8 55.9 52.5 38.0 7.1 22.4 34.6 8.1 14.6 20.2 

Total 34.1 55.4 44.2 37.2 24.6 30.5 35.9 19.3 35.6 30.9 

Notes: 

*Unit of analysis: F = facility; C = client.

ARI = acute respiratory infection; BEmOC = basic emergency obstetric care; na = not applicable; ORS = oral rehydration salts; WASH = water, sanitation, and hygiene.

Scale: 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0
30

4.3 Haiti

Although Haiti received an overall score of 47 out of a possible 100, the results varied from department to 

department. As seen in Figure 8, half of the departments (i.e., five out of eleven) had scores above 50. 

Nippes department received a score of 59—the highest composite score. Of the departments with scores 

below 50, Ouest department had the lowest, at 38.

Figure 8 QOCI results in the departments of Haiti

On a national level, family planning had the lowest score (Figure 9). Although the results fluctuated among

departments, ranging from 11 to 28, the overall score was only 19. This was low compared to the other 

services, notably child curative care, ANC, and WASH, which received national scores of 52, 52, and 70,

respectively. Although most services did not vary greatly from department to department, immunization 

had the most extreme variation (Table 5), where availability of viable vaccines and syringes ranged from 

23% in Reste-Ouest to 93% in Nippes.

Within ANC and child curative care services, indicators ranged by 65 and 81 percentage points, 

respectively, at the national level. For the ANC service, 94% of ANC clients nationally had their blood

pressure measured. Across Haiti, not a single department was below 86% for this indicator. In contrast, 

counseling on iron and counseling on breastfeeding (i.e., the two other indicators making up the ANC 

service) were observed less often; nationally, only 33% and 29% of clients, respectively, received 

counseling on these topics. Child curative care was more complicated. As shown in Table 1, this service is 

made up of seven indicators—some facility-based and some client-based. Generally, availability of 

treatments for pneumonia and diarrhea were observed more often than appropriate assessment of childhood 

illness and nutrition. For example, antibiotics for children had the highest scores across the departments; 
31

not a single department had fewer than 72% of facilities with antibiotics. On the other end of the spectrum, 

only 2% of children nationally received the recommended assessment of nutritional status, ranging from 

1% in Artibonite department to 7% in Centre department. Nationally, ARI assessment (i.e., counting 

breaths) was observed in only 38% of children whose caretaker reported and provider discussed symptoms 

of ARI, ranging from 16% in Centre to 47% in Ouest. Finally, malaria diagnostic and treatment capacity 

ranged from 33% in Aire Metropolitaine to 85% in Nord’Est. It should be noted that malaria endemicity 

varies greatly within the country and within departments, although malaria readiness does not necessarily 

correlate to endemicity. 

Figure 9 National average score, service scores, and highest- and lowest-scoring indicators, 

Haiti 2017-18
32

Table 5 Summary indicators of quality of care: subnational and national percentages and averages of facility availability of se

provision among observed clients, Haiti SPA 2017-18

Unit* Service or indicator

Aire 

Metropolitaine Reste-Ouest Sud'Est Nord Nord'Est Artibonite Centre Sud Grand'Anse No

Family planning

F Method availability 15.1 4.3 8.0 16.1 13.9 8.8 28.9 10.9 12.8 

C Counseling on side effects 37.5 30.0 27.0 15.2 10.3 22.0 27.4 11.9 34.2 

Family planning average 26.3 17.2 17.5 15.7 12.1 15.4 28.2 11.4 23.5 

Antenatal care

C Blood pressure measurement 86.6 95.1 95.6 98.0 100.0 90.4 100.0 96.4 96.4 

C Counseling on iron 27.6 27.0 42.1 34.4 52.7 39.1 27.3 23.7 29.3 

C Counseling on breastfeeding 24.7 25.9 34.0 29.2 29.3 34.8 28.5 26.9 45.3 

Antenatal care average 46.3 49.3 57.2 53.9 60.7 54.8 51.9 49.0 57.0 

Delivery care

F BEmOC signal functions performed 27.0 14.3 25.7 36.1 28.6 35.3 50.0 16.0 15.0 

F Essential drugs 47.6 26.5 40.0 38.9 61.9 35.3 62.5 52.0 45.0 

F Neonatal resuscitation 74.6 45.2 62.9 77.8 71.4 64.7 58.3 64.0 70.0 

Delivery care average 49.7 28.7 42.9 50.9 54.0 45.1 56.9 44.0 43.3 

Immunization

F Availability of viable vaccines and 

syringes 37.7 22.6 68.9 58.5 75.0 33.0 65.8 54.1 71.1 

Child curative care

F Antibiotics for children 75.8 72.2 80.6 93.2 92.7 80.8 86.3 91.8 84.6 

F ORS/Zinc for diarrhea 53.1 63.9 82.1 74.8 82.9 69.2 84.3 94.5 98.1 

F Malaria diagnosis and treatment capacity 32.6 35.3 52.2 55.3 85.4 64.2 84.3 65.8 73.1 

C ARI assessment 44.2 47.3 30.1 40.7 23.6 37.7 16.3 31.3 35.3 

C Diarrhea assessment 68.2 55.6 42.9 66.7 46.2 52.8 36.5 40.1 33.8 

C Anemia assessment 51.7 54.2 41.4 51.2 47.3 46.0 39.7 54.7 46.9 

C Nutritional status assessment 3.5 1.5 1.8 1.2 1.9 0.0 6.6 1.8 2.5 

Child curative care average 47.0 47.1 47.3 54.7 54.3 50.1 50.6 54.3 53.5 

WASH

F Basic services for WASH 72.1 67.1 72.1 79.0 68.3 61.2 69.2 80.8 60.4 

Total 46.5 38.7 51.0 52.1 54.1 43.3 53.8 48.9 51.5 

Notes: 

*Unit of analysis: F = facility; C = client.

ARI = acute respiratory infection; BEmOC = basic emergency obstetric care; ORS = oral rehydration salts; WASH = water, sanitation, and hygiene.

Scale: 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0
33

4.4 Malawi

Nationally, Malawi received a score of 55, and its three regions—North, Central, and South—scored 59, 

54, and 55, respectively (Figure 10). Of the seven countries in this study, Malawi had both the fewest 

administrative divisions (i.e., three) and the smallest range of quality scores (i.e., five points). Although the 

North scored higher than the other two regions in most services, the regional scores were largely similar. 

Individual service scores differed by only 12 points at most among the three regions.

Of the six services, half (ANC, delivery care, and 

WASH) had scores above 50, and the other half

(family planning, immunization, and child curative 

care) scored slightly below 50, as seen in Figure 11. 

The lowest-scoring service was child curative care, 

which had a score of 47. This was 21 points below the 

highest-scoring service, basic WASH services. In the 

WASH service area, the North, Central, and South 

regions had scores of 66, 70, and 67, respectively

(Table 6).

Two services (delivery care and child curative care) 

performed fairly evenly across regions, though the 

prevalence of individual indicators varied. Although 

large percentages of facilities offered essential drugs 

and neonatal resuscitation (82% and 93%,

respectively), only 15% of facilities had performed 

BEmOC signal functions in the three months 

preceding the survey. Of the seven indicators 

comprising the child curative care service, two were 

80% or higher nationally; antibiotics and ORS or zinc 

for diarrhea were available in 76% and 91% of 

facilities, respectively. The ARI assessment and the

nutritional assessment (both client-based indicators)

scored the lowest. They were observed in 24% and 

2% of cases, respectively.

Within two other services, family planning and ANC, results varied more across regions. In the family 

planning service, the availability of a mix of methods ranged from 46% of facilities in the South to 65% in 

the North—a difference of 19 percentage points. Blood pressure measurement, a client-based ANC 

indicator, varied even more. In the Central region, 41% of ANC clients received this service. In the North, 

however, 81% of ANC clients had their blood pressure measured.

Figure 10 QOCI results in the regions of Malawi
34

Figure 11 National average score, service scores, and highest- and lowest-scoring indicators, Malawi 

2013-14
35

Table 6 Summary indicators of quality of care: subnational and national percentages and averages of 

facility availability of services and service provision among observed clients, Malawi SPA 2013-14

Unit* Service or indicator North Central South National

Family planning

F Method availability 64.9 46.3 54.5 53.2

C Counseling on side effects 45.1 43.5 42.9 43.4

Family planning average 55.0 44.9 48.7 48.3

Antenatal care

C Blood pressure measurement 80.5 40.9 52.9 50.9

C Counseling on iron 63.4 66.7 61.2 63.8

C Counseling on breastfeeding 52.7 52.6 52.5 52.6

Antenatal care average 65.5 53.4 55.5 55.8

Delivery care

F BEmOC signal functions performed 16.3 16.1 12.4 14.5

F Essential drugs 79.6 82.3 83.1 82.1

F Neonatal resuscitation 97.1 95.1 90.2 93.3

Delivery care average 64.3 64.5 61.9 63.3

Immunization

F Availability of viable vaccines and syringes 54.3 43.2 50.4 48.5

Child curative care

F Antibiotics for children 81.8 81.3 68.8 75.7

F ORS/Zinc for diarrhea 90.0 93.7 90.0 91.4

F Malaria diagnosis and treatment capacity 48.1 44.2 42.8 44.2

C ARI assessment 27.2 27.5 16.7 24.2

C Diarrhea assessment 37.3 47.0 37.3 42.1

C Anemia assessment 47.0 44.5 40.9 43.6

C Nutritional status assessment 0.2 1.4 2.1 1.5

Child curative care average 47.4 48.5 42.7 46.1

WASH

F Basic services for WASH 66.4 70.2 67.4 68.2

Total 58.8 54.1 54.4 55.0

Notes: 

*Unit of analysis: F = facility; C = client.

ARI = acute respiratory infection; BEmOC = basic emergency obstetric care; ORS = oral rehydration salts; WASH = water, sanitation, and hygiene.

Scale: 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0
36

4.5 Nepal

Nepal also had few administrative regions and little variation among them. Together, the regions of Nepal 

received a composite score of 38. Separately, they had similar scores, which were all within a range of five

points. The Central region scored 37, while the Far-Western region scored 42 (Figure 12).

Figure 12 QOCI results in the regions of Nepal

Figure 13 shows that all but one service score (for ANC) varied by fewer than 15 points across Nepal’s 

regions. There was, however, variation between the service scores themselves. Although 67% of facilities 

had basic resources for WASH, family planning received a low score of 22. The lowest-scoring service was 

immunization. As a whole, only 6% of facilities in Nepal were equipped with all (properly stored) basic 

vaccines and syringes (Table 7).

Several indicators stood out from the others in their respective services. Blood pressure measurement was

much higher than the other two counseling-related indicators in the ANC service area. Although counseling 

on iron and counseling on breastfeeding received scores of 27 and 16, respectively, the majority (81%) of 

clients had their blood pressure measured in Nepal. Counseling also varied across regions. Only 8% of ANC 

clients in the Central region were counseled on breastfeeding, while 34% of ANC clients in the Far-Western 

region were counseled.

Additionally, the BEmOC indicator scored much lower than the other two indicators of delivery care. Only 

5% of facilities had performed BEmOC signal functions in the three months preceding the survey, but 

essential drugs were available in 69% of facilities (ranging from 58% to 85%), and neonatal resuscitation 

equipment was available in 84% (ranging from 78% to 93%). The indicators comprising child curative care 

also varied greatly. Despite the high availability of ORS/zinc for diarrhea (97%), the composite score for 

child curative care was 37. This was due, in part, to the two lowest-scoring indicators, the anemia and 

nutritional status assessments, which were observed nationally among 14% and 1% of sick children, 

respectively.
37

Figure 13 National average score, service scores, and highest- and lowest-scoring indicators, Nepal 2015
38

Table 7 Summary indicators of quality of care: subnational and national percentages and averages of 

facility availability of services and service provision among observed clients, Nepal SPA 2015

Unit* Service or indicator Eastern Central Western Mid-Western Far-Western National

Family planning

F Method availability 22.0 21.1 21.5 30.8 33.4 23.9

C Counseling on side effects 16.7 16.1 17.8 29.8 30.4 19.0

Family planning average 19.4 18.6 19.7 30.3 31.9 21.5

Antenatal care

C Blood pressure measurement 80.2 77.1 85.4 91.0 87.7 81.1

C Counseling on iron 26.2 22.6 34.7 37.0 23.9 26.9

C Counseling on breastfeeding 21.3 8.4 12.0 31.2 34.0 15.9

Antenatal care average 42.6 36.0 44.0 53.1 48.5 41.3

Delivery care

F BEmOC signal functions performed 3.6 7.2 2.9 5.2 1.8 4.5

F Essential drugs 62.2 57.8 82.2 66.0 85.3 69.1

F Neonatal resuscitation 83.0 92.5 78.2 78.6 88.6 84.3

Delivery care average 49.6 52.5 54.4 49.9 58.6 52.6

Immunization

F Availability of viable vaccines and 

syringes

4.5 11.0 3.3 2.2 8.4 6.4

Child curative care

F Antibiotics for children 16.5 30.6 29.0 14.4 23.1 24.1

F ORS/Zinc for diarrhea 95.7 96.4 99.3 97.2 99.8 97.3

F Malaria diagnosis and treatment capacity na na na na na na

C ARI assessment 53.0 52.4 56.6 57.1 65.5 55.1

C Diarrhea assessment 22.4 32.7 47.8 24.5 29.0 30.0

C Anemia assessment 11.9 13.4 20.0 15.2 15.4 14.4

C Nutritional status assessment 0.8 0.7 1.8 2.6 2.9 1.3

Child curative care average 33.4 37.7 42.4 35.2 39.3 37.0

WASH

F Basic services for WASH 72.1 63.2 69.7 64.1 66.1 67.0

Total 36.9 36.5 38.9 39.1 42.1 37.6

Notes: 

*Unit of analysis: F = facility; C = client.

ARI = acute respiratory infection; BEmOC = basic emergency obstetric care; na = not applicable; ORS = oral rehydration salts; WASH = water, sanitation, and 

hygiene.

Scale: 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0
39

4.6 Senegal

Senegal received an overall quality score of 48, with a range of 23 points among regions. The highestscoring regions were Dakar and Diourbel, which both received a score of 58. As illustrated in Figure 14,

the only other regions with composite scores of at least 50 were Fatick and Ziguinchor. Kolda, the lowestscoring region, scored only 35. The remaining nine regions had scores between 40 and 50.

Figure 14 QOCI results in the regions of Senegal

Of all the services, only two had scores above 50 on the national level (Figure 15). Family planning scored 

52 and basic WASH services scored 81. The latter was 57 points higher than Senegal’s lowest-scoring 

service, immunization. As a whole, immunization scored 24, but results varied across Senegal’s regions

(Table 8). On the high end, 46% of facilities in Dakar had viable vaccines and syringes. On the other hand, 

only 9% of facilities in Thiès had them. Despite the high score for WASH at the national level, there was 

large regional variation within this service as well. Although 99% of facilities in Dakar had basic WASH 

services, about half of the facilities (51%) in Kedougou and Kolda had such services—a 48-point difference.

Individual indicators revealed additional variability across Senegal’s regions. Neonatal resuscitation and 

the diarrhea assessment, in particular, varied greatly from region to region. In Kaffrine, 84% of facilities 

offered neonatal resuscitation—a service available in only a quarter of Kolda’s facilities. The diarrhea 

assessment had even more variability. In Kaolack, 79% of children whose caretakers reported diarrhea were 

checked for dehydration. In Sédhiou and Ziguinchor, however, 5% and less than 1% of children with 

diarrhea, respectively, were checked for dehydration. Although it had less variability, the nutritional status 

assessment was one of the lowest-scoring indicators (8% nationally), followed by the anemia assessment 
40

(18% nationally). Although 29% of sick children received a nutritional status assessment in Kedougou, 

fewer than 1% of sick children in Matam and Tambacounda received one.

Figure 15 National average score, service scores, and highest- and lowest-scoring indicators, Senegal 

2016 and 2017
41

Table 8 Summary indicators of quality of care: subnational and national percentages and averages of facility availability of servi

among observed clients, Senegal SPA 2016 and 2017

Unit* Service or indicator Dakar Diourbel Fatick Kaffrine Kaolack Kedougou Kolda Louga Matam

SaintLouis SédhiouT

c

Family planning

F Method availability 79.6 78.3 55.9 50.2 45.6 52.9 28.4 47.7 62.4 52.7 53.7 

C Counseling on side effects 33.4 78.7 52.2 48.9 65.1 86.4 54.2 24.1 38.1 48.9 47.5 

Family planning average 56.5 78.5 54.1 49.6 55.4 69.7 41.3 35.9 50.3 50.8 50.6 

Antenatal care

C Blood pressure measurement 97.6 98.1 98.1 91.2 100.0 88.8 100.0 98.3 97.6 95.4 98.0 

C Counseling on iron 49.8 30.3 53.9 33.2 63.6 40.6 15.3 45.3 32.7 51.5 58.0 

C Counseling on breastfeeding 5.1 1.9 1.9 15.7 2.6 4.7 4.0 0.0 2.4 0.0 4.1 

Antenatal care average 50.8 43.4 51.3 46.7 55.4 44.7 39.8 47.9 44.2 49.0 53.4 

Delivery care

F BEmOC signal functions performed 17.8 14.8 8.1 11.9 12.6 0.0 6.1 12.4 8.2 11.9 5.3 

F Essential drugs 57.4 56.2 63.5 51.1 42.7 31.2 28.5 33.1 17.7 35.9 59.7 

F Neonatal resuscitation 77.0 76.8 71.4 83.5 49.1 49.3 24.9 53.5 70.2 69.6 53.4 

Delivery care average 50.7 49.3 47.7 48.8 34.8 26.8 19.8 33.0 32.0 39.1 39.5 

Immunization

F Availability of viable vaccines and 

syringes

46.4 37.0 21.1 30.1 34.3 27.0 18.8 13.5 32.7 27.2 21.2 

Child curative care

F Antibiotics for children 66.3 53.0 45.1 40.0 24.0 29.9 21.6 35.3 47.0 54.1 34.4 

F ORS/Zinc for diarrhea 48.7 75.3 55.2 42.6 40.3 43.5 21.1 49.6 72.9 56.9 49.0 

F Malaria diagnosis and treatment capacity 61.5 55.2 54.9 45.3 28.0 43.9 20.7 51.4 66.7 56.2 49.4 

C ARI assessment 54.0 77.2 65.0 85.7 81.6 94.6 85.2 57.1 67.5 79.9 82.0 

C Diarrhea assessment 38.6 34.8 21.3 52.6 78.7 62.9 73.6 38.2 38.5 37.3 4.7 

C Anemia assessment 19.1 6.1 9.5 15.1 29.5 41.0 41.2 23.7 11.6 23.1 2.8 

C Nutritional status assessment 11.7 6.7 4.2 8.6 10.1 28.6 2.3 5.0 0.6 3.6 4.2 

Child curative care average 42.8 44.0 36.5 41.4 41.7 49.2 38.0 37.2 43.5 44.4 32.4 

WASH

F Basic services for WASH 98.7 94.1 89.0 75.1 73.4 50.9 51.3 77.1 84.1 82.1 86.2 

Total 57.7 57.7 49.9 48.6 49.2 44.7 34.8 40.8 47.8 48.8 47.2 

Notes: 

*Unit of analysis: F = facility; C = client.

ARI = acute respiratory infection; BEmOC = basic emergency obstetric care; ORS = oral rehydration salts; WASH = water, sanitation, and hygiene.

Scale: 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0
42

4.7 Tanzania

Altogether, Tanzania received a score of 48. Despite being the country in this study with the most 

administrative divisions, Figure 16 shows that Tanzania’s regions did not have a large range of composite 

results. The quality scores for each region ranged by 18 points, from 40 in Lindi to 58 in the Kilimanjaro, 

Dar es Salaam, and Singida regions.

Figure 16 QOCI results in the regions of Tanzania

On the national level in Tanzania, all services received scores in either the 40s or 50s (Figure 17). Family 

planning, delivery care, child curative care, and basic WASH services all scored between 40 and 49. ANC 

and immunization scored 57 and 52, respectively. Table 9 shows the greatest variation in service scores was 

in the immunization and WASH services. In terms of immunization, 88% of facilities in Simiyu had viable 

vaccines and syringes, compared with 0% and 16% of facilities in Kusini Unguja and Kaskazini Unguja,

respectively. In Kusini Unguja, 94% of facilities had basic WASH services. However, the estimates in the 

Unguja region of Zanzibar were based on fewer than 20 facilities. In Dar es Salaam, the second highestscoring region for WASH, 80% of facilities had basic WASH resources available. In Njombe, for 

comparison, only 20% of facilities were equipped.
43

Figure 17 National average score, service scores, and highest- and lowest-scoring indicators, Tanzania 

2014-15

Results for individual indicators varied substantially at the national and subnational levels. There was a 

range of 85 points between the highest- and lowest-scoring indicators nationally and a 70-point difference 

across regions for several indicators. At the national level, only 2% of children had a nutritional status 

assessment and 5% of facilities reported performing BEmOC signal functions, whereas 84% and 86% of 

facilities, respectively, had antibiotics and diarrhea treatment available. Across regions, counseling on iron, 

neonatal resuscitation, and malaria diagnosis and treatment all had more than 70 points of variation in their 

regional results. Approximately 6% of clients in Mjini Magharibi and 90% in Katavi were counseled on 

iron; equipment for neonatal resuscitation was present in 14% of facilities in Kaskazini Pemba and in all 

facilities (> 99%) in Lindi, Singida, and Tanga. Malaria diagnosis and treatment capacity was lowest in 

Kigoma (9%), in Mjini Magharibi (11%) and Kaskazini Pemba (14%) in the Zanzibar Archipelago, and in 

Arusha (9%). On the other hand, 81% of facilities were equipped for malaria diagnosis and treatment in 

Tanga. Although malaria is nearly nonexistent in Arusha and Zanzibar, Kigoma has much higher endemicity

(PMI 2014). 
44

Table 9 Summary indicators of quality of care: subnational and national percentages and averages of facility availability of se

provision among observed clients, Tanzania SPA 2014-15

Unit* Service or indicator Dodoma Arusha Kilimanjaro Tanga Morogoro Pwani

Dar es

Salaam Lindi Mtwara Ruvuma Iringa Mbeya Singi

Family planning

F Method availability 21.2 30.1 29.9 43.7 13.9 53.3 71.4 27.5 21.6 38.0 48.2 43.8 49.1 

C Counseling on side effects 51.3 75.8 54.3 37.6 34.8 40.5 42.8 32.3 27.2 54.1 63.7 66.5 78.3 

Family planning average 36.3 53.0 42.1 40.7 24.4 46.9 57.1 29.9 24.4 46.1 56.0 55.2 63.7 

Antenatal care

C Blood pressure 

measurement

88.5 97.9 93.4 93.3 80.5 75.3 82.1 61.4 48.3 70.3 78.8 54.5 90.7 

C Counseling on iron 84.1 65.0 63.0 42.3 63.3 18.3 29.4 54.4 80.0 76.7 76.4 64.3 81.0 

C Counseling on 

breastfeeding

27.0 35.6 61.2 56.1 50.8 48.8 49.9 33.6 38.4 37.0 60.5 19.0 41.9 

Antenatal care average 66.5 66.2 72.5 63.9 64.9 47.5 53.8 49.8 55.6 61.3 71.9 45.9 71.2 

Delivery care

F BEmOC signal functions 

performed

4.7 3.2 2.3 4.8 1.7 2.5 33.9 2.9 2.6 3.4 2.2 2.4 8.4 

F Essential drugs 11.6 18.2 50.2 41.4 30.4 49.4 69.2 46.9 47.6 32.3 36.6 46.6 32.8 

F Neonatal resuscitation 69.3 98.4 89.2 100.0 87.5 89.1 96.2 100.0 68.2 94.3 94.3 91.7 100.0 

Delivery care average 28.5 39.9 47.2 48.7 39.9 47.0 66.4 49.9 39.5 43.3 44.4 46.9 47.1 

Immunization

F Availability of viable 

vaccines and syringes

34.9 73.1 73.2 35.2 36.8 56.6 53.2 35.8 59.6 39.0 51.5 65.4 61.9 

Child curative care

F Antibiotics for children 86.3 76.0 89.9 88.5 88.8 81.6 77.4 77.9 77.4 74.6 78.3 94.0 88.1 

F ORS/Zinc for diarrhea 91.5 76.5 88.9 92.5 78.1 78.7 83.1 72.0 73.0 79.0 84.1 88.7 94.3 

F Malaria diagnosis and 

treatment capacity

54.7 15.1 38.8 81.4 55.4 30.3 42.9 64.2 39.3 58.0 53.7 54.8 46.7 

C ARI assessment 14.8 37.6 32.0 31.6 16.7 10.7 14.8 2.6 34.4 6.8 18.2 23.7 43.2 

C Diarrhea assessment 28.0 52.0 65.9 53.0 28.5 26.4 24.7 20.8 32.8 79.7 65.7 50.1 64.9 

C Anemia assessment 34.0 39.9 30.5 26.0 46.7 43.8 29.4 27.3 55.8 52.9 52.6 34.9 43.4 

C Nutritional status

assessment

0.0 6.8 4.5 1.8 3.1 3.3 0.6 0.0 0.0 0.5 0.7 0.3 4.1 

Child curative care

average

44.2 43.4 50.1 53.5 45.3 39.3 39.0 37.8 44.7 50.2 50.5 49.5 55.0 

WASH

F Basic services for WASH 43.6 37.3 63.4 53.7 47.1 36.0 80.4 40.1 40.5 35.1 56.0 39.8 49.9 

Total 42.3 52.1 58.1 49.3 43.1 45.5 58.3 40.6 44.0 45.8 55.0 50.4 58.1 

Notes: 

*Unit of analysis: F = facility; C = client.

ARI = acute respiratory infection; BEmOC = basic emergency obstetric care; ORS = oral rehydration salts; WASH = water, sanitation, and hygiene.

Scale: 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0
45

Table 9—Continued

Unit* Service or indicator Kagera Mwanza Mara Manyara Njombe Katavi Simiyu Geita

Kaskazini 

Unguja

Kusini 

Unguja

Mjini 

Magharibi

Family planning

F Method availability 27.6 37.7 33.9 78.2 18.1 30.5 45.1 33.6 70.0 38.8 36.8 

C Counseling on side effects 46.7 55.2 28.9 70.2 48.8 55.6 47.1 65.7 47.8 55.1 65.7 

Family planning average 37.2 46.5 31.4 74.2 33.5 43.1 46.1 49.7 58.9 47.0 51.3 

Antenatal care

C Blood pressure 

measurement

74.5 65.4 61.7 74.7 68.3 55.9 58.4 62.7 93.2 100.0 85.9 

C Counseling on iron 88.6 55.7 63.7 80.9 75.3 90.0 88.7 87.2 20.7 42.9 6.2 

C Counseling on 

breastfeeding

36.7 41.1 27.4 44.0 73.2 35.8 9.7 16.4 34.5 56.4 36.2 

Antenatal care average 66.6 54.1 50.9 66.5 72.3 60.6 52.3 55.4 49.5 66.4 42.8 

Delivery care

F BEmOC signal functions 

performed

1.6 3.9 1.3 15.2 3.4 5.4 1.8 5.7 0.0 0.0 50.0 

F Essential drugs 11.3 30.6 40.1 23.4 34.8 41.3 26.4 15.7 53.8 60.9 #### 

F Neonatal resuscitation 34.0 55.7 34.7 97.1 93.8 15.9 31.2 71.3 64.5 45.7 75.0 

Delivery care average 15.6 30.1 25.4 45.2 44.0 20.9 19.8 30.9 39.4 35.5 75.0 

Immunization

F Availability of viable 

vaccines and syringes

70.1 51.4 80.7 70.8 43.5 24.0 88.4 35.3 15.7 0.0 46.4 

Child curative care

F Antibiotics for children 80.8 93.6 100.0 91.6 81.3 96.3 76.6 92.0 77.8 81.6 82.2 

F ORS/Zinc for diarrhea 99.1 87.3 98.5 90.9 99.2 96.3 90.2 93.6 66.7 68.4 59.8 

F Malaria diagnosis and 

treatment capacity

64.3 28.4 39.4 37.9 68.0 70.5 51.3 36.0 74.4 52.4 11.4 

C ARI assessment 29.5 16.2 18.0 54.1 33.2 5.3 30.2 7.6 33.2 46.4 19.9 

C Diarrhea assessment 37.9 43.5 32.8 75.0 59.9 22.1 46.2 54.4 50.9 21.3 64.3 

C Anemia assessment 43.8 48.2 46.9 39.4 29.2 33.2 61.1 56.9 25.2 20.0 24.4 

C Nutritional status 

assessment

2.5 2.2 1.0 6.4 0.0 0.0 0.0 0.6 0.0 0.0 0.0 

Child curative care

average

51.1 45.6 48.1 56.5 53.0 46.2 50.8 48.7 46.9 41.4 37.4 

WASH

F Basic services for WASH 67.1 36.8 68.2 26.9 20.0 60.5 33.6 48.0 80.0 93.9 80.2 

Total 51.3 44.1 50.8 56.7 44.4 42.5 48.5 44.7 48.4 47.4 55.5 

Notes: 

*Unit of analysis: F = facility; C = client.

ARI = acute respiratory infection; BEmOC = basic emergency obstetric care; ORS = oral rehydration salts; WASH = water, sanitation, and hygiene.

Scale: 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0

47

5 DISCUSSION

Using RMNCHN and WASH data from the SPA surveys, we constructed a composite QOCI using a mix of 

structural and process indicators. Overall, the proposed index is easy to interpret and can help countries 

assess performance on RMNCHN quality of care at the national and subnational levels to identify

geographic inequalities as well as service areas in need of further investigation of supply chains or service 

delivery. This measure provides a glimpse into the readiness of facilities and provision of care for 

individuals using formal health services among a nationally representative sample or census of health 

facilities. 

Like the CCI (Wehrmeister et al. 2016), the QOCI can be used to benchmark quality and examine changes 

over time. Using clearly defined indicators described in this report, countries are also encouraged to 

calculate their own scores with context-specific modifications. Although future endeavors could examine 

the scores by facility characteristics (e.g., facility type, managing authority), we recommend examining the 

index in aggregate only. In this report, we applied the index to existing data to illustrate its ability to 

demonstrate service gaps or regional disparities within countries. Although the index is not without 

limitations, this analysis represented a first step in identifying a core set of health system indicators that can 

be used to report and track country performance on RMNCHN quality of care. 

5.1 Overview of Findings

Although quality could not be directly compared across countries given differences in indicators and timing

of the surveys, we can draw some conclusions from this analysis. As expected, quality of care varied not 

only from country to country but, in some cases, from region to region within a country. Regional variation 

was most prominent in the DRC, with 48 points between the highest- and lowest-scoring regions. The three

countries with the lowest variation among regions were those with the fewest regions: Bangladesh, Malawi,

and Nepal. These three had fewer than eight points of variation across fewer than nine subnational divisions. 

This was in sharp contrast to the country with the most geographically varied results, the DRC, which also 

has the second-highest number of administrative level 1 units. As Malawi uses a census survey, further 

analysis could examine scores across districts rather than regions for a more granular understanding of 

within-country differences in quality of care. 

The indices revealed not only national and regional differences but also differences in and among the 

services themselves. Such patterns emerged for the WASH and immunization services in particular. In 

Bangladesh, Haiti, Malawi, Nepal, and Senegal, WASH was the highest-scoring service (ranging from 66% 

to 81% of facilities with basic WASH services). On the other end of the quality index, the immunization 

service was the lowest-scoring of all services measured in Bangladesh, Malawi, and Nepal, and the second 

lowest-scoring domain in the DRC. Although immunization was the second highest-scoring service in 

Tanzania, the availability of immunizations at facilities ranged by 88 percentage points between its highestand lowest-scoring regions. 

Excluding the services composed of only one indicator (WASH and immunization), three additional

indicators displayed patterns of note. Within ANC, the blood pressure indicator scored high across most 

countries. In five out of the six countries in which it was measured, more than 70% of clients had their
48

blood pressure measured. Across all countries in this study, the percentage of facilities with ORS or zinc in 

stock for diarrhea was also high; it was often the highest-scoring individual indicator within the child 

curative care service area or among all indicators. In five of this study’s seven countries, more than 80% of 

facilities provided ORS or zinc for diarrhea. In contrast, few clients had a full nutritional status assessment. 

Of the facilities in the DRC, Haiti, Malawi, Nepal, and Tanzania, 2% or fewer included a nutritional status 

assessment during child curative care.

5.2 Limitations of the Index and Broad Recommendations

Both the index and, more broadly, the SPA surveys have some important limitations in terms of measuring 

quality of care. These are summarized in Table 10.

Table 10 Limitations and broad recommendations to improve the index and SPA surveys

Limitations Recommendations

 The QOCI is not a comprehensive measure of quality across all 

RMNCHN and WASH services; however, it does highlight key 

indicators across the continuum of care.

 The index includes structural and process domains of quality of care 

but does not include client experience of care.

 Assessment of availability of medications is cross-sectional; 

medications may have varying degrees of stock outs.

 Client variables may be biased by sample design, limited sample size, 

and the Hawthorne effect.

 There is a gap in information about the role of community health 

workers.

 The selected indicators should be reviewed by a larger body of quality 

of care experts in tandem with SPA revisions.

 Future revisions to the SPA survey should align with recommendations 

such that the core set of RMNCHN and WASH indicators are 

accurately captured and information about user experience is more 

robustly collected.

 Client sample size should be carefully considered when conducting a 

SPA survey.

 A community health worker or community-based program module 

could be developed to better meet the information needs of countries.

First, broadly speaking, our index is not a comprehensive measure of quality. In fact, it is quite the opposite. 

Although the intent was to provide a simple summary of key indicators of quality of care within health 

areas, the index only scratches the surface of quality within and across these areas. Although the index 

includes indicators from each health area of RMNCHN and WASH, it does not include indicators reflecting 

service provision for labor and delivery, or structural or process information on adolescent health, HIV, 

sexually transmitted infections, tuberculosis, chronic diseases, and other conditions. Some health areas have

only structural indicators, as observation of related services was not part of the SPA survey (e.g., labor and 

delivery); the lack of data prohibited inclusion of process indicators for those areas. Existing literature 

shows that structural indicators cannot be used as proxies for process indicators, as the two indicators are 

not consistently correlated (Leslie, Sun, and Kruk 2017). In addition, the indicators that we included in the 

index reflect the structural or process components but omit indicators from client experience, which others 

have cited in frameworks related to quality of care (Kruk et al. 2018; WHO 2016b). Selection of the 

RMNCHN indicators was restricted to those that met our selection criteria and were prioritized by content 

experts. Given that the purpose of the analysis was to create a summary index to complement the CCI and 

highlight key indicators in the SPA surveys, and that the index includes only 17 indicators, we have likely 

omitted some important indicators.

Further, within each health area, quality encompasses several domains within each structural and process 

component, as well as a multitude of indicators within each service. For example, the design of a summary 

index of quality of care for family planning conceptually drew from eight domains with 53 indicators 

(Mallick, Temsah, and Wang 2019)—only two of which are included in our index. Even the Jain et al. 

(2019) shortened, validated, family planning process quality of care index comprised 10 items. As the 
49

structural domains include equipment, medication, infrastructure, and staffing and the process domains 

include appropriate assessment, accurate diagnosis, treatment, counseling, and respectful care, our index 

cannot fully capture quality with only 17 indicators across six health areas. However, many indicators, such 

as malaria diagnostic and treatment capacity, are themselves composite indicators comprising several 

indicators on their own. Although the composite indicators conceal issues with their individual pieces, they

can point to the cascade of care needed to provide adequate care and uncover areas where stakeholders can 

delve further.

There are some limitations regarding the SPA instruments. First, for medication availability, it is important 

to note that the SPA survey is a cross-sectional tool. Commodities may have temporary stockouts or chronic 

shortages, indicating true supply-chain issues. However, SPA surveys do not distinguish between these 

issues. Logistics management information systems can help inform understanding about commodity 

availability. Further, visits are observed during interviews, and providers may conduct their observed visits 

differently than their unobserved visits—a phenomenon known as the Hawthorne effect (Leonard and 

Masatu 2006). Although observers use a checklist to indicate whether care, counseling, and assessments 

are given, they do not verify whether practices are appropriate or whether assessments are accurate and

complete (Taylor, Ahmed, and Wang 2019). Exit interview responses are subject to courtesy bias—the 

client’s desire to represent the provider and their interactions favorably (Hameed et al. 2017). Exit 

interviews also pose a question-order bias in which caregivers’ experience with the provider may bias their 

answers. For example, a caregiver may not cite a child’s symptom if it was never addressed by the provider 

(Taylor, Ahmed, and Wang 2019). 

In addition, client-based samples may be biased by the types of facilities from which they are drawn (e.g., 

facilities that have higher client volume and provide the service more frequently). Although interviewer 

teams and team leaders attempt to arrange visits around the facilities’ schedules, clients are not always 

observed at all facilities providing services. That is, facilities that provide care less frequently (e.g., on 

select days of the week or month) but do not provide care on the day(s) of the interview (or on a subsequent 

follow-up visit) are not represented in the client variables. Because these facilities are typically lower-level, 

smaller facilities (e.g., clinics or dispensaries), the sample of clients may not reflect the quality of care they 

provide. Applying sample weights would reduce the influence of clients at higher-level facilities (e.g., 

hospitals), thus restoring representativeness. However, clients attending higher-level facilities may be 

different in that they may be seeking care for more severe conditions. Accordingly, previous analyses have 

excluded clients seeking care at hospitals (Taylor et al. 2019). Further, it can be difficult to obtain a reliable 

sample of clients for some indicators. In some facilities, very few clients are observed, particularly if the 

service is not highly utilized, such as family planning in the DRC. In several provinces in the DRC in our 

study, there were very few family planning clients observed in total, so the indicator was omitted from the 

index entirely. For this same reason, SPA surveys do not typically observe labor and delivery services, as

they may be unpredictable, making it difficult to obtain an adequate sample.

Recommendations

This index, specifically the indicators within it, could be strengthened by undergoing a thorough review by 

a larger body of quality of care experts, complemented by a more robust literature review. Harmonization 

with other complementary tools would also help ensure that measurement of quality of care is as universal 

and optimal as possible. The index could also be improved with a better balance of the components of 
50

care—structure, process, and outcomes—although outcomes may be limited given the cross-sectional 

nature of studies. Although the index includes nine indicators reflecting the structural component and eight

indicators reflecting process, some health areas are based only on process indicators (e.g., ANC) or only on 

structural indicators (e.g., delivery care). The omission of user experience from our index is a serious 

limitation, but since SPA surveys collect some information on this area, it is possible to include indicators 

from this domain in subsequent iterations of the index. Future revisions of the SPA survey could also include 

more and better questions that capture user experience by drawing from international guidelines and 

standards reviewed in this report. Developing a module to collect more information about the responsibility 

of community health workers or community-based programs that are managed through interviewed 

facilities could also be considered. 

For user experience, observations, and client exit interviews, larger sample sizes would provide more 

reliable information; however, increasing sample sizes raises the cost and thus decreases the acceptability 

of the survey. In the interim, sampling statisticians should develop concrete cutoffs to reliably capture and 

describe indicators. In the DHS household surveys, a cutoff of 25 cases is imposed, and indicators based on 

a denominator of less than 25 are suppressed. There is no parallel for SPA surveys; however, we 

recommended exploring this as a guide for future SPA surveys. 

5.3 Limitations of the Indicators and Related Recommendations

This section details the limitations of specific indicators in capturing their related aspects of quality of care. 

Table 11 summarizes the limitations and recommendations, with a detailed discussion to follow.

Table 11 Summary of limitations and recommendations

Limitations Recommendations

Family planning

 During observation, counseling is only recorded for clients who leave

with a method (or prescription) and is specific to that method.

 The sample size was small in some countries, and too small for 

evaluating new contraceptive users.

 Revise the observation protocol to capture validated measures.

 Observation should include recording counseling regardless of 

whether a method is prescribed.

 Increase the sample size when possible.

Antenatal care

 All indicators are client-based.

 Breastfeeding counseling is based on client exit interviews to capture 

group counseling, but this may be biased.

 For key indicators and QOCI revisions, consider including a structural 

component.

 Content of group counseling could be captured in the SPA survey; 

observation and exit interview questions should be aligned to better 

capture counseling.

Delivery care

 Observation of deliveries is not feasible in SPA surveys.

 Facility inventories have insufficient information about small and sick 

newborns.

 For future SPA surveys, consider record reviews or postpartum exit 

interviews.

 Include more information about interventions for small and sick 

newborns.

Immunization

 This indicator includes only four basic vaccines.  This indicator could include country-specific vaccines in future 

iterations of the QOCI or for country dissemination purposes.

Continues...
51

Table 11—Continued

Limitations Recommendations

Child curative care

 The malaria indicator does not include provider training on

administration of RDT or microscopy.

 Little information is collected on what assessments or symptoms lead 

to diagnoses; testing for malaria is captured only among those with a 

diagnosis.

 Observation does not capture height or mid-upper arm circumference, 

so nutritional assessment may be incomplete.

 The provider training questions could be expanded to include 

supervisory training.

 Refine the observation protocol to better define the denominator (i.e., 

children with suspected illness) so that the SPA survey can assess

appropriate diagnosis and treatment of sick children.

 The observation protocol could include recording height or mid-upper 

arm circumference.

 Consider developing a module for growth monitoring and 

immunizations during well-child visits.

 Modify ORS/zinc to include both elements (not one or the other). 

Water, sanitation, and hygiene

 The items used in the WASH composite indicator are outdated and 

may not capture the ability to meet the WASH needs of a facility. 

 Revise the inventory to align with current recommendations to 

measure universal standards for WASH.

Notes:

 Indicates recommendations that require a change to the data collection.

 Indicates recommendations that focus on a change to indicator inclusion and calculation.

For many indicators, the captured information only approximates the sought-after information. The 

following sections explain these indicators in detail and provide concrete recommendations for revising

SPA surveys to better capture information.

5.3.1 Family planning

Counseling about family planning may not be well captured using the current observation protocol. Provider 

interactions related to specific methods are captured only among clients who leave with a method or a 

prescription. As method choice and information exchange are critical to the framework of quality of care 

for family planning, it is imperative to understand whether a client receives counseling related to a wider 

range of methods. For instance, if a returning client discusses a different method but ultimately decides to 

continue with the previous method, those discussions aren’t recorded. Further, if a client does not leave 

with a method despite attending a family planning service, the current structure of the protocol does not 

allow the researcher to understand the nature of the client-provider interactions because the counseling 

would not have been recorded. In addition, counseling may not be expected if returning users attend the 

service only for a refill. However, as it stands, the sample size in some countries is not large enough to 

study only new users. Also, although SPA surveys capture private facilities, which is an advantage over 

routine health management information systems (Mallick et al. 2020), family planning users (especially 

users of short-term methods) may obtain their methods from pharmacies; accordingly, this sample of clients 

is not representative of all family planning users. Finally, the indicators used in this study were only a proxy 

for the primary factor of the validated index developed by Jain et al. (2019); elements of that factor are 

omitted from this index because of lack of data. 

Recommendations

We have several concrete suggestions based on these limitations. Additional questions could be added to 

assess frequency or duration of contraceptive stockouts. Counseling should be recorded for all clients and 

all methods, regardless of whether the client leaves with a particular method. The protocol can be improved

by aligning with the validated measured described by Jain et al. (2019). Within budget constraints, a larger 

sample of clients is often warranted to better study critical clients. 
52

5.3.2 Antenatal care

For ANC, all indicators were client-based, describing the process of care. The counseling indicator for iron 

supplementation reflects counseling that was received during the consultation with the provider and was 

limited to women attending their first ANC visit. Although iron counseling can occur during group sessions, 

the 2016 WHO ANC guidelines recommend that the first visit be an individual consultation (WHO 2016c). 

Therefore, we expect minimal impact of group iron counseling on our indicator. Although the interviewer 

notes whether group counseling is provided, the content of group counseling is not recorded. 

In contrast, the breastfeeding counseling indicator reflects the clients’ self-report of receipt of counseling 

regardless of timing of visit. This means that breastfeeding counseling could have occurred during the 

consultation or prior to the consultation, during group health education sessions. In addition, the exit 

interviewer queries about counseling on exclusive breastfeeding, while the observation captures counseling 

related to early, prolonged, and exclusive breastfeeding. These two instruments should also align to better 

understand true counseling and successful knowledge transfer. It is possible that our indicator is biased 

since it is based solely on client self-report with no corresponding observations of either group or individual 

consultations (Assaf, Wang, and Mallick 2016; Bessinger and Bertrand 2001; Hameed et al. 2017). 

Recommendations

Considering the 2016 ANC WHO guidelines, the ANC indicators could be strengthened by first collecting 

information on the content covered during group education sessions, as implementation of the guidelines 

may vary in different countries and types of facilities. Second, in addition to observing individual 

consultations, which provide useful information around meeting standards of care, it is important to 

incorporate observations of group education sessions, especially around counseling. This could be captured 

in the facility inventory as well as client exit interview, with additional detail about the content of group 

counseling. Further, the client exit interview questions could be aligned with the observation protocol to 

better understand effective counseling (such as successfully conveying information to clients as tested 

through the exit interview) and to better capture client biases. 

5.3.3 Delivery care

Observing labor and delivery has many challenges. First, labor and delivery services are unpredictable. The 

volume of clients is much smaller than for other services; thus, it is difficult to acquire an adequate sample

size for observations, especially in lower-level facilities. In addition, the extremely detailed observation 

protocol coupled with the time needed to fully observe this service can be prohibitive at scale. As a result 

of having no observation of delivery, the composite indicator reflecting whether the facility reports having

performed six signal functions of BEmOC in the past three months is used as a proxy process indicator. 

However, in our report we defined it as a structural indicator, as it is based only on facility report. 

This BEmOC signal function indicator is additionally limited by the nature of the report of the interviewee.

A previous examination of SPA data found that facilities report services that are not actually observed in 

practice (Mallick, Benedict, and Wang 2020). In the case of signal functions, performance of some 

procedures (e.g., parenteral administration of anticonvulsants for hypertensive disorders of pregnancy) also 

depends on having emergency cases requiring each signal function, although facility inventories do not 
53

explicitly inquire about this. Facilities may also report the procedure even if it was performed more than 

three months ago.

In addition, the SPA instrument does not robustly assess care for small and sick newborns who require

interventions to survive, such as support for thermoregulation, breathing, infections, or other lifethreatening conditions (Moxon et al. 2018). Prematurity, infections, and complications at birth cause the 

majority of neonatal deaths (Hug et al. 2019); 80% of neonatal mortality is attributable to small size at birth 

(Lawn et al. 2014). Thus, monitoring health care for small and sick newborns is vital for identifying areas 

that can improve mortality outcomes. 

Recommendations 

As approximately half of all maternal deaths happen around the time of labor and delivery, observation of 

these services could provide important information about the health system at a critical juncture along the 

continuum of care. Although some countries have included a module for observing labor and delivery in 

their SPA survey—namely, Malawi (MoH Malawi and ICF International 2014) and Kenya (NCAPD/Kenya 

et al. 2011), this is not standard. Future SPA survey revisions could, however, include a short module such 

as the validated short assessment of the quality of the process of intrapartum and immediate postpartum 

care, developed by Tripathi and colleagues (Tripathi et al. 2019), with the option of a full module (Tripathi 

et al. 2015). This short assessment includes newborn care; however, more is needed to assess care for small 

and sick newborns, as proposed by Moxon et al. (2018). For example, SPA surveys could assess whether

KMC is delivered on site or if mothers and babies are referred to a specialty facility; if delivery and 

postpartum care are observed, the surveys could also assess whether there is adherence to KMC guidelines. 

Several other recommendations are detailed by Moxon et al. (2018), for example harmonizing with other 

tools, querying facilities about complex interventions for small and sick newborns, and including more 

detailed questions about specialist health workers. Finally, in lieu of the gold standard of observation, which 

is ideal but cost-prohibitive, SPA revisions could consider adapting postpartum interviews of providers and 

clients, for example as was included in the Nepal 2015 SPA survey. Although this would be subject to recall 

bias (Molina et al. 2019), it could alleviate the burden on the interviewer (and the cost). Similarly, reviews

of delivery records could be adapted as part of SPA surveys (Leslie and Gage, 2020).

5.3.4 Immunization

One limitation that is easily resolvable is that the immunization indicator we used included only basic 

vaccinations against polio, measles, tuberculosis, diphtheria, pertussis, and tetanus. Country-specific 

analysis should be encouraged to include all recommended vaccinations administered within the country. 

For this analysis, however, we limited the indicator to basic vaccines with well-established 

recommendations and administration. This exercise identified no recommendations for improving data 

collection around immunization. 

5.3.5 Child curative care

The health indicator that reflects readiness to treat and diagnose malaria does not include whether facilities

have trained providers who can administer RDT or an appropriate microscopy test. This element is 

traditionally incorporated into indicator definitions that reflect facility capacity to diagnose and treat 

malaria. However, it was omitted from our index because the provider training information collected is 
54

limited to in-service training (Taylor et al. 2018); it does not include whether a provider received training 

from a supervisor, which can be a valid method of training. In fact, the U.S. President’s Malaria Initiative

conducts a small proportion of its training in classroom settings, while most training occurs on the job or 

through supervision (USAID and CDC 2019). Thus, inclusion of this limited indicator could have 

inaccurately punished facilities where training may not have been technically considered in-service. 

Regardless, omitting provider training means that this indicator cannot be directly compared to the global 

definition of malaria diagnostic capacity. It also means that the indicator used in this report may 

overestimate true diagnostic capacity, considering that facilities may have diagnostic equipment without 

trained providers to administer them. Similarly, omitting provider training in other service areas may also 

overestimate a facility’s true capacity to administer high-quality care, diagnostic tools, or treatment.

Additionally, the “Test, Treat, and Track” initiative is aimed at training providers to treat after accurate 

testing, in hopes of eliminating presumptive treatment of malaria (WHO 2012).

Observation data from child curative care visits may represent a limited view of what occurs during the 

visit. Some important elements may be missed during observation, such as children’s temperatures being

taken during triage or intake, or in a waiting room before the observation begins. In addition, accounting 

for the true denominator for indicators to reflect appropriate diagnoses is difficult. To assess diarrhea 

appropriately, all children presenting with diarrhea must be checked for dehydration. This symptom, like 

difficulty breathing for ARI assessments, must be mentioned during the visit by the caretaker or the provider 

and in the exit interview. It is difficult to know if this denominator excludes children who should be assessed 

for one of these diagnoses; this calculation can be assumed to be only a proxy for suspected cases. Finally, 

during the visit, some treatment and diagnostic questions are asked of the provider only if a diagnosis is 

made. For example, our study did not include an indicator reflecting appropriate malaria diagnosis. 

Information on the use of lab tests (RDT and microscopy) is only collected if there is a malaria diagnosis;

these data are not collected for those who do not receive a diagnosis (Leslie and Gage 2020; Taylor, Ahmed, 

and Wang 2019). In fact, although data are collected on assessments, little information is collected on what 

assessments or symptoms led to the diagnosis. 

There are also some caveats for the nutritional status assessment indicator in the context of child curative 

care. In facilities, acute malnutrition in children can be assessed by weight-for-height or mid-upper arm 

circumference and bilateral pitting edema (WHO 2019b). Although SPA surveys capture structural 

indicators such as availability of weighing scales, height boards, and mid-upper arm circumference tape,

the nutritional status assessment process indicator includes only measurements of weight, plotting of growth 

charts, and discussions of growth with the caregiver. This indicator does not include assessment of edema, 

which can be considered in future iterations of the index. Further, SPA surveys do not capture process 

information on measurements of height or mid-upper arm circumference. The SPA observation also does 

not indicate whether the provider plots weight for height or for age; plotting weight for height is important 

for determining whether the child is experiencing acute malnutrition (wasting), whereas plotting weight for 

age is not recommended. Thus, the information currently collected does not allow for determination of 

whether the provider adhered to the WHO standards for nutritional assessment (WHO 2018). 

Recommendations

We suggest several areas for SPA revisions to better capture data on key indicators. First, relevant to 

provider training, the health worker questionnaire can be adapted to include supervisory training as a form 
55

of training. Next, in line with an in-depth review of the SPA protocol conducted by Leslie and Gage (2020), 

we suggest refining data collection to capture appropriate assessment and treatment, which would facilitate 

research to look beyond basic care and explore further components of quality such as provider capacity to 

treat and diagnose. Refining these data could involve observers recording the results of certain assessments,

such as temperature or number of respirations (Leslie and Gage 2020). To better understand appropriate 

malaria treatment for children, the protocol should be expanded to record RDT for all children presenting 

with appropriate symptoms, not just those who receive a malaria diagnosis (Leslie and Gage 2020; Taylor, 

Ahmed, and Wang 2019). In addition, to align with the WHO standards on quality of care for children in 

facilities, the nutritional status assessment indicator could be strengthened by revising SPA surveys and 

incorporating the measurement of height and mid-upper arm circumference as well as plotting weight for 

height. Although the nutrition status indicator is collected in the context of child curative care, routine 

growth monitoring is also a core nutrition intervention provided in health facilities. We recommend that 

SPA surveys also potentially include a module to assess routine growth monitoring and other services such 

as immunizations during well-child visits. SPA inventories could also collect more detailed information 

about community-based nutrition programs, as there is a gap in data on these programs in the health system 

(Mallick et al. 2020). 

5.3.6 Water, sanitation, and hygiene

We used one indicator to summarize a facility’s improved WASH amenities. This indicator is indicative of 

the minimum necessities for hygiene, but it is only a crude indicator of the hygiene clients experience during 

care visits, procedures, and treatment. Although WASH amenities may be available in general facilities, 

SPA data do not capture whether these facilities are accessible or clean. The indicator also does not capture 

hand hygiene within close proximity to toilets, and the indicator for improved toilet does not provide 

sufficient information to measure WHO Standard 8.1, input measure 6 (WHO 2016b), or the Joint 

Monitoring Programme for Water Supply, Sanitation, and Hygiene indicator 2.1.2, which seeks to capture

the proportion of health care facilities with improved and usable sanitation facilities, with at least one toilet 

dedicated for staff, at least one sex-separated toilet with menstrual hygiene facilities, and at least one toilet 

accessible for users with limited mobility (WHO and UNICEF 2018). In addition, an improved water source

includes any source that is onsite or within 500 meters—a distance that may impede its accessibility and 

belie the appearance of available amenities. Previous reporting by the Joint Monitoring Programme for 

Water Supply, Sanitation, and Hygiene has noted that improved water that is not on the premises but is 

within 500 meters is considered “limited availability”; higher tiers of availability require that an improved 

water source be located on the facility premises (WHO and UNICEF 2018).

Using an indicator that measures the presence of running water and hand soap or alcohol-based hand rubs

in client examination rooms may more accurately reflect facility hygiene. WASH resources are especially 

critical for services such as delivery or surgery. However, examining this would limit the sample 

(denominator) for this indicator to only those facilities that provide that specific service; the indicator is 

calculated based on availability of WASH resources in general, or in outpatient areas. The existing 

observation protocol for ANC, family planning, or curative care for children could be expanded to include 

WASH-related provider behaviors. We encourage continued investigation on this WASH topic, specifically 

when examining facilities providing this care. 
56

Recommendations

SPA inventories, when updated, should align with current recommendations to measure universal standards. 

Inventories should also capture a more precise proximity to improved water source, as a binary measure of 

a water source within 500 meters does not provide sufficient information on whether this source meets the 

needs of the facility. Current observation protocols can also be adapted to include whether providers adhere 

to guidelines for hygiene and sanitation, such as handwashing. 

5.4 Conclusion and Next Steps

The index proposed in this report was developed to serve as a quality of care complement to the CCI, which 

summarizes coverage of eight RMNCH interventions. This proposed QOCI reflects critical components of 

quality similarly across the RMNCH continuum, with additional indicators representing readiness or 

delivery of care for nutrition, malaria, and WASH-related services. The QOCI averages 17 indicators across 

six health service areas using a weighted additive approach. Using data from seven countries with recent 

SPA surveys, we illustrated the utility of the index in identifying subnational areas, health service areas, 

and specific aspects of health services that need improvement. In many ways, quality of care data may be 

inaccessible or difficult to comprehend, especially given the vast number of indicators we identified in our

study. Our hope is that our index and short list of indicators may facilitate the communication of quality of

care needs to a broader audience of stakeholders to garner support for the most impactful life-saving 

interventions. 

The development of such an index is the first step in a series of endeavors that will include revising both

the index and the SPA questionnaires. The proposed indicators, although already reviewed by a small set of 

content experts, should undergo additional scrutiny to ensure that they hold the highest construct validity

(i.e., accurately capture what they are intended to capture). Efforts to refine these indicators should focus 

on building consensus so that the indicators ultimately chosen for the QOCI are not only valid but also best 

placed to capture quality most broadly, to the extent possible given the task of developing a concise and 

easily understandable index.

It is clear from this exercise that despite the strengths of SPA surveys in collecting an enormous amount of 

information and uniquely capturing observation of visits in some health areas, more information or revisions 

are needed in several areas. Notwithstanding our recommendations for improvements to the SPA and the 

QOCI, this index presents a new opportunity to more broadly monitor progress toward global goals for 

universal coverage of high-quality health care.
57

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APPENDIX

Appendix Table 1 Original set of indicators for consideration for inclusion in the quality of care index

Health area Indicator Definition

Quality of care 

component

Family planning (FP) Contraceptive method choice Percentage of FP facilities that provide at least one short-acting, one long-acting, and 

one barrier method 

Structure

Counseling on method side effects Percentage of FP clients who are counseled about side effects and health concerns 

about the method chosen/provided

Process 

Constellation of services Percentage of health facilities that offer FP and maternal and child health services on 

the same day (e.g., at least 20 days per month for both services)

Structure

Maternal and 

newborn health

Basic emergency obstetric care 

(BEmOC)

Percentage of facilities that performed the BEmOC signal functions at least once during 

the past 3 months

Structure

Comprehensive emergency obstetric 

are (CEmOC)

Percentage of facilities that performed the CEmOC signal functions at least once during 

past 3 months

*Note: Not all facilities are expected to provide this service.

Structure

Blood pressure measurement during 

ANC visits

Percentage of antenatal clients whose blood pressure is measured Process

Newborn resuscitation equipment Percentage of facilities with functional bags and masks (two neonatal mask sizes) in the 

delivery areas

Structure

Injectable antibiotics for neonatal 

sepsis

Percentage of facilities with injectable antibiotics for neonatal sepsis Structure

Kangaroo mother care Percentage of facilities that provide kangaroo mother care Structure

Child health Availability of vaccines Percentage of facilities that have all age-appropriate primary vaccines available Structure

Antibiotics for severe pneumonia Percentage of health facilities that have first-line antibiotics (i.e., amoxicillin) Structure

Provider adherence to IMCI diagnostic 

guidelines

Percentage of sick-child visits in which the child is checked for all the following:

1) Three danger signs (inability to eat/drink, vomiting everything, history of febrile 

convulsions)

2) Three main symptoms (cough/difficulty breathing, diarrhea, fever) 

3) Basic physical examination (counting respiration rate, assessing dehydration, 

measuring temperature)

Process

Counseling on childhood illnesses Percentage of sick-child visits in which the provider tells the caregiver about the child 

illness, the symptoms that require immediate return, a scheduled or discussed return 

visit, and feeding practices

Process

Malaria Malaria service readiness Percentage of facilities that are malaria-service ready (with diagnostic capacity for 

malaria and with drugs available for artemisinin-based combination therapy) 

Structure

Management of suspected malaria 

cases

Percentage of suspected malaria cases that receive the following services:

1) Provider asked about fever

2) Child was felt for temperature, had temperature taken with a thermometer, or was 

checked for pallor by looking at palms 

3) Provider instructed child to see another provider or laboratory for a finger or heel 

stick for blood testing

*Note: SPA data currently collected are not suitable for measuring quality of clinical 

management of suspected malaria cases.

Process

Nutrition Availability of iron-containing 

supplements for women

Percentage of facilities with iron-containing supplements Structure

Iron-containing supplements

provided/prescribed to client

Percentage of clients who are observed and reported to receive iron-containing 

supplements

Process

Counseling on use or side effects of

iron supplementation 

Percentage of clients who are observed and reported to receive counseling on use or 

side effects of iron-containing supplements

Process

Counseling on maternal nutrition Percentage of clients who receive advice on nutrition during pregnancy Process

Provider training on breastfeeding Percentage of health providers providing antenatal care who have received training on 

breastfeeding or infant and young child feeding

Structure

Breastfeeding counseling Percentage of clients who receive breastfeeding counseling during antenatal care Process

Malnutrition assessment for sick 

children

Percentage of sick-child visits in which the child’s weight is taken, the weight is plotted 

on a growth chart, and the child’s growth is discussed

Process
70

Appendix Table 2 Facility categories by country

Country Facility categories

Bangladesh District hospital

General hospital

Mother and child welfare center

Upazila health complex

Upazila hospital

Union hospital

Union subcenter

Union health and family welfare center

Community clinic

The Democratic Republic of the Congo Hospital

Health center

Referral health center

Clinic

Haiti Hospital

Health center with beds

Health center without beds

Dispensary

Community health center

Malawi Hospital

Health center

Dispensary

Clinic

Health post

Nepal Central hospital

Regional hospital

Zonal hospital

District hospital

Urban health center

Primary health care center 

Health post 

Stand-alone HIV testing center

Primary health care outreach clinic

Expanded Program on Immunization clinic

Community health unit

Senegal Hospital

Health center

Health post

Health hut

Tanzania Hospital

Health center

Dispensary

Clinic
71

Appendix Table 3 Subnational and national weighted (and unweighted) samples of facilities and clients analyzed for 

each indicator, Bangladesh SPA 2017

Service or indicator Barishal Chattogram Dhaka Khulna Rajshahi Rangpur Sylhet Mymensingh National

Family planning

Method availability 109(239) 262(264) 267(164) 175(145) 201(146) 158(129) 93(151) 113(115) 1,377(1353)

Counseling on side effects na na na na na na na na na

Antenatal care

Blood pressure measurement na na na na na na na na na

Counseling on iron na na na na na na na na na

Counseling on breastfeeding na na na na na na na na na

Delivery care

BEmOC signal functions performed 33(150) 80(178) 78(105) 36(76) 54(91) 38(74) 19(84) 21(60) 358(818)

Essential drugs 33(150) 80(178) 78(105) 36(76) 54(91) 38(74) 19(84) 21(60) 358(818)

Neonatal resuscitation 33(150) 80(178) 78(105) 36(76) 54(91) 38(74) 19(84) 21(60) 358(818)

Immunization

Availability of viable vaccines and 

syringes

101(201) 257(232) 269(154) 165(129) 186(124) 176(122) 85(136) 115(108) 1354(1206)

Child curative care

Antibiotics for children 112(253) 277(296) 298(183) 185(160) 212(153) 193(155) 96(162) 122(125) 1,495(1,487)

ORS/Zinc for diarrhea 112(253) 277(296) 298(183) 185(160) 212(153) 193(155) 96(162) 122(125) 1,495(1,487)

Malaria diagnosis and treatment capacity 112(253) 277(296) 298(183) 185(160) 212(153) 193(155) 96(162) 122(125) 1,495(1,487)

ARI assessment na na na na na na na na na

Diarrhea assessment na na na na na na na na na

Anemia assessment na na na na na na na na na

Nutritional assessment na na na na na na na na na

WASH

Basic services for WASH 113(260) 288(302) 304(188) 187(164) 220(161) 193(158) 96(163) 123(128) 1,524(1,524)

Notes: ARI = acute respiratory infection; BEmOC = basic emergency obstetric care; na = not applicable; ORS = oral rehydration salts; WASH = water, sanitation, and hygiene.
72

Appendix Table 4 Subnational and national weighted (and unweighted) samples of facilities and clients analyzed for each ind

Republic of the Congo SPA 2017-18

Service or indicator Sud-Kivu Kinshasa

KongoCentralMaiNdombe Kwilu Kwango EquateurSudUbangiNordUbangi Mongala Tshuapa 

Family planning

Method availability 75(57) 62(55) 58(65) 19(28) 57(60) 27(35) 35(39) 29(39) 21(41) 30(33) 9(25) 

Counseling on side effects na na na na na na na na na na na 

Antenatal care

Blood pressure measurement 885(221) 352(368) 119(244) 65(85) 227(292) 43(100) 57(80) 313(184) 104(193) 70(130) 151(264) 

Counseling on iron 513(119) 150(168) 48(104) 18(31) 106(151) 26(57) 27(40) 190(110) 67(130) 47(88) 105(186) 

Counseling on breastfeeding 885(221) 352(368) 119(244) 65(85) 227(292) 43(100) 57(80) 313(184) 104(193) 70(130) 151(264) 

Delivery care

BEmOC signal functions performed 76(59) 103(71) 85(78) 38(48) 75(69) 32(42) 37(41) 32(41) 21(41) 35(40) 29(41) 

Essential drugs 76(59) 103(71) 85(78) 38(48) 75(69) 32(42) 37(41) 32(41) 21(41) 35(40) 29(41) 

Neonatal resuscitation 76(59) 103(71) 85(78) 38(48) 75(69) 32(42) 37(41) 32(41) 21(41) 35(40) 29(41) 

Immunization

Availability of viable vaccines and 

syringes

74(33) 97(63) 74(63) 36(31) 69(36) 32(33) 35(27) 30(26) 20(32) 36(33) 27(28) 

Child curative care

Antibiotics for children 86(62) 106(73) 88(80) 38(50) 77(70) 33(43) 37(41) 32(41) 21(41) 37(41) 29(41) 

ORS/Zinc for diarrhea 86(62) 106(73) 88(80) 38(50) 77(70) 33(43) 37(41) 32(41) 21(41) 37(41) 29(41) 

Malaria diagnosis and treatment capacity 86(62) 106(73) 88(80) 38(50) 77(70) 33(43) 37(41) 32(41) 21(41) 37(41) 29(41) 

ARI assessment 203(117) 76(78) 93(115) 12(24) 41(52) 13(29) 15(23) 115(73) 61(107) 55(42) 50(75) 

Diarrhea assessment 102(56) 43(35) 45(56) 17(22) 16(23) 6(20) 19(21) 87(57) 74(127) 41(38) 26(47) 

Anemia assessment 269(142) 112(117) 141(165) 31(47) 69(73) 19(44) 42(51) 179(108) 114(190) 132(97) 101(138) 

Nutritional assessment 269(142) 112(117) 141(165) 31(47) 69(73) 19(44) 42(51) 179(108) 114(190) 132(97) 101(138) 

WASH

Basic services for WASH 86(62) 106(73) 88(80) 38(50) 77(70) 33(43) 37(41) 32(41) 21(41) 37(41) 29(41) 
73

Appendix Table 4—Continued

Service or indicator Ituri Nord-Kivu

HautKatanga LualabaHautLomami TanganyikaKasaïOriental Sankuru Lomami KasaïK

C

Family planning

Method availability 35(44) 77(78) 78(62) 41(37) 38(36) 9(11) 15(24) 31(39) 20(24) 44(45) 

Counseling on side effects na na na na na na na na na na 

Antenatal care

Blood pressure measurement 105(120) 447(361) 283(377) 80(123) 256(167) 107(154) 148(102) 69(127) 40(64) 30(78) 15

Counseling on iron 48(68) 223(169) 112(163) 19(27) 90(68) 88(115) 101(61) 47(96) 14(32) 24(60) 

Counseling on breastfeeding 105(120) 447(361) 283(377) 80(123) 256(167) 107(154) 148(102) 69(127) 40(64) 30(78) 15

Delivery care

BEmOC signal functions performed 68(71) 94(90) 100(69) 42(40) 41(40) 32(41) 42(43) 33(41) 42(41) 71(53) 

Essential drugs 68(71) 94(90) 100(69) 42(40) 41(40) 32(41) 42(43) 33(41) 42(41) 71(53) 

Neonatal resuscitation 68(71) 94(90) 100(69) 42(40) 41(40) 32(41) 42(43) 33(41) 42(41) 71(53) 

Immunization

Availability of viable vaccines and 

syringes

65(47) 91(54) 99(64) 40(32) 39(28) 33(36) 42(29) 30(25) 39(27) 66(37) 

Child curative care

Antibiotics for children 71(73) 107(94) 104(72) 44(41) 42(41) 34(42) 44(44) 33(41) 42(42) 71(53) 

ORS/Zinc for diarrhea 71(73) 107(94) 104(72) 44(41) 42(41) 34(42) 44(44) 33(41) 42(42) 71(53) 

Malaria diagnosis and treatment capacity 71(73) 107(94) 104(72) 44(41) 42(41) 34(42) 44(44) 33(41) 42(42) 71(53) 

ARI assessment 26(46) 165(119) 103(93) 58(61) 44(55) 49(67) 48(25) 63(70) 19(25) 73(60) 

Diarrhea assessment 21(32) 131(85) 34(41) 39(47) 14(27) 27(39) 26(10) 36(41) 15(18) 29(28) 

Anemia assessment 45(73) 264(178) 123(123) 66(78) 69(84) 116(153) 56(34) 96(101) 29(33) 137(104) 12

Nutritional assessment 45(73) 264(178) 123(123) 66(78) 69(84) 116(153) 56(34) 96(101) 29(33) 137(104) 12

WASH

Basic services for WASH 71(73) 107(94) 104(72) 44(41) 42(41) 34(42) 44(44) 33(41) 42(42) 71(53) 

Notes: ARI = acute respiratory infection; BEmOC = basic emergency obstetric care; na = not applicable; ORS = oral rehydration salts; WASH = water, sanitation, and hygiene.
74

Appendix Table 5 Subnational and national weighted (and unweighted) samples of facilities and clients analyzed for each 

indicator, Haiti SPA 2017-18

Service or 

indicator

Aire 

Metropolitaine Ouest Sud'Est Nord Nord'Est Artibonite Centre SudGrand'

Anse Nord'Ouest Nippes National

Family planning

Method availability 139(139) 117(116) 50(50) 62(62) 36(36) 102(102) 38(38) 64(64) 47(47) 75(74) 28(28) 756(756)

Counseling on 

side effects

310(249) 115(118) 59(74) 97(94) 28(37) 149(147) 110(108) 72(83) 59(69) 76(83) 31(42) 1,107(1,104)

Antenatal care

Blood pressure 

measurement

366(377) 225(228) 86(111) 151(161) 115(72) 184(173) 172(119) 64(82) 37(49) 91(109) 35(45) 1,526(1,526)

Counseling on iron 139(137) 123(124) 42(54) 57(62) 67(38) 105(101) 94(62) 42(54) 22(31) 46(55) 17(23) 754(741)

Counseling on 

breastfeeding

366(377) 225(228) 86(111) 151(161) 115(72) 184(173) 172(119) 64(82) 37(49) 91(109) 35(45) 1,526(1,526)

 

Delivery care

BEmOC signal 

functions 

performed

63(63) 49(49) 35(35) 36(36) 21(21) 34(34) 24(24) 25(25) 20(20) 43(42) 12(12) 361(361)

Essential drugs 63(63) 49(49) 35(35) 36(36) 21(21) 34(34) 24(24) 25(25) 20(20) 43(42) 12(12) 361(361)

Neonatal 

resuscitation

63(63) 49(49) 35(35) 36(36) 21(21) 34(34) 24(24) 25(25) 20(20) 43(42) 12(12) 361(361)

Immunization

Availability of 

viable vaccines 

and syringes

122(122) 107(106) 45(45) 53(53) 32(32) 94(94) 38(38) 61(61) 45(45) 79(78) 27(27) 701(701)

Child curative care

Antibiotics for 

children

190(190) 145(144) 67(67) 103(103) 41(41) 120(120) 51(51) 73(73) 52(52) 85(83) 34(34) 958(958)

ORS/Zinc for 

diarrhea

190(190) 145(144) 67(67) 103(103) 41(41) 120(120) 51(51) 73(73) 52(52) 85(83) 34(34) 958(958)

Malaria diagnosis 

and treatment 

capacity

190(190) 145(144) 67(67) 103(103) 41(41) 120(120) 51(51) 73(73) 52(52) 85(83) 34(34) 958(958)

ARI assessment 363(331) 232(216) 59(72) 150(158) 25(31) 182(163) 126(100) 88(105) 33(52) 44(61) 33(39) 1,334(1,328)

Diarrhea 

assessment

167(155) 73(68) 14(18) 44(46) 8(9) 56(56) 62(50) 29(35) 9(15) 19(25) 15(17) 496(494)

Anemia 

assessment

605(551) 340(318) 92(112) 238(254) 48(59) 287(263) 226(176) 128(155) 48(74) 101(139) 54(65) 2,166(2,166)

Nutritional 

assessment

605(551) 340(318) 92(112) 238(254) 48(59) 287(263) 226(176) 128(155) 48(74) 101(139) 54(65) 2,166(2,166)

WASH

Basic services for 

WASH

221(222) 150(149) 68(68) 105(105) 41(41) 121(121) 52(52) 78(78) 53(53) 86(84) 34(34) 1,007(1,007)

Notes: ARI = acute respiratory infection; BEmOC = basic emergency obstetric care; ORS = oral rehydration salts; WASH = water, sanitation, and hygiene.
75

Appendix Table 6 Subnational and national weighted (and unweighted) samples of facilities and 

clients analyzed for each indicator, Malawi SPA 2013-14

Service or indicator North Central South National

Family planning

Method availability 140(142) 307(310) 361(358) 809(810)

Counseling on side effects 131(196) 754(668) 597(614) 1,482(1,478)

Antenatal care

Blood pressure measurement 232(318) 884(851) 952(899) 2068(2,068)

Counseling on iron 90(134) 370(348) 410(377) 871(859)

Counseling on breastfeeding 232(318) 884(851) 952(899) 2068(2,068)

Delivery care

BEmOC signal functions performed 102(103) 198(203) 227(234) 528(540)

Essential drugs 102(103) 198(203) 227(234) 528(540)

Neonatal resuscitation 102(103) 198(203) 227(234) 528(540)

Immunization

Availability of viable vaccines and 

syringes

129(131) 255(260) 314(315) 698(706)

Child curative care

Antibiotics for children 158(160) 338(342) 418(416) 915(918)

ORS/Zinc for diarrhea 158(160) 338(342) 418(416) 915(918)

Malaria diagnosis and treatment capacity 158(160) 338(342) 418(416) 915(918)

ARI assessment 318(412) 1,170(950) 653(715) 2,141(2,077)

Diarrhea assessment 121(151) 395(342) 294(319) 809(812)

Anemia assessment 488(629) 1,680(1,400) 1,161(1,300) 3,329(3,329)

Nutritional assessment 488(629) 1,680(1,400) 1,161(1,300) 3,329(3,329)

WASH

Basic services for WASH 165(167) 362(364) 450(446) 977(977)

Notes: ARI = acute respiratory infection; BEmOC = basic emergency obstetric care; ORS = oral rehydration salts; WASH = water, 

sanitation, and hygiene.
76

Appendix Table 7 Subnational and national weighted (and unweighted) samples of facilities and clients 

analyzed for each indicator, Nepal SPA 2015

Service or indicator Eastern Central Western Mid-Western Far-Western National

Family planning

Method availability 204(196) 298(273) 201(165) 127(136) 89(106) 919(876)

Counseling on side effects 186(186) 332(296) 104(82) 64(76) 68(100) 754(740)

Antenatal care

Blood pressure measurement 385(350) 661(563) 232(241) 135(167) 96(188) 1,509(1,509)

Counseling on iron 147(144) 212(194) 77(82) 52(74) 35(79) 524(573)

Counseling on breastfeeding 385(350) 661(563) 232(241) 135(167) 96(188) 1,509(1,509)

Delivery care

BEmOC signal functions performed 86(134) 113(174) 85(112) 105(114) 67(87) 457(621)

Essential drugs 86(134) 113(174) 85(112) 105(114) 67(87) 457(621)

Neonatal resuscitation 86(134) 113(174) 85(112) 105(114) 67(87) 457(621)

Immunization

Availability of viable vaccines and 

syringes

192(178) 279(246) 190(151) 123(125) 86(95) 870(795)

Child curative care

Antibiotics for children 208(201) 307(291) 201(165) 129(139) 89(107) 934(903)

ORS/Zinc for diarrhea 208(201) 307(291) 201(165) 129(139) 89(107) 934(903)

Malaria diagnosis and treatment capacity na na na na na na

ARI assessment 190(219) 380(357) 128(144) 164(166) 86(127) 948(1,013)

Diarrhea assessment 108(86) 150(115) 55(60) 90(104) 73(102) 476(467)

Anemia assessment 495(485) 896(780) 285(312) 313(338) 197(271) 2,186(2,186)

Nutritional assessment 495(485) 896(780) 285(312) 313(338) 197(271) 2,186(2,186)

WASH

Basic services for WASH 211(205) 308(294) 202(166) 130(141) 89(109) 940(915)

Notes: ARI = acute respiratory infection; BEmOC = basic emergency obstetric care; na = not applicable; ORS = oral rehydration salts; WASH = water, sanitation, 

and hygiene.
77

Appendix Table 8 Subnational and national weighted (and unweighted) samples of facilities and clients analyzed for each 

indicator, Senegal SPA 2016 and 2017

Service or indicator Dakar Diourbel Fatick Kaffrine Kaolack Kedougou Kolda Louga Matam

SaintLouis SédhiouTambacounda ThièsZiguinchor National

Family planning

Method availability 101(90) 57(78) 74(70) 59(61) 83(68) 27(57) 94(62) 85(83) 46(65) 93(88) 41(69) 68(83) 155(98) 75(75) 1,058(1,047)

Counseling on side 

effects

116(92) 86(68) 51(53) 21(30) 24(26) 5(15) 15(17) 41(47) 22(32) 65(63) 34(49) 25(31) 83(62) 52(50) 639(635)

Antenatal care

Blood pressure 

measurement

223(138) 77(64) 66(57) 38(61) 39(44) 8(22) 18(25) 57(65) 39(52) 66(72) 33(57) 26(31) 110(104) 48(57) 849(849)

Counseling on iron 91(58) 30(25) 29(25) 11(20) 16(18) 2(5) 5(6) 14(17) 18(22) 28(30) 14(24) 8(10) 32(29) 15(18) 313(307)

Counseling on 

breastfeeding

223(138) 77(64) 66(57) 38(61) 39(44) 8(22) 18(25) 57(65) 39(52) 66(72) 33(57) 26(31) 110(104) 48(57) 849(849)

Delivery care

BEmOC signal 

functions 

performed

60(65) 55(70) 62(60) 38(43) 59(52) 23(52) 79(55) 74(70) 45(62) 62(58) 35(58) 57(67) 113(79) 70(70) 831(861)

Essential drugs 60(65) 55(70) 62(60) 38(43) 59(52) 23(52) 79(55) 74(70) 45(62) 62(58) 35(58) 57(67) 113(79) 70(70) 831(861)

Neonatal 

resuscitation

60(65) 55(70) 62(60) 38(43) 59(52) 23(52) 79(55) 74(70) 45(62) 62(58) 35(58) 57(67) 113(79) 70(70) 831(861)

Immunization

Availability of 

viable vaccines 

and syringes

82(76) 51(57) 66(62) 64(64) 82(67) 34(70) 98(64) 78(74) 47(66) 81(75) 43(74) 67(80) 152(98) 76(75) 1,022(1,002)

Child curative care

Antibiotics for 

children

109(102) 63(85) 85(82) 70(71) 98(81) 36(74) 107(74) 94(91) 46(64) 91(89) 45(78) 74(90) 167(109) 89(93) 1,174(1,183)

ORS/Zinc for 

diarrhea

109(102) 63(85) 85(82) 70(71) 98(81) 36(74) 107(74) 94(91) 46(64) 91(89) 45(78) 74(90) 167(109) 89(93) 1,174(1,183)

Malaria diagnosis 

and treatment 

capacity

109(102) 63(85) 85(82) 70(71) 98(81) 36(74) 107(74) 94(91) 46(64) 91(89) 45(78) 74(90) 167(109) 89(93) 1,174(1,183)

ARI assessment 91(80) 125(95) 60(53) 41(61) 51(62) 7(23) 21(28) 65(55) 19(30) 56(55) 27(45) 23(30) 115(78) 44(46) 746(741)

Diarrhea 

assessment

38(33) 43(35) 16(16) 15(25) 21(24) 2(8) 14(18) 28(21) 8(10) 34(31) 13(22) 11(14) 29(22) 13(12) 285(291)

Anemia 

assessment

146(125) 149(112) 87(78) 51(79) 57(72) 8(28) 33(45) 91(74) 50(63) 100(94) 43(72) 42(54) 142(102) 64(66) 1,064(1,064)

Nutritional 

assessment

146(125) 149(112) 87(78) 51(79) 57(72) 8(28) 33(45) 91(74) 50(63) 100(94) 43(72) 42(54) 142(102) 64(66) 1,064(1,064)

WASH

Basic services for 

WASH

144(123) 63(85) 85(82) 72(74) 101(85) 37(76) 111(79) 96(94) 51(77) 96(92) 45(78) 75(91) 178(116) 93(97) 1,249(1,249)

Notes: ARI = acute respiratory infection; BEmOC = basic emergency obstetric care; ORS = oral rehydration salts; WASH = water, sanitation, and hygiene.
78

Appendix Table 9 Subnational and national weighted (and unweighted) samples of facilities and clients analyzed for each indicat

Service or indicator Dodoma Arusha

Kilimanjaro TangaMorogoro PwaniDar es 

Salaam Lindi Mtwara Ruvuma Iringa Mbeya Sing

Family planning

Method availability 51(41) 37(35) 42(35) 49(39) 44(38) 38(34) 43(41) 35(33) 31(30) 39(32) 30(31) 67(48) 30(

Counseling on side effects 136(61) 40(44) 58(56) 109(74) 48(46) 21(24) 51(47) 109(81) 120(86) 112(100) 29(51) 67(83) 70(

Antenatal care

Blood pressure measurement 139(125) 104(147) 64(116) 148(92) 136(107) 56(69) 167(218) 74(88) 115(124) 188(236) 78(140) 151(164) 104(1

Counseling on iron 74(61) 48(63) 27(46) 60(42) 60(47) 24(27) 75(70) 27(32) 38(45) 92(101) 26(41) 60(51) 47(

Counseling on breastfeeding 139(125) 104(147) 64(116) 148(92) 136(107) 56(69) 167(218) 74(88) 115(124) 188(236) 78(140) 151(164) 104(1

Delivery care

BEmOC signal functions performed 47(40) 26(33) 36(37) 47(40) 54(45) 38(35) 22(41) 32(35) 35(35) 40(38) 37(36) 64(49) 32(

Essential drugs 47(40) 26(33) 36(37) 47(40) 54(45) 38(35) 22(41) 32(35) 35(35) 40(38) 37(36) 64(49) 32(

Neonatal resuscitation 47(40) 26(33) 36(37) 47(40) 54(45) 38(35) 22(41) 32(35) 35(35) 40(38) 37(36) 64(49) 32(

Immunization

Availability of viable vaccines 

and syringes

55(44) 39(38) 50(42) 49(39) 51(44) 36(33) 44(44) 35(37) 33(33) 43(40) 37(36) 64(50) 28(

Child curative care

Antibiotics for children 60(48) 52(45) 64(51) 55(43) 58(47) 45(40) 90(74) 35(37) 35(37) 47(42) 39(39) 72(52) 34(

ORS/Zinc for diarrhea 60(48) 52(45) 64(51) 55(43) 58(47) 45(40) 90(74) 35(37) 35(37) 47(42) 39(39) 72(52) 34(

Malaria diagnosis and treatment 

capacity

60(48) 52(45) 64(51) 55(43) 58(47) 45(40) 90(74) 35(37) 35(37) 47(42) 39(39) 72(52) 34(

ARI assessment 85(86) 122(122) 126(109) 164(133) 169(103) 54(62) 66(101) 109(88) 133(89) 89(111) 67(104) 103(93) 113(1

Diarrhea assessment 47(52) 76(85) 63(56) 75(58) 95(59) 20(27) 34(51) 37(34) 61(37) 69(117) 39(65) 55(72) 82(

Anemia assessment 145(147) 202(199) 210(184) 279(200) 339(185) 122(134) 190(238) 190(169) 246(167) 218(264) 106(150) 170(183) 167(2

Nutritional assessment 145(147) 202(199) 210(184) 279(200) 339(185) 122(134) 190(238) 190(169) 246(167) 218(264) 106(150) 170(183) 167(2

WASH

Basic services for WASH 60(48) 52(45) 67(52) 59(47) 61(49) 45(41) 96(87) 35(37) 35(37) 47(42) 39(39) 72(53) 34(
79

Appendix Table 9—Continued

Service or indicator Shinyanga Kagera Mwanza Mara Manyara Njombe Katavi Simiyu Geita

Kaskazini 

Unguja

Kusini 

Unguja

Mjini 

Maghar

Family planning

Method availability 26(29) 41(32) 45(33) 38(34) 22(28) 34(29) 10(31) 28(32) 21(32) 5(18) 6(18) 6(10) 

Counseling on side effects 38(57) 103(103) 80(63) 51(27) 55(69) 46(48) 29(70) 19(31) 36(63) 5(18) 10(27) 49(57) 

Antenatal care

Blood pressure measurement 125(132) 277(190) 155(196) 184(147) 97(145) 75(100) 35(127) 162(133) 184(181) 17(63) 13(49) 86(93) 

Counseling on iron 61(59) 157(111) 99(98) 89(76) 52(76) 23(33) 20(70) 81(75) 92(88) 9(29) 4(14) 39(30) 

Counseling on breastfeeding 125(132) 277(190) 155(196) 184(147) 97(145) 75(100) 35(127) 162(133) 184(181) 17(63) 13(49) 86(93) 

Delivery care

BEmOC signal functions performed 28(31) 43(41) 41(34) 40(39) 25(31) 38(38) 9(30) 29(33) 19(29) 2(8) 1(5) 1(4) 

Essential drugs 28(31) 43(41) 41(34) 40(39) 25(31) 38(38) 9(30) 29(33) 19(29) 2(8) 1(5) 1(4) 

Neonatal resuscitation 28(31) 43(41) 41(34) 40(39) 25(31) 38(38) 9(30) 29(33) 19(29) 2(8) 1(5) 1(4) 

Immunization

Availability of viable vaccines and 

syringes

26(28) 43(40) 46(36) 36(35) 23(28) 34(36) 11(33) 27(31) 19(30) 5(17) 6(18) 6(10) 

Child curative care

Antibiotics for children 32(35) 49(44) 58(43) 40(39) 27(32) 36(38) 11(35) 30(34) 23(35) 5(18) 7(20) 16(28) 

ORS/Zinc for diarrhea 32(35) 49(44) 58(43) 40(39) 27(32) 36(38) 11(35) 30(34) 23(35) 5(18) 7(20) 16(28) 

Malaria diagnosis and treatment 

capacity

32(35) 49(44) 58(43) 40(39) 27(32) 36(38) 11(35) 30(34) 23(35) 5(18) 7(20) 16(28) 

ARI assessment 78(69) 236(160) 94(137) 67(63) 65(97) 44(66) 25(80) 92(99) 90(114) 34(66) 26(61) 41(36) 

Diarrhea assessment 57(56) 111(101) 82(93) 32(38) 32(58) 18(40) 14(47) 60(61) 72(84) 5(11) 6(15) 17(15) 

Anemia assessment 136(133) 380(260) 182(225) 143(116) 93(149) 81(121) 48(160) 129(140) 141(172) 50(101) 37(84) 83(76) 

Nutritional assessment 136(133) 380(260) 182(225) 143(116) 93(149) 81(121) 48(160) 129(140) 141(172) 50(101) 37(84) 83(76) 

WASH

Basic services for WASH 32(35) 49(44) 59(46) 45(41) 27(33) 38(39) 11(35) 30(34) 23(35) 6(20) 7(20) 17(30) 

Notes: ARI = acute respiratory infection; BEmOC = basic emergency obstetric care; ORS = oral rehydration salts; WASH = water, sanitation, and hygiene.