## Summary: Interpretation of results

In sum, the SDI surveys from Kenya, Sierra Leone and Tanzania identify some strengths of the existing health system along with some areas for improvement. For example, the potential repurposing of lowerlevel facilities and available resources for inpatient care during the current pandemic can inform resource allocation strategies at national and sub-national levels. Assessing the availability of a variety of resources, from number of medical personnel to availability of medical supplies, can help prevent and preemptively address potential challenges such as facility overcrowding, health care worker safety, burnout and psychological well-being, and supply chain management for essential medicines and medical supplies. Likewise, while the importance of handwashing for infection prevention is made salient across the globe and citizens are urged to repeatedly wash their hands throughout the day, a concerningly large proportion of health facilities across these three countries lack appropriate handwashing facilities for patients. These humbling statistics compel policy makers to reevaluate priorities for health system strengthening, during and beyond the pandemic period.

While SDI survey data fill some important gaps in the evidence base, the available data do not paint a comprehensive picture of preparedness and some critical chasms persist. For instance, as has been noted previously, a binary indicator for availability of personal protective equipment is a useful starting point for assessing preparedness, but not knowing the stockpile of supplies limits the scope of targeted, evidencebased action. Furthermore, these surveys were not designed for collecting comprehensive information on pandemic preparedness, and as a result, information on key aspects of preparedness is missing. As described in previous sections and illustrated in Appendix Table 1, SDI indicators could be mapped to only seven of 18 items identified in the WHO guidelines for health services pandemic preparedness planning. For example, SDI data lack any information on management of excess mortality, an emerging challenge even for high-resource health systems in this current pandemic. Collectively, the strengths and the limitations of the existing large-scale health facility surveys in assessing pandemic preparedness signal the pressing need to reflect on the future of health service delivery measurement, especially in light of the future threat of large-scale disease outbreaks or other public health emergencies.

# Health service delivery measurement: The future

## More and better measurement is required to inform resource allocation and response

Comprehensive measurement to understand pandemic preparedness is paramount to inform resource allocation and pandemic response strategies. Up-to-date information on facility capacity, including referral systems and transport, coordination, and communication; health service personnel; and availability of key supplies, including PPE, medicines, and backup stockpiles, is needed to identify facilities that can safely and effectively deliver care in a pandemic. Identified high-capacity facilities can both serve as models for others and potentially as treatment/referral centers as part of a national preparedness strategy. Conversely, facilities with inadequate pandemic preparedness need to be identified so that they can either be supported with additional resources for retooling, or only utilized in a manner befitting their capacity.

Beyond preparedness to address acute, pandemic-related care needs, information on facility capacity to continue to provide normal services and to recover from pandemic-related strains is also a key part of comprehensive preparedness. Specifically, extreme pressure on curative services during the pandemic peak periods could result in disruption of essential preventative services and curative services for health problems other than COVID-19. Survey data like that from the SDI could help identify services and platforms that require reinforcement and reorganization, so that health systems are prepared to respond effectively to population needs overall, and not just those related to the pandemic.

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