# 3.2 Indicators

The SDI provides information on a wide variety of indicators and this paper highlights selected variables measuring service readiness, provider ability and effort. Brief descriptions of each variable are provided below, with further detail on the calculation of each in **Appendix Table A1** .

## 3.2.1 Infrastructure availability

Adequate infrastructure is a prerequisite for high quality care, and includes safe water, sanitation and hygiene (WaSH). The SDI measures the presence of an improved toilet and an improved water source, per JMP guidelines.<sup>12</sup> Running water is necessary for handwashing, cleaning and disinfecting. Toilets are a basic part of sanitation and help ensure patient dignity in facilities and while preventing open defecation, which can lead to infections. Both WaSH measures are necessary for infection prevention and control, ensuring the safety of both patients and health care providers and these metrics are particularly important for pandemic preparedness. In addition, the SDI measures the availability of electricity, necessary for maintaining the vaccination cold chain over longer periods and for operating diagnostic equipment, for example. Overall infrastructure availability is defined as the availability and functioning of all three inputs: an improved toilet, an improved water source and electricity.

## 3.2.2 Medicine and equipment availability

The availability of adequate medicine and equipment does not guarantee system performance, but any gaps in these inputs present a limiting factor in optimizing service delivery, regardless of the technical ability and behavior of the health care providers.<sup>13</sup> The medicines needed for a facility depend on the complexity of care offered and the national medicine requirements at each facility type. Our definition of medicine availability focuses on 14 common medicines, a subset of WHO’s Model List of Essential Medicines.<sup>14</sup> The metric is calculated as the percentage of those 14 medicines which are available and in-stock on the day of the facility visit. The list of equipment necessary for a fully functional facility also varies, depending on the level and type of care provided. The SDI reports on four basic pieces of equipment (a thermometer, stethoscope, blood pressure cuff and weighing scale) which should be expected in any facility offering preventative and curative health care services. Equipment availability is reported as the percent of facilities with all four pieces of equipment available, while medicine availability is reported as the average percent of the 14 medicines available at facilities.

## 3.2.3 Caseload

Good care depends on having facilities adequately staffed, with the right type and number of health care providers. The SDI measures caseload, defined as the number of outpatient visits per health care provider per day, and this indicator is intended to measure the burden of care placed on each provider and the relative utilization of each facility. The indicator is calculated based on the number of outpatient visits within the last three months, the number of days per week that the facility is open, and the number of health care providers (including all types of providers that regularly offer outpatient consultations). The denominator is adjusted for the presence of providers to reflect the total number of health care providers available to provide care.

## 3.2.4 Provider absence rate

In order to provide quality care, doctors, nurses and other medical staff must be available at the facility. The SDI collects a full roster of staff during the initial survey data collection visit and then measures the presence or absence of up to 10 randomly selected staff during an unannounced second visit. The absence rate is calculated as the percent of randomly selected staff who are absent from the facility on the day of the second visit, out of

> 12 UNICEF (2019). 13 Leslie et al.(2017). 14 WHO (2017).