SARA Implementation Guide Eng

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HEALTH FACILITY ASSESSMENT OF SERVICE AVAILABILITY AND READINESS
Service Availability and Readiness
Assessment (SARA)
An annual monitoring
system for service delivery
Implementation Guide
WHO/HIS/HSI/RME/2013/2
© World Health Organization 2013
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Cover photo credit: WHO/Evelyn Hockstein
Service Availability and Readiness
Assessment (SARA)
An annual monitoring
system for service delivery
Implementation Guide
Version 2.1
September 2013
Acknowledgements
The service availability and readiness assessment (SARA) methodology was developed through a joint World
Health Organization (WHO) United States Agency for International Development (USAID) collaboration. The
methodology builds upon previous and current approaches designed to assess service delivery including the
service availability mapping (SAM) tool developed by WHO, and the service provision assessment (SPA) tool
developed by ICF International under the USAID-funded MEASURE DHS project (monitoring and evaluation to
assess and use results, demographic and health surveys) project, among others. It draws on best practices and
lessons learned from the many countries that have implemented health facility assessments as well as
guidelines and standards developed by WHO technical programmes and the work of the International Health
Facility Assessment Network (IHFAN).
Particular thanks are extended to all those who contributed to the development of the service readiness
indicators, indices, and questionnaires during the workshop on "Strengthening Monitoring of Health Services
Readiness" held in Geneva, 2223 September 2010.
Many thanks to The Norwegian Agency for Development Cooperation (Norad) whom has supported Statistics
Norway to take part in the development of the SARA tools. The support has contributed to the development
and implementation of a new electronic questionnaire in CSPro and data verification guidelines.
A special thanks to the Medicines Information and Evidence for Policy unit at WHO for their contribution to the
SARA training materials and to the Unidad de Calidad y Seguridad de la Atención Médica-Hospital General de
México for their contribution of photographs to the SARA data collectors' guide.
Project Management Group
The SARA methodology and tool were developed under the direction and management of Kathy O’Neill and
Ashley Sheffel with valuable inputs from Ties Boerma and Marina Takane.
Project Advisory Group
Carla AbouZahr, Maru Aregawi Weldedawit, Sisay Betizazu, Paulus Bloem, Krishna Bose, Maurice Bucagu,
Alexandra Cameron, Daniel Chemtob, Meena Cherian, Richard Cibulskis, Mario Dal Poz, Sergey Eremin, Jesus
Maria Garcia Calleja, Sandra Gove, Neeru Gupta, Teena Kunjumen, Thierry Lambrechts, Richard Laing, Blerta
Maliqi, Shanthi Mendis, Claire Preaud, Andrew Ramsay, Leanne Riley, Cathy Roth, Willy Urassa, Adriana
Velasquez Berumen, Junping Yu, Nevio Zagaria, and Evgeny Zheleznyakov.
Service Availability and Readiness Assessment (SARA) | Implementation Guide
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Table of contents
Acknowledgements ...........................................................................................................4
CHAPTER 1 | PLANNING AND METHODOLOGY ..................................................................7
1.1 Background .................................................................................................................................... 9
1.2 Objectives ....................................................................................................................................... 9
1.3 Key topics of the assessment .......................................................................................................10
1.4 Methodology ................................................................................................................................11
1.5 Survey steps .................................................................................................................................11
1.6 Requirements ...............................................................................................................................13
1.7 Budget ..........................................................................................................................................16
Annexes ..................................................................................................................................................17
CHAPTER 2 | SAMPLING ................................................................................................... 25
2.1 Sampling strategies ......................................................................................................................27
2.2 List sample methodology .............................................................................................................28
2.3 Probability sampling in Excel .......................................................................................................35
Annex .....................................................................................................................................................38
CHAPTER 3 | QUESTIONNAIRE ADAPTATION .................................................................... 39
3.1 Country adaptation ......................................................................................................................41
3.2 Editing the structure of the questionnaire ..................................................................................42
3.3 Important tips ..............................................................................................................................42
3.4 Questionnaire implementation ....................................................................................................43
3.5 Adding modules ...........................................................................................................................43
CHAPTER 4 | CSPRO FOR SARA ......................................................................................... 45
CHAPTER 5 | DATA COLLECTOR’S GUIDE........................................................................... 49
5.1 Overview of data collection procedures ......................................................................................51
5.2 Interviewer skills ..........................................................................................................................56
5.3 Completing the SARA questionnaire ............................................................................................60
5.4 Using CSPro for data entry ...........................................................................................................67
5.5 Using GPS for geographic coordinates collection ........................................................................73
CHAPTER 6 | SUPERVISOR’S GUIDE .................................................................................. 79
6.1 Roles and responsibilities .............................................................................................................81
6.2 Conducting field activities ............................................................................................................81
6.3 Using CSPro for data checking and validation .............................................................................87
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CHAPTER 7 | DATA PROCESSING ...................................................................................... 91
7.1 Concatenation ..............................................................................................................................93
7.2 Data cleaning ................................................................................................................................94
7.3 Data verification for completeness ..............................................................................................98
7.4 Calculating sample weights ..........................................................................................................98
7.5 Calculating SARA indicators .......................................................................................................100
7.6 Exporting data from CSPro .........................................................................................................100
CHAPTER 8 | ANALYSIS AND OUTPUT ............................................................................. 101
Introduction ..........................................................................................................................................103
Introduction ..........................................................................................................................................103
8.1 Calculating SARA results .............................................................................................................104
8.2 Alternative method of calculations ............................................................................................118
8.3 Sample weights ..............................................................................................................................119
8.4 Importing data to the SARA analysis tool ..................................................................................126
8.5 Data visualization .......................................................................................................................128
8.6 Survey report .............................................................................................................................140
8.7 Results dissemination ................................................................................................................141
HEALTH FACILITY ASSESSMENT OF SERVICE AVAILABILITY AND READINESS
7
1. Planning and
methodology
Service Availability and Readiness Assessment (SARA) | Implementation Guide
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1.1 Background
Ensuring access to quality health services is one of the main functions of a health system. Sound information on
the supply and quality of health services is necessary for health systems management, monitoring and
evaluation. Efforts to achieve the Millennium Development Goals (MDGs) and scale-up interventions for
HIV/AIDS, tuberculosis, malaria, safe motherhood, child health and non-communicable diseases have drawn
attention to the need for strong country monitoring of health services and their readiness to deliver key
interventions.
The Service availability and readiness assessment (SARA) is designed to function as a systematic tool to support
annual verification of data and service delivery at the facility level. It intends to cover public as well as private
and faith-based health facilities. The goals of the survey is to provide evidence based data on health system
progress to inform the annual health sector review, identify gaps and weaknesses responsible for sub-optimal
service provision and intervention coverage that need to be addressed, provide a baseline for planning and
monitoring scale-up intervention for service delivery improvement. From that perspective, SARA serves as an
M&E tool of the national health strategy and provides key information on progresses of the health system
strengthening over time.
SARA is jointly administered with a data verification module that allows record review in health facilities being
surveyed. The goal of the data verification module is to provide key information on data quality of monthly
reported data from health facilities to the superior/next level in the system (discrepancies between data in
primary source and monthly report). This crucial information is complementary with the DQRC (Data Quality
Report Card) that assesses data quality of the routine system, providing key information on the reliability of the
data used for analysis of the progress and performance of the health system. It is recommended that the
quality of the routine data be assessed on a yearly basis and results included on the annual progress report and
statistical booklets.
1.2 Objectives
The overall objective of the Service Availability and Readiness Assessment is to assess on a regular basis service
delivery (availability and readiness) and conduct data verification in public and private facilities. This evidence
based information collected as an independent verification aims to provide regular and reliable information on
progress and performance of the health system. It is intended to be conducted according to the country
planning cycle to provide a one-time key information on service delivery and data quality of the HMIS (data
verification and DQRC) in order to inform the health sector review.
The specific objectives of the SARA and data quality assessment are:
detect change and measure progress in health system strengthening over time;
plan and monitor the scale-up of (those) interventions that are key to achieving the MDGs, such as
implementing interventions to reduce child and maternal mortality, HIV/AIDS, tuberculosis and malaria,
and to respond to the increasing burden of non-communicable diseases;
generate the evidence base to feed into country annual health sector reviews, to better inform the
development of annual operational plans and to guide country and partners towards making more
effective investments;
support national planners in planning and managing health systems (e.g. assessing equitable and
appropriate distribution of services, human resources and availability of medicines and supplies).
ensure systematic assessment of completeness and consistency (both internal and external) of reported
data and intervention coverage rates;
identify data quality problems that are part of the routine monitoring system and need to be addressed.
1. Planning and methodology
10
1.3 Key topics of the
assessment
The service availability and readiness assessment tool is designed to generate a set of core indicators on key
inputs and outputs of the health system, which can be used to measure progress in health system
strengthening over time. Tracer indicators aim to provide objective information about whether or not a facility
meets the required conditions to support provision of basic or specific services with a consistent level of quality
and quantity. Summary or composite indicators, also called indices, can be used to summarize and
communicate information about multiple indicators and domains of indicators. Indices can be used for general
and service-specific availability and readiness.
There are three main focus areas of SARA-
I. Service availability refers to the physical presence of the delivery of services and encompasses health
infrastructure, core health personnel and aspects of service utilization.
II. General service readiness refers to the overall capacity of health facilities to provide general health
services. Readiness is defined as the availability of components required to provide services, such as
basic amenities, basic equipment, standard precautions for infection prevention, diagnostic capacity
and essential medicines.
III. Service-specific readiness refers to the ability of health facilities to offer a specific service, and the
capacity to provide that service measured through consideration of tracer items that include trained
staff, guidelines, equipment, diagnostic capacity, and medicines and commodities.
The key topic areas and core functional capacities assessed include:
Identification, location and managing authority of health facility (public and private).
General facility status (e. g. availability of water supply, telecommunications, electricity, beds, etc).
Basic medical equipment, such as X-ray, oxygen, weighing machines, etc.
Availability of health workforce (e.g. cadre of human resources, staff training and guidelines).
Drugs and commodities - availability of general medicines.
Diagnostic facilities - availability of lab tests (e.g. HIV, malaria, TB, others).
Standard precautions - availability of injection, sterilization, disposal, and hygiene practices.
Specialized services, such as for maternal and newborn child health, family planning, child and
adolescent health, communicable diseases (e.g. HIV, TB, malaria), non-communicable diseases (diabetes,
cardiovascular, etc…).
Standard and specialized surgery services and blood transfusion
The SARA facility assessment is usually combined with a record review for verification of health facility reported
data on diseases or interventions. The data verification module aims to verify the quality of routinely reported
data by comparing facility data (from register, tally sheets, etc.) with monthly aggregated reports sent at
district level. The information generated by the collected information will be included in the data quality record
card (DQRC), assessing the data quality of the routine system at national and subnational levels.
Service Availability and Readiness Assessment (SARA) | Implementation Guide
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1.4 Methodology
The SARA survey requires visits to health facilities with data collection based on key informant interviews and
observation of key items. The survey can either be carried out as a sample or a census; the choice between
these methodologies will depend on a number of elements including the country's resources, the objectives of
the survey and the availability of a master facility list (MFL). For example, if the objective of the survey is to
have nationally representative estimates, a sample survey would be appropriate. However, if the objective is to
have district estimates, the sampling methodology must be adjusted to either a larger sample or in some cases
a full census.
The recommended data source for information on service availability is a national master facility list and
database of all public and private facilities. A facility census is usually required to establish and maintain the
master facility list (MFL) and database. Service availability data should be updated annually through routine
facility based reporting and validated approximately every 5 years through a facility census.
Service readiness data can be generated through sample surveys. Sampling is done in a systematic way to
ensure that the findings are representative of the country or state/province in which the survey is being
conducted. Basic service readiness should be an important input into health sector reviews and sample surveys
should be organized annually about 4-6 months in advance of the annual review. The national database of
health facilities should be used to provide the sampling frame (MFL). In cases where a national database of
facilities is not available or up-to-date, the service readiness survey can be carried out at the same time as the
facility census for service availability.
FIGURE 1.4.1: TIMELINE OF IMPLEMENTATION
1.5 Survey steps
A Service Availability and Readiness Assessment (SARA) should be planned to coincide with and generate data
to feed into the national health planning cycle. The time needed to complete a SARA depends on the size of the
country whether or not there is a need for a full facility census. From the initial country-adaptation of the
assessment tool to the dissemination of data and production of country reports, the entire process generally
takes from three to six months.
1. Planning and methodology
12
The table below provides an overview of the survey's steps and the activities to be undertaken at each step.
Steps Survey activities
1. Survey planning and
preparation
Establish a survey coordinating group of country stakeholders to oversee and
facilitate the objectives, scope, design, implementation and analysis
Obtain a list of all health facility sites (public, private, nongovernmental organizations
(NGOs) and faith-based organizations (FBOs)), including country facility registry codes
Determine appropriate design methodology (census or sample), develop an
implementation plan and budget, and secure funding
Review and adapt questionnaires to meet country-specific needs
Recruit survey personnel (survey manager, field supervisors, data collectors, data
entry/processing personnel, data analysts)
Prepare a survey schedule
Identify the survey sites (sampling frame). Select the sample size and sample of
health facilities (if sampling methodology is chosen)
Procure logistics including equipment and transport, taking into consideration the
number of sites to be visited, the number of data collection teams, drivers, vehicles,
petrol, etc.
Plan and conduct training courses for interviewers and field supervisors
Pilot test the survey in a selected number of health facilities, evaluate results and
make amendments if necessary
2. Data collection in the
field
Plan the data collection visits (prepare a letter of introduction, contact each site,
prepare a schedule of visits)
Prepare materials and tools for data collectors
Arrange for transport and regular communications during fieldwork
Assemble materials necessary for local data collection
Confirm appointments with health facilities
Visit health facilities and collect SARA data in teams (usually two interviewers and a
driver)
At the end of the interview, check questionnaire and resolve missing/unreliable
information
Return completed forms and/or transfer electronic files to field supervisor at the
conclusion of each day
Return forms (paper and/or electronic) to survey manager when data collection is
complete
3. Data entry, analysis and
interpretation
Enter data using the CSPro application1
Edit, validate and clean data set, check for consistency and accuracy
Export the data set for analysis (SARA indicators)
Conduct analyses of SARA data using the standard core indicators (SARA automated
tool for results graphs and tables) as well as any country-specific indicators of
interest
4. Results dissemination
Meet with survey coordinating group to analyze and interpret survey results and to
finalize recommendations
Prepare the final report
Plan and implement dissemination activities. The results should be used to support
annual health reviews and feed into the M&E platform for the national health plan
Document and archive the survey using metadata standards
1 http://www.census.gov/population/international/software/cspro/csprodownload.html
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1.6 Requirements
The data collection planning phase requires consideration of the logistical needs for data collection teams as
well as an assessment of the hardware and software needs for data collection.
1.6.1 Resources requirements for SARA and data quality assessment
I. Data resources
Master Facility List (MFL)
List of all health facilities in country (including private sector)
National reference documents Official health workforce classification
National drug policies (essential medicines, ARV treatment strategy,etc.)
Health services provision/basic package by facility types (reference list of
service provision)
HMIS tools Standard registers, tally sheet and reporting forms
Country adapted questionnaire
The following areas of the SARA tool must always be adapted to the country
context:
Types of facilities
National guidelines for services
Staffing categories
Tuberculosis medications
HIV & AIDS medications
Country adapted data verification
module
Selection of 4 or 5 indicators from the module proposed indicators’ list
DQRC data requirements In order to develop the data quality report card (DQRC) the following HMIS
data should be made available:
ANC1, DTP1, DTP3, institutional deliveries and OPDs (district monthly
data for the year of the next Annual Health Sector Review (AHSR))
Annual totals at district level for the above indicators for the preceding
3 years
Other country specific indicators (depending on the data verification
selection)
Estimated denominators for the above indicators (for the year of the
AHSR and preceding years if possible)
Data on # of facilities reporting and # of facilities in the district (for each
district)
Data on # of districts reporting every month/trimester
Latest household survey data
II. Human resources
Survey manager
Field supervisors
Data collectors
Data entry personnel
Data analysts
Key resource persons from the survey team, technical units and partners to
be involved
1. Planning and methodology
14
III. Logistics
Transport for data collection field
work activities
Vehicles and drivers
Field accommodation for data
collectors
IV. Training resources
Training venue
Daily accommodation for
participants
Transport
Vehicles and drivers
Includes transport to/from the training venue and for the pilot test
V. Electronic equipment
Computer
Computer (PC): for data entry and processing
Charger
Mobile electronic data collection
devices (EDC)
Mobile data collection unit (such as PDA, tablet computer, laptop computer):
for training purposes, one per participant; for survey purposes, one per data
collection team plus two backup units
Charger/battery: two chargers per unit, two sets of batteries per unit
Mobile unit carry case: one per unit
PC/mobile unit connector cable: one per unit
GPS devices (if running adjunct to
primary EDC)
purposes, one unit per data collection team plus two backup units
Charger/battery: two chargers per unit, two sets of batteries per unit
GPS carry case: one per unit
Communication equipment
Cell phones: one per data collection team
Chargers: one per unit
Mobile phone credit
Software for data collection/entry
The Census and Survey Processing System (CSPro) is recommended unless
the country already uses other software. CSPro is a public domain software
package for entering, editing, tabulating, and disseminating data from
censuses and surveys. It can be downloaded from
www.census.gov/ipc/www/cspro/index.html. More information on
hardware and software specifications can be found in Table 2.
Data analysis program
VI. Supplies
Printing
Printer/copier (two in one or as separate machines):
PC/Printer connector cable: one per pair
Ink cartridge:
Pens, pencils
Projector and projector screen
Multi-port extension cable
International power adapters
USB keys (1GB)
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1.6.2 Hardware and software specifications
Computer and software specifications PDA hardware and software specifications
Desktop or laptop computer
Pentium Processor
512 MB of Ram
SVGA monitor
Mouse
100MB of free hard drive space
Microsoft Windows 98se, Me, NT, 4.0,
2000, XP, Vista or Windows 7.0
CSPro Version 5.2 (or 4.1 if using PDAs)
Pocket PC
Windows Mobile 5.0 or 6.0
USB cable or cradle to connect the Pocket PC to the
desktop or laptop computer.
Microsoft ActiveSync 4.2 or later. This should come
with your Pocket PC and is also available for download
at http://www.microsoft.com/windowsmobile/en-
us/help/synchronize/device-synch.mspx
CSProMobile. This is the installer for the Pocket PC. It
is separate from the installer for the "standard version"
of CSPro on a desktop computer. It can be found on
the CSPro CD or downloaded from the CSPro website.
1. Planning and methodology
16
1.7 Budget
Area of work Activities Unit Cost Activity Cost
1. Preparation and
training of data
collectors
Adaptation of the questionnaire(s) and data entry application
Translation of the questionnaire (if applicable)
Training workshop for field supervisors and data collectors
(xx data collectors & xx supervisors):
- per diem xx USD * nbr persons * nbr days
- travel cost of participants (if applicable)
- venue, lunch
Pilot testing in 3 facilities
- USD xx per diem * nbr people * 1 day
- USD xx transportation * 3 facilities * 1 day
Printing of documents for training
Technical assistance (travel, fee & per diem of 2 facilitators)
Subtotal
2. Field survey Data collector per diem
(USD xx per diem * nbr people * nbr days)
Field supervisors per diem
(USD xx per diem * nbr people * nbr days)
Driver, vehicle and petrol@ USD xx * nbr days
Equipment ; Data collection devices * nbr needed
Supplies (e.g. paper forms, mobile phone + units, …)
Subtotal
3. Data processing,
analysis and
dissemination
Data processing and analysis
-manager/analyst * 6 weeks
-statistician/analyst * 6 weeks
Production of analytical report
Analytical workshop
- per diem xx USD * nbr person * 1 day
- travel cost of participants (if applicable)
- venue, lunch
Validation workshop
- per diem xx USD *nbr persons * nbr days
Dissemination of results (report printing, web posting,…)
Subtotal
Total activities
Contingency/unpredictable costs (around 10%)
GRAND TOTAL Nbr facilities
Service Availability and Readiness Assessment (SARA) | Implementation Guide
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Annex 1 | Excel template: budget for SARA implementation
ACTIVITY
1. PREPARATORY ACTIVITIES
No/quantity
Frequency
Cost/unit
Total
Adaptation of technical documents and data entry application
1
1000
Translation of questionnaire (if applicable - 12$ per page)
Training of field supervisors, data collectors (4 days)
Data collector per diem (per pers.)
Supervisor per diem (per pers.)
23
5
20
2,300
Facilitator per diem (per pers.)
-
Travel costs (if applicable)
25
5
45
5,625
Venue
Coffee break
Lunch
Vehicules (pilot test)
1
1
1
1
Fuel for the car
Supplies
Pinting documents
• SARA questionnaire
• Data verification module
• Data collector's kit
• Supervisor's kit
Subtotal
7,926
2. DATA COLLECTION IN THE FIELD
No/quantity
Frequency
Cost/unit
Total
Data collector per diem
12
10
50
6,000
Transportation
•Vehicule
-
•Fuel
-
•Driver
-
Electronic equipment
•Laptops/Tablet/PDA
-
•USB memory sticks (1 per supervisor)
-
Printing of documents for data collection
•Questionnaire
-
•Data collector's kit
-
Subtotal
6,000
3. DATA PROCESSING, ANALYSIS & DISSEMINATION
No/quantity
Frequency
Cost/unit
Total
Data processing and analysis
Manager/analyst (for 6 weeks)
-
Statistician/analyst (for 6 weeks)
-
1. Planning and methodology | Annexes
18
ACTIVITY
Analytical workshop
Paricipants per diem
-
Travel cost for participants (if applicable)
-
Venue
-
Coffee break
-
Lunch
-
Validation workshop
-
Paricipants per diem
-
Travel cost for participants (if applicable)
-
Venue
-
Coffee break
-
Lunch
-
Dissemination of results
Report printing
-
Subtotal
-
Total activities
13,926
Contingency/unpredictable costs (around 10%)
1,393
GRAND TOTAL
15,319
Service Availability and Readiness Assessment (SARA) | Implementation Guide
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Annex 2 | Template: agenda, data collectors and supervisors training
Objectives :
1. Common understanding of the Service Availability and Readiness Assessment (SARA) by all participants;
2. Train field supervisors in the SARA survey procedures and introduce their roles and responsibilities during
the survey ;
3. Train data collectors in using the SARA questionnaire and data verification module (including electronic
versions) and introduce their roles and responsibilities during data collection ;
4. Develop a detailed timeframe and plan for the field implementation ;
Training of SARA data collectors
Day 1: Date
8:30 – 9:00 Registration and opening
9:00 – 10:00 SARA introduction and overview
Objectives and expected outputs
10:00 – 10:30 Break
10:30 – 13:00 Review of questions and response options
SARA questionnaire
13:00 – 14:00 Lunch
14:00 – 18:00 Review of questions and response options
SARA questionnaire
Day 2: Date
8:30 – 10:30 Review of questions and response options
SARA questionnaire
10:30 – 11:00 Break
11:00 – 13:00 Review of questions and response options
SARA questionnaire
13:00 – 14:00 Lunch
14:00 – 18:00 Understanding the questions and response options
Data verification
1. Planning and methodology | Annexes
20
Day 3: Date
8:30 – 10:30 Roles and responsibilities of data collectors
Procedure before, during, and after site visits
10:30 – 11:00 Break
11:00 – 12:30 Administering the SARA questionnaire
Interviewer skills
12:30 – 1:30 Lunch
1:30 – 3:30 Data entry on PDAs
3:30 – 5:30 Practice administering SARA questionnaire
5:30 – 6:00 Review of procedures and materials for data collection
Day 4: Date
8:00 – 1:30 Pilot test
Field test in at least 3 health facilities
1:30 – 2:30 Lunch
2:30 – 6:00 Debrief of pilot test and troubleshooting
Conclusion of training of SARA data collectors
Training of SARA supervisors (SARA supervisors and technical committee)
Day 5: Date
8:30 – 9:30 Lessons learned from SARA
9:30 – 11:00 Responsibilities of field supervisors
Procedures for field work supervision
11:00 – 11:30 Break
11:30 – 12:30 Transferring data from PDAs/tablets/laptops
12:30 – 1:30 Using CSPro (data checking and correcting answer)
1:30 – 2:30 Lunch
2:30 – 4:30 Planning of data collection logistics, teams and itineraries
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Annex 3 | Template, SARA data analysis and HMIS data quality
assessment workshop
SARA country, year data analysis and HMIS data quality assessment
--------
Place Date
Objectives :
Strengthen skills of the technical unit XXX from the Ministry of Health in charge of the SARA and of the
data quality assessment, in the production and the analysis of the SARA data for year as well as in the
development of the data quality record card based on the HMIS data.
Support SARA institutionalization through dissemination and use of SARA results by stakeholders in the
context of the annual health sector review.
Expected outputs :
National technical team has been trained in the procedures for the calculation of SARA indicators and in
the use of CSPro and the SARA Excel tool for the automated production of result tables and graphs as
well as manual calculation for country specific needs;
The national team has been trained on the use of the DQRC tool for an assessment of the HMIS data
quality, as well as the procedures for the analysis of the data collected using the data verification
module;
« Standard » tables and graphs of SARA results are produced and a first analysis of the results is done;
Drafts of the SARA year results overview and summary analysis by health services;
A draft of the DQRC of the HMIS data is developed;
Use of the SARA results in preparation of the annual health sector review for year is clearly defined;
Senior staff in the Ministry of Health as well as the technical and financial partners of the health sector
are informed on the potential use and interest of SARA in the monitoring and evaluation of the health
sector reforms.
Pre-requisites:
Collection of SARA data and data verification module completed;
Data compiling, entry and cleaning completed;
Availability of monthly routine data from the HMIS for the year of the annual health sector review (year)
as well as population data and information on the completeness of reporting.
1. Planning and methodology | Annexes
22
Participants (maximum 15 participants):
National team [Name from the department/unit at MoH] from the Ministry of Health in charge of the
SARA and the HMIS.
Key persons in the domains of the country health system organization, mother and child health,
communicable diseases and medicines (from the 2nd day when data analysis starts).
AGENDA
Day 1 - Date
8:00 – 8:30 Workshop objectives and expected outputs WHO/Dpt in charge of SARA
8:30 – 10h30 Field survey and data collection
- Data collection, entry and cleaning
- Response rate
- Lessons learnt from the field experience : strengths and areas
for improvement
Dpt in charge of SARA
10:30 – 10:45 Break
10 :45 – 11 :15 Overview of SARA/DQA data processing and analysis
WHO
11 :15 – 13 :00 Other steps in data processing
- Validation by field supervisors
- Calculating the weights
WHO/ Dpt in charge of SARA
13:00 – 14:00 Lunch
14:00 – 18:00 SARA indicator calculation
Adaptation of the « batch edit » in CSPro (SARA specificities)
SARA indicators calculation
Use of the Excel tool for automated production of « standard » SARA
tables and graphs
Manual calculation of results
WHO
Day 2 - Date
8:00 – 8:30 Expected outputs (overview and summary report)
8:30 – 13:00 Availability and readiness of general services results and analysis
Production of tables and graphs
Analysis
(break from 10:30 to 10:45)
WHO/ Dpt in charge of SARA
Entire groupe
13:00 – 14:00 Lunch
14:00 – 18:00
Development of SARA draft analysis documents (overview and summary
report)
WHO/ Dpt in charge of SARA
Availability and readiness of specific services results and analysis
Working group I : Tables/ graphs production and analysis
Working group II : Tables/ graphs production and analysis
Working group III : Tables/ graphs production and analysis
Working group IV : Tables/ graphs production and analysis
(break from 16:00 to 16h15)
Working groups I, II, III & IV
Service Availability and Readiness Assessment (SARA) | Implementation Guide
23
Day 3 - Date
8:00 – 10:00 Plenary session on group work : presentation of the SARA analytical
results
Discussion
Identification of country specific results (tables and graphs)
Group rapporteurs
Entire group
10:00 – 10:15 Break
10:15 – 13:00 Manual production of tables and graphs
- Development and analysis of country specific tables and graphs
- Interpretation
Entire group
13:00 – 14:00 Lunch
14:00 – 16:30 HMIS data quality assessment data verification
Introduction- HMIS data verification
Processing of collected data (data verification module)
Parallel session I
14:00 – 16:30
Development of SARA draft analysis documents (overview and summary
report) (cont’d)
Parallel session II
Availability and readiness of specific services results and analysis
Working group I : Tables/ graphs production and analysis
Working group II : Tables/ graphs production and analysis
Working group III : Tables/ graphs production and analysis
Working group IV : Tables/ graphs production and analysis
16:30 – 18:00 Plenary session on group works : presentation of the results
Discussion, results analysis
Entire group
Day 4 - Date
8:00 – 10:30 HMIS data quality assessment
Introduction and presentation of the DQRC Excel tool for assessment
of the HMIS data quality
WHO
10:30 – 10:45 Break
10:45 – 13:00 HMIS data quality assessment
Development of the DQRC and analysis
Group work
13:00 – 14:00 Lunch
14:00 – 16:30 HMIS data quality assessment
- Development of the DQRC and analysis (cont’d)
Group work
16:30 – 16:45 Break
16:45 – 18:00 Plenary feedback on group works: presentation of the results
Discussion, results analysis
Entire group
1. Planning and methodology | Annexes
24
Day 5 - Date
8:00 – 10h30 SARA report development and preparation for the annual health sector
review
SARA report template and other country best practices
Use of SARA and DQA data in preparation for the annual health sector
review
Discussions
WHO
Dpt in charge of the SARA
Entire group
10:30 – 11:00 Break
11:00 – 13:00 Presentation of the SARA and DQRC results to stakeholders from the
Ministry of Health and Technical and Financial partners (objectives,
methodology, preliminary results, next steps) and discussion.
Dpt in charge of the SARA
13:00 – 14:00 Lunch
14:00 – 16:15 Technical support requirements and specific questions WHO
Dpt in charge of the SARA
16:15 – 16:45 Next steps WHO/ Dpt in charge of the SARA
16:45 – 17:00 Wrap-up and close
25
2. Sampling
Service Availability and Readiness Assessment (SARA)
27
2.1 Sampling strategies
Determining the sample size and selecting the sample for a facility survey is a complex subject, which will vary
considerably from case to case depending on the desired precision and type of estimates, the number of
facilities in the country as well as the specific objectives of the assessment. For example, a SARA conducted to
produce national estimates will require a much smaller sample size than if district-level estimates are desired.
Before concluding on a sampling strategy it should be decided if breakdowns by categories such as region,
facility type, managing authority, urban/rural are desired. In order to ensure that the sample is representative,
it is best to consult with a sampling expert or a statistician to select an appropriate sampling methodology. For
the SARA, the most common sampling strategy is Option 1 in the table belowa nationally representative
sample obtained by taking a simple random sample of facilities within each stratum (facility type and managing
authority) at the national level. The table below presents different sampling options that could be used to
conduct a SARA based on the desired level of estimates and available resources:
Domains of estimation Sampling method Sample size
(estimate)1
Approximate cost
Option 1: National estimates
only
National estimates with
disaggregation by facility type
(3 levels) and managing
authority (public/private)
Small country
Stratification by facility type and
managing authority, simple/systematic
random sampling within each stratum
with census or oversampling of
hospitals (design effect = 1)
150 – 250 facilities
$60K-100K
Medium country
Blend of list and area sampling: list
sampling for large health facilities, and
area sampling for small facilities (census
of facilities in sampled area PSUs 2)
(design effect = 1.2)
250 – 500 facilities
$100K-200K
Option 2: Subnational
estimates
Regional and national
estimates with
disaggregation by facility type
(3 levels) and managing
authority (public/private)
Small country
Stratification by region, facility type and
managing authority, simple/systematic
random sampling within each stratum,
with census or oversampling of
hospitals (design effect = 1)
5 regions: 250 – 500
facilities
10 regions: 500 – 800
facilities
$100K-130K
$130K-180K
Medium/large country
Blend of list and area sampling: list
sampling for large health facilities, and
area sampling for small facilities (census
of facilities in sampled area PSUs2)
(design effect = 1.2)
Medium country
4 regions: 300 – 500
facilities
Large country
4 regions: 400 – 800
facilities
$120K-200K
$180K-360K
Option 3: Subnational
estimates
Regional estimates for a
subset of regions, with
disaggregation by facility type
(3 levels) and managing
authority (public/private) for
selected regions; no national
estimates
Large country
Purposive sample of regions,; within
regions, stratification by facility type
and managing authority,
simple/systematic random sampling
within each stratum with oversampling
of hospitals for each region (design
effect = 1)
4 regions (150 facilities
per region): 600
facilities
$60-100K per region
1 Sample size estimates assume a margin of error of 0.1 and 95% level of confidence
2 Administrative units that form the PSUs (Primary Sampling Units) for the area sample should contain approximately
1-5 health facilities each (communes, sub-counties, villages)
2. Sampling
28
Domains of estimation Sampling method Sample size
(estimate)1
Approximate cost
Option 4: District sample
District estimates for sampled
districts; national estimates if
sufficiently many facilities are
sampled
Small, medium and large countries
List sampling for regional and national
hospitals plus sampling of districts (two-
level cluster sample: selection of
districts as first level, selection of
facilities within these districts as the
second level) (design effect = 2)
Small country
300-500 facilities (10-
30 districts3)
Medium country
400-800 facilities (20+
districts)
Large country
600-1000 facilities (30+
districts)
$100K-200K
$160K-320K
$270K-470K
Option 5: Facility census
All possible domains of
estimation
Small, medium and large countries
Census of all facilities
Very expensive
Small country: 50 – 100 hospitals, 1000 2000 health facilities total, 10 80 districts (e.g. Sierra Leone, Togo, Burkina Faso)
Medium country: 100-500 hospitals, 2000 5000 health facilities total, 80 500 districts (e.g. Uganda, Tanzania)
Large country: 500 – 1000 hospitals, 5000 10000 health facilities total, 500 1000 districts (e.g. DRC, Nigeria)
2.2 National estimates
The recommended sampling method for SARA is a nationally representative sample stratified by health facility
type and managing authority.
The advantages of using this sampling approach are:
(1) the relative simplicity of sample selection if a list of all facilities is available
(2) there are no cluster effects, and
(3) the sample size per facility type and managing authority can be controlled precisely.
The particular sample design for the facility survey will differ in each country; however, selection of a nationally
representative sample stratified by facility type and managing authority will generally involve the following five
steps:
(1) determination of eligible facilities
(2) construction of the list frame
(3) determination of domains and/or strata
(4) sample size determination, and
(5) selection of the sample from the list.
The steps will be elaborated in the reminder of this section.
3 Number of districts in sample depends on the number of facilities per district
Service Availability and Readiness Assessment (SARA)
29
Step 1. Determination of eligible facilities
The first step is to determine the characteristics of the facilities that form the study population. The sampling
frame will be all health facilities that meet defined eligibility criteria in a country. Examples of eligibility criteria
include:
(1) the managing authority;
(2) the type of facility (from primary health-care centres to tertiary-level hospitals); or
(3) facilities within a certain geographical area.
Often, a combination of several such criteria is used. For SARA, it is recommended to include in the sampling
frame health facilities of all types and all managing authorities (public, private-for-profit, NGO, FBO, etc.).
Specialized health facilities such as eye hospitals, dental clinics, etc. may be excluded.
Step 2. Construction of the sampling frame
Whenever a list frame for any survey, including facility survey sampling, is constructed, three principles must
be kept in mind. The frame must be, in so far as is practicable:
(1) complete,
(2) accurate, and
(3) up to date.
A complete list consists of a list of all facilities in a country (both public and private) and contains a unique
identifier along with information on region/district, facility type, managing authority, and urban/rural
designation for each facility. If a Master Facility List (MFL) exists for a country, this can serve as the sampling
frame.
Often a list frame that is complete, accurate and up-to-date, covering both public and private sectors does not
exist. Then it will need to be constructed before a sample can be selected. Unless the country maintains a
comprehensive master facility list, authorities do not always have up-to-date records of health facilities
functioning in the country. Coverage of private facilities is often spotty and outdated; they may have closed or
moved, and there is generally no standard definition for facility type in the private sector.
An initial list obtained from the MoH will usually need to be complemented with information from multiple
other sources, such as private sector coordinating bodies, social ministries where NGOs register their activities,
or directly from faith-based, private and parastatal organizations. In situations where it is not possible to obtain
a reliable sampling frame list of facilities a dual-frame sampling methodology4 may be used. This method
combines a simple random sample of hospitals and large facilities, with a sample of geographically-defined
areas in the country.
Accuracy of the list can pose a problem on important details such as location, type and managing authority of a
given facility. Finally, any list may suffer from outdated information such as inclusion of facilities that may not
be operational at the time of the survey. Compilation of the facility list will likely involve coordinating and
4 Sampling manual for facility surveys for population, maternal health, child health and STD programs in
developing countries. North Carolina, MEASURE Evaluation, 2001 (MEASURE Evaluation Manual Series, No.3)
http://www.cpc.unc.edu/measure/publications/pdf/ms-01-03.pdf, accessed 17 December 2011).
2. Sampling
30
verifying information gathered from a number of sources. It is recommended that the government’s MoH be
contacted first, to obtain a comprehensive list of government facilities. However, the MoH list itself may be
incomplete or out of date, in which case it will be necessary to supplement it with information from other
sources such as private foundations, NGOs and religious organizations. These secondary sources should be
used to correct and update information from the MoH. It is expected, for example, that private hospitals and
other specialized clinics would more likely be identified through the secondary sources than through the MoH.
Depending upon time constraints and budgetary resources, additional sources may also be tapped to refine the
frame. These would include local NGOs and the local offices of external donors who may be able to supplement
and update the MoH list in regions of the country where each is active. Preliminary lists may also be verified
with district or regional health officials. Finally, community informants may also be valuable resources in some
instances, especially to verify whether facilities from central institutional lists are currently operational. See
Creating a master facility list5 for a more comprehensive methodology for constructing a list of all facilities in a
country.
Step 3. Determination of domains and/or strata
Once the sampling frame has been established, probability sampling principles are used to draw a selection of
facilities for inclusion in the assessment. Usually, a multistage or stratified sampling plan is followed to ensure
representation across various domains of the eligible facilities. In stratified random sampling, the sampling
frame (or the population) is partitioned into strata (or subpopulations), which are then independently sampled
(usually a simple or systematic random sample within each stratum). The results from the different strata are
then combined to form estimates for the entire population.
There are a number of reasons why it is better to use a stratified sample for SARA rather than a simple random
sample of all facilities. First, a stratified sample guarantees that a prescribed number of facilities from each
strata (or subpopulation) will be assessed, whereas taking a simple random sample of all facilities might result
in under-representation of certain types of facilities. Also, the number of hospitals in a country is generally
small compared with the number of primary care facilities, and thus a simple random sample of all facilities in a
country is likely to include only a very small number of hospitals or might miss them altogether. By stratifying
the sample by facility type, the number of hospitals and primary care facilities can be controlled to ensure that
a sufficient number of hospitals are included in the sample. Secondly, more precise estimates can be obtained
in cases where facilities within each stratum are relatively homogeneous and the variation between strata is
relatively large. The recommended sampling methodology for SARA is to select all tertiary-level facilities or
hospitals in a country plus a simple random sample of the lower-level facilities stratified by a combination of
region, facility type, managing authority and urban-rural distribution. If disproportionate allocation is used,
sample weights need to be applied when analyzing the data to calibrate for national representation. Please
refer to SARA implementation guide chapter 8: Analysis and Outputs for more information on calculating
weights.
Often, it is desirable to have separate estimates by region, facility type or other groupings of facilities called
domains. Domains are the analytical groupings, whether geographical or categorical, for which separate
estimates are wanted when analysing the results (for example, primary care facilities versus hospitals; urban
areas versus rural areas; public sector facilities versus private sector facilities; different regions). Domains and
strata are often synonymous, but this is not always the case, as the former is determined by analytical
considerations, while the latter serves to improve sampling efficiency. For SARA, the domains of interest are
usually the same as the strata, and are generally a subset of the following: region, facility type, managing
authority and urban-rural location. The greater the number of domains, the larger the sample size is required
to obtain good estimates.
5 Creating a master facility list. Draft document. Geneva, World Health Organization, 2013
Service Availability and Readiness Assessment (SARA)
31
Step 4. Determination of sample size
Determining sample size is a complex subject for any survey. The overall sample size for a facility survey will
vary from country to country, depending upon conditions, precision requirements, and need for domain
estimates. The larger the sample size, the greater the precision of the estimates; however, the total size of the
sample will generally also depend on budget, time, and other constraints6.
Given a desired level of precision (or margin of error) and confidence level, it is fairly easy to determine the
necessary sample size using well-known mathematical formulas, assuming that some reasonable assumptions
about the unknown parameters can be made. The SARA survey produces hundreds of estimates, each of which
would require a different sample size according to the sample size formulas. It is customary in these cases to
choose a small number of the most important estimates, then calculate the sample size requirements for each
of these and to choose the largest. A formula commonly used for calculating the sample size for SARA is given
in Annex 1.
Adjusting sample size for the number of domains
The survey design will most likely require that the estimates be disaggregated for important estimation
domains regions, facility types, urban-rural. If there is particular interest in obtaining very reliable data for a
given domain, it may be necessary to increase the sample size in that domain. For example, if equally reliable
data were desired for urban and rural areas separately it would be necessary to sample the two areas
disproportionately to assure the same sample size. By way of illustration, use of a proportionate sampling
scheme when the urban-rural distribution is 65 and 35 percent respectively would give a sample size for the
urban part that is about twice as big as the rural part, in which case the reliability of the urban sample would be
much better than the rural. The desire for equal reliability in this case would demand that the rural sample size
be increased commensurately. The most efficient sample we will get when the two groups have equal size.
In general, the sample size for domains when equal reliability is wanted for each necessitates multiplying the
calculated sample size needed for a domain by the number of categories in the domain. Thus, if equally reliable
estimates were wanted for, say, five regions, the sample size would be about five times the value calculated
using the equation above. The survey budget would likely preclude such a large sample, so certain
compromises would have to be made. One such compromise is to relax the confidence interval criterion for the
domain estimates. Another possibility is to select the most important domains for the stricter reliability and
allow the others to be measured with whatever reliability a proportionately allocated sample would yield.
An alternative approach for determining domain and overall sample sizes is to carry out the calculations from
the formula in Annex 1 separately for each domain of interest. The total sample size would then be the sum of
the domain samples.
Sampling to estimate change
Often facility surveys aim to monitor change over time. The need to estimate change has implications for
survey operations and sample design of a facility survey. When making considerations for selecting the sample
for a repeat SARA in a country, three methodologies may be considered:
(a) use of the same sample of facilities on each occasion,
(b) use of rotating or replacement panels of facilities, or
(c) use of new, different samples each time.
Proceeding from (a) to (c), sampling error on estimates of change increases. Sampling error is least when the
same sample facilities are used on each occasion, because the correlation between observations is highest.
6 The following is adapted from MEASURE Evaluation (2001). Sampling Manual for Facility Surveys for population,
maternal health, child health and STD programs in developing countries, MEASURE Evaluation Manual Series, No.3, July
2001. http://www.cpc.unc.edu/measure/publications/pdf/ms-01-03.pdf
2. Sampling
32
Adjusting for non-response
The sample size calculation assumes that all facilities in the sample will be covered in the assessment. However,
complete response is rarely attainable in the field, so the calculated sample size should be increased by a factor
to reflect the anticipated non-response rate. Absent any other prior information, it is recommended that the
sample size be increased by at least 10% to take into account non-response.
Adjusting the sample size for finite population size
When there are few facilities in the universe to be assessed, the sample size becomes a significant proportion
(e.g. 5 percent or more) of that total. Then the calculated sample size (n) should be reduced by the factor, 1-
n/N, where N is the total number of facilities in a country.
Summary of sample size calculation methodology
1. Ascertain main estimates of interest.
2. Identify those closest to zero or 100 percent: The ones with small or large value of p.
3. Use formula in Annex 1 to calculate the sample size (n).
4. Choose the largest n.
5. Adjust n upward to account for non-response.
6. Adjust n upwards to account for estimation domains.
7. Evaluate inclusion of previously sampled facilities for a repeat SARA
8. Evaluate n in relation to budget and field constraints; revise if necessary.
Step 5. Sample selection
Stratified sampling
Once the stratification and the sample size have been selected, the final step is to select the sample of facilities
to be assessed from the list frame. The simplest sampling strategy is to use proportional allocation, in which
the same sampling fraction is used for each stratum. For example, if there are 1000 health facilities in a country,
and the sample size is 150, then 150/1000= 15% of facilities that need to be selected from each stratum.
Sometimes it is desirable to use a different sampling fraction for each stratum. For example, hospitals tend to
make up a small percentage of the total number of facilities in a country, but it is often desirable to report
results for this subgroup. If the same sampling fraction is used for hospitals as for other facility types, the
number of hospitals included in the sample would be small, and any estimates based on such a small sample
would be too unreliable to report. The problem can be solved by oversampling the hospitals in order to reduce
the associated error. This is called disproportionate sampling, as different sampling fractions are used for
different strata, and requires the application of sampling weights in the analysis of data to account for
unbalanced sampling.
It is recommended that all hospitals in the list frame be included in the sample if possible. If it is not possible to
cover all hospitals due to budget or other constraints, then all tertiary hospitals should be included in the
sample, and a sample of the other hospitals should be taken. The proportion of hospitals to be included in the
sample depends highly on the available resources, and should be oversampled relative to the other health
facility types.
Service Availability and Readiness Assessment (SARA)
33
Cluster sampling
Cluster sampling means sampling in two stages. First a geographical area is sampled. Then facilities are sampled
from within that area. The primary reason to use this kind of sampling is to reduce the distance between the
sampled facilities, and hence reduce costs. The approach can be used in very large countries or countries were
traveling for other reasons is time-consuming. In general, using a one-stage sample of facilities would be the
recommended procedure in most countries.
If the approximate number of facilities in a primary sampling area (like province, district or local government
area) is known, sampling areas proportional to the number of facilities in each area is recommended. This
means that areas with many facilities will have a higher probability of being sampled. An equal number of
facilities from each area should then be sampled. Information on which area a facility belongs to, will generally
be available through a master facility list. To sample the areas, use the same approach as for sampling facilities,
except the names of the sampled areas are selected, instead of the facility name. Then the sampling procedure
will have to be repeated for selecting facilities within the selected geographical areas. How to do random
sampling in excel is described in section 1.4.
Using the described approach for cluster sampling will not influence the chance of a given facility to be sampled.
Hence, the weights used for the facilities will remain unchanged.
Using cluster sampling makes it necessary to increase the sample size. The design of a cluster sample makes it
less representative because facilities located close to each other tend to be relatively equal, compared to other
facilities. This is described as the design effect, and can be adjusted for by inflating the sample by the design
effect factor. The design effect is described in more detail in Annex 1.
Blend of list and area sampling
More details on the blend of the list and area sampling methodology can be derived from the Sampling Manual
for Facility Surveys for Population, Maternal Health, Child Health and STD Programs in Developing Countries7.
Replacement facilities
Replacement facilities should be selected in the event that a facility in the sample cannot be surveyed (i.e.
facility is closed, facility has relocated, etc.).
The replacement facilities should be selected In the Excel worksheet used to identify the sampled facilities. As a
rule of thumb, identify the next 10 facilities listed after the facilities in the sample for each strata. These will
serve as the replacement facilities in case of need.
7 Sampling manual for facility surveys for population, maternal health, child health and STD programs in
developing countries. North Carolina, MEASURE Evaluation, 2001 (MEASURE Evaluation Manual Series, No.3)
http://www.cpc.unc.edu/measure/publications/pdf/ms-01-03.pdf, accessed 17 December 2011).
2. Sampling
34
Example 1: Determining sample size
The following example will describe the steps for calculating the sample size for a nationally representative
sample stratified by facility type and managing authority. Note: this is a simple example for calculating sample
size in order to demonstrate the basic steps.
1. Determine how many facilities are in the sampling frame categorized by facility type/managing authority.
Facility type/ managing
authority
Total number
of facilities
Hospital- public
27
Hospital- private
19
Health centre- public
51
Health centre- private
235
Health post- public
713
Health post- private
152
Total
1197
2. Determine the sample size for primary level facilities based on the total number of facilities in the sampling
frame and the strata of interest. For the SARA, hospitals are typically oversampled to ensure there is a
sufficient number of them in the sample for the hospital specific indicators. Hence, it is suggested to
include all hospitals in the sample.
Using the following formula:
n = [[ ( z2 * p * q ) + ME2 ] / [ ME2 + z2 * p * q / N ]]*d
where:
n = sample size
z = confidence level at 95% (1.96)
ME = margin of error (15%)
p = the anticipated proportion of facilities with the attribute of interest (.5)
q = 1-p
d = design effect (1) add footnote on design effect
All
facilities
Hospitals
Primary
z
p
q
ME
Primary
sample
size
Hospitals
Total
sample
size
Hospital- public
27
27
0
1.96
0.5
0.5
0.15
0
27
27
Hospital- private
19
19
0
1.96
0.5
0.5
0.15
0
19
19
Health centre- public
51
0
51
1.96
0.5
0.5
0.15
24
0
24
Health centre- private
235
0
235
1.96
0.5
0.5
0.15
37
0
37
Health post- public
713
0
713
1.96
0.5
0.5
0.15
41
0
41
Health post- private
152
0
152
1.96
0.5
0.5
0.15
34
0
34
Total
1197
46
1151
136
46
182
Service Availability and Readiness Assessment (SARA)
35
3. Oversampling of strata where there is most likely to be variations (strata with less than 30 facilities) should
be done. This will give the final sample size and sampling proportions for the sample.
All
facilities
Hospitals
Primary
z
p
q
ME
Primary
sample
size
Hospitals
Total
sample
size
Oversampling
of strata
Hospital- public
27
27
0
1.96
0.5
0.5
0.15
0
27
27
27
Hospital- private
19
19
0
1.96
0.5
0.5
0.15
0
19
19
19
Health centre- public
51
0
51
1.96
0.5
0.5
0.15
24
0
24
30
Health centre- private
235
0
235
1.96
0.5
0.5
0.15
37
0
37
37
Health post- public
713
0
713
1.96
0.5
0.5
0.15
41
0
41
41
Health post- private
152
0
152
1.96
0.5
0.5
0.15
34
0
34
34
Total
1197
46
1151
136
46
182
188
2.3 Probability sampling
in Excel
Once the sampling fractions for each stratum have been determined, the facilities from each stratum should be
selected using a probability sampling method. The list frame should be partitioned according to the chosen
stratification, and within each stratum (e.g. a list of hospitals in Region 1), the facilities to be included in the
sample should be selected by simple random sampling or systematic sampling. Replacement facilities for those
facilities that are closed or otherwise cannot be accessed can be selected using the same method. Alternatively,
to facilitate logistics, the closest facility of the same type in the same geographical area can be selected.
First select the facilities to be included in the sample from the MFL. The MFL should be divided up according to
the categories selected to determine the sample (e.g. the ones mentioned in step 5 in section 1.3). If the MFL is
in a Microsoft excel workbook, copy and paste each strata of facilities into a new worksheet within the
workbook.
On each sheet add a column called Random. Type “Random” into the first cell. In the column to the right of the
column called Random, type the word “TRUEin the first cell, as illustrated by the yellow fields in the figure
below.
2. Sampling
36
Use the following formula to assign a random unique number to each facility.
=IF($B$1, TRUNC(RAND()*(1000000-1)+1), A2)
Copy and paste the formula into the first cell of the column called Random. Place the cursor at the lower right
corner of the cell with the formula and pull it downwards. If the columns named “Random” and “TRUE” is not
in the first two columns (A and B), please change A to the letter of the “Random” column and B to the letter of
the “TRUE” column in the formula. A random number will be assigned to each of the facilities.
Then change the word TRUE to FALSE. This will freeze the random numbers so that they don’t regenerate new
random numbers.
A warning box may appear similar to the following:
Click on OK. Then filter the data so that the column Random is in descending order, from the largest to the
smallest.
Service Availability and Readiness Assessment (SARA)
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See the final sampling table in section 1.2 step 5 and determine how many facilities in the strata should be
selected. Highlight starting from the first facility in the list through the total number of facilities needed for the
sample in that strata. These facilities will be included in the survey sample. Repeat for each of the strata
identified above. Then select the next ten facilities in each worksheet as replacement facilities.
2. Sampling | Annex
38
Annex 1 | Calculating the sample size for SARA
The following formula is commonly used to calculate the sample size for SARA8:
n = [[ ( z2 * p * q ) + ME2 ] / [ ME2 + z2 * p * q / N ]]*d
where
n
is the sample to be calculated,
2
Z
is the square of the normal deviate at the required confidence level,
ME
is the margin of error,
p
is the anticipated proportion of facilities with the attribute of interest,
q
is
p1
, and
d
is the design effect
Each parameter is explained in detail in the table below:
2
Z
It is customary to use a 95% level of confidence, for which the corresponding value of
Z
is 1.96.
Thus
2
Z
=3.84.
ME
The margin of error is the amount of random sampling error in a survey's results. For SARA, a
margin of error of 15% is generally used.
p
Most SARA estimates are of the form “percent
p
of facilities with attribute X.” It is necessary to
have some idea of the value of
p
in order to use the formula to calculate sample size. It is not
necessary for the value of
p
used for the sample size calculation to be very accurate (otherwise
there would be no need to conduct the survey), and it
can be obtained from previous surveys
conducted in the country, or from similar countries that conducted similar surveys.
d
The design effect is a value that reflects the ratio of sampling variances, where the numerator is
the variance of the sample design being used for the particular facility survey in question, and the
denominator is the variance that would result if a simple random sample of facilities with the
identical sample size had been used. The design effect reflects the effects of stratification, stages of
selection and degree of clustering used in the facility survey. Generally, the clustering component,
which is a measure of the degree to which two facilities in the same cluster have the same
characteristic compared to two selected at random in the population of facilities, contributes the
biggest effect. The interpretation of the design effect is that it shows how much more unreliable
the sample is compared to a simple random sample of the same size. If the design effect were 1.2,
for example, the facility sample would have sampling variance 20 percent greater than an
alternative design using simple random sampling.
For a stratified sample drawn from a list frame without clustering, the recommended sampling
strategy for SARA, the design effect should be approximately 1.0. Therefore it is recommended to
use a value of
d
= 1.0 for a stratified list sample.
If a different sampling strategy is used, then the design effect could be higher. For example, a
cluster sample is expected to have a higher value of
d
. If a country has information from a
previous survey that suggests the value of the design effect, this value should also be used to
calculate the sample sizes. For the blend of list and area sampling mentioned earlier, it is
recommended to use a value of
d
= 1.2.
8 Several equivalent formulas exist.
39
3. Questionnaire
adaptation
3. Questionnaire adaptation
40
The standard SARA questionnaire for measuring service availability and readiness should be adapted for
country use to reflect the needs and specificities of each health-care system. When adapting the health facility
questionnaire, consideration should be given to how changes will affect data collection, and adjustments
should be made to ascertain that definitions are specific enough to assure comparability across the country and
within districts.
It is important to remember that the SARA methodology is not intended to provide comprehensive data on all
aspects of health system functioning. Rather, it focuses on key "tracer" elements that are critical to
programmes that are scaling up or that are indicative of the essential health system underpinnings or
"readiness" to do so. This should be kept in mind while adapting the questionnaire and adding additional
questions or modules.
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3.1 Country adaptation
The adaptation of the SARA questionnaire should take place in the planning and preparation phase. It should
be conducted by the SARA survey technical team in close collaboration with national stakeholders and the key
resource persons from the appropriate technical units.
The following areas of the SARA tool should always be adapted to the country context:
Areas References Comments
Health facility types
National classification of health
infrastructures
The facility types classification should
reflect the national classification,
including both public and private
structures. It should be in conformity
with the service package offered by
each facility profile (based on the
national Basic Package of Essential
Services, if available).
Health facility managing authority National classification of health
infrastructures
The managing authority types should
reflect the national classification of
authorities potentially in charge of a
facility.
Staffing categories Official categorization of human
resources for health
The proposed human resources list
available in the questionnaire should
be mapped to the official
classification of certified health
personnel and appropriate cadres
added.
Guidelines for services National guidelines for health
services
List of guidelines in the questionnaire
should reflect official guidelines.
Country specific medicines policy National drug policy and any other
specific drug policies (essential
medicines, TB, …)
Standard lists of tracer items for
medicines are proposed in the
questionnaire according to
international standards*. If there is a
country specific regimen for certain
treatments it should be edited
accordingly (tracer items).
ARV national protocol The ARV section of the questionnaire
lists all ARV drugs. The ARV section
should be customized based on the
official recommended first line
treatment and medicines
recommended for PMTCT.
Trained staff Official training cycle for health
workers
A standard of 2 years interval in
training cycle updates for staff is used
in the questionnaire. If the timeframe
for staff training updates is different
according to the official policy it
should be reflected in the
questionnaire.
* Details references for medicines are available in the SARA Indicators Index.
3. Questionnaire adaptation
42
3.2 Editing the structure
of the questionnaire
The SARA questionnaire is also available in electronic format along with automated tools for data processing
and production of results. If these automated tools are to be used, editing the structure of the questionnaire
should be done as follows:
Adding a question: -Country-specific questions that are key in measuring tracer elements for service
delivery can be added to the questionnaire. A practical and recommended way to number these specific
country questions is to use the country ISO.2 code*. For example:
SL_01 : where SL corresponds to the ISO.2 code for Sierra Leone + numbering (sequential according
to the number of questions added)
*For detail list of country ISO codes please refer to:
http://www.iso.org/iso/country_codes/iso_3166_code_lists/country_names_and_code_elements.htm
Deleting a question: It is possible that certain questions might not be relevant and applicable to a
country. In this case a question can be deleted. It should be removed from the questionnaire and the
question number should be deleted as well and not re-used. This should remain occasional- the SARA
aims to measure a minimum of tracer elements that are defined for service delivery. Deleting too many
questions will change the measurement’s parameters.
Changing a question’s text: Question text should not be replaced by another question text. Clarification
can be added in parenthesis to help the respondent understand the question if needed. It is very
important to keep each question with its original numbering, therefore we ask that you add or delete
questions but DO NOT change the content of existing questions.
Skip patterns: Any addition or deletion affecting a skip pattern in the questionnaire should be updated
accordingly.
3.3 Important tips
Do not change numbering: the original numbering structure of the standard questionnaire should be
kept. Changing the numbering will affect links to the existing tools for automated data processing and
results production.
The goal of the SARA is to measure based on key tracer items the minimum package of services that
should be available in the health facilities. It is important not to stray from the SARA concept by adding
a long list of additional items (SARA doesn’t aim to be a census of all items that should be present in a
facility).
It is also important to remember that adding more to the tool will impact the training, the data
collection and the data analysis. Any question addition should also be consider in term of the analysis
outputs. Before a question is added, it should first be added to the analysis plan so that it is clear how it
will be used in the analysis.
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3.4 Questionnaire
implementation
The SARA questionnaire is available in paper and electronic format.
Paper questionnaire: Any changes should be made according to the country adaptation.
Electronic questionnaire: For the SARA survey, the recommended software for electronic questionnaires is
CSPro. A standard version of the questionnaire is available in that format and all changes should be made
according to the country adaptation. Further information on CSPro can be found at:
http://who.int/healthinfo/systems/sara_introduction/en/index.html
http://www.census.gov/population/international/software/cspro/csprodownload.html
3.5 Adding modules
Commonly, the SARA questionnaire is jointly administered with a data verification module that allows for a
record review in health facilities being surveyed.
The Data Verification module will also need to be adapted based on country requirements. Adaptation consists
of the selection of 4 or 5 core indicators from the proposed module list. The selection should be reflected in the
paper version as well as the electronic format of the DV section (also available in CSPro format).
The SARA questionnaire can also be used in conjunction with additional modules such as management
assessment or quality of care. These specific modules are not part of the standard package and will need to be
designed accordingly.
45
4. CSPro for SARA
4. CSPro for SARA
46
For the SARA survey, automated tools for electronic data collection, data processing, and indicator generation
is have been developed using the Census and Survey Processing System (CSPro) software.
A detailed manual with step by step instructions for using CSPro is available as a stand-alone document. The
following topics are covered in the CSPro manual:
Introduction
CSPro capabilities
CSPro for SARA
Technical information
Hardware and software requirements
Software installation
SARA CSPro application
Preparing to open the SARA CSPro application
The SARA CSPro files structure
Configuring SARA
Create the sample file
Create the file containing name and number of all the interviewers
Configure what DV modules to include in the survey
Change the display language
Getting to know CSPro
Start CSPro and open the SARA
Explore the data entry application
Modifying the SARA application
Modify a dictionary item
Delete a dictionary item
Modify a value set
Modify logic
Add a new module to SARA
Run the data entry application
Check the settings
Review forms
Run the application on a desktop or laptop computer
Concatenate data after data collection
Structure the data correctly
Edit the core SARA dictionary
Edit the concatenation programs
Run the concatenation programs
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Review and edit data in CSPro
Step 1: Run edit_data application
Step 2: Open merged data file and check key items
Step 3: Delete empty records
Step 4: Check for duplicate facility IDs
Step 5: Recode “other” responses
Step 6: Check validity of GPS coordinates
Step 7: Supervisor validation cases
Step 8: Batch application for completeness
Step 9: Dependent verification (if applicable)
Batch edit application for indicator generation
Step 1: Open and explore the batch application
Step 2: Assign strata for analysis
Step 3: Apply weights
Step 4: Edit country specific items
Step 5: Run the batch application
Export indicators
Step 1: Open the CSPro Export Data application
Step 2: Select items for export
Step 3: Export data
49
5. Data collector’s guide
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5.1 Overview of data
collection procedures
The Service availability and readiness assessment (SARA) is designed to function as a systematic tool to support
annual verification of data and service delivery at the facility level. It intends to cover public as well as private
and faith-based health facilities. The goals of the survey is to provide evidence based data on health system
progress to inform the annual health sector review, identify gaps and weaknesses responsible for sub-optimal
service provision and intervention coverage that need to be addressed. It also provides a baseline for planning
and monitoring scale-up intervention for service delivery improvement for maternal and child health, HIV,
TB,malaria and NDCs among others .
The Data Collector's Guide is designed to provide interviewers with the knowledge and skills necessary to
effectively conduct a health facility assessment. It is intended to support and guide staff members who have
been identified as interviewers for conducting health facility assessments. The guide provides general
instructions on the interviewing skills required to gather information; detailed explanations and definitions of
specific questions to ensure a uniform understanding of the content and a consistent approach to recording
results by different data collectors across different facilities; and instructions on how to collect data at a facility.
The primary objectives of the Data Collector's Guide are to:
Introduce participants to the Service Availability and Readiness Assessment tool (SARA) as well as the
Facility Reporting Data Verification Tool (record review).
Gain an understanding of the rationale for conducting a health facility assessment
Instruct participants on how to conduct an interview and complete the questionnaires
Familiarize participants with paper-based and CSPro data collection methodologies
5.1.1 Survey approach
Objectives of the Service Availability and Readiness Assessment tool
The Service Availability and Readiness Assessment tool has been developed for interviewers to collect
information on core functional capacities and availability of services in health facilities. The assessment tool is
designed to rapidly assess and monitor service availability and readiness with a focus on a number of core
health interventions. It does not attempt to measure the quality of services or resources, nor is it disease
specific.
The SARA methodology has been developed by USAID and WHO in close collaboration with Ministries of Health
and global partners to:
Assist countries in assessing and monitoring service availability at district and health facility levels;
Monitor scale up programs;
Assess equitable and appropriate distribution of services and resources; and
Support decision making by providing national and district planners with the skills and tools required to
map and monitor service and resource availability on a regular basis.
This approach aims to fill critical data gaps required for monitoring health systems strengthening and is
designed to be implemented as a routine monitoring system of services at district and national levels.
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52
Objectives of the facility reporting data verification tool
The Facility Reporting Data Verification Tool is jointly administered with the SARA and allows record review in
health facilities being surveyed. The goal of the data verification module is to provides key information on data
quality of monthly reported data from health facilities to the superior level by comparing discrepancies
between data in primary source and monthly report). This crucial information is integrated in the data quality
report card (DQRC).
Data collection instruments
A standard core questionnaire has been developed for the SARA. This questionnaire is typically adopted in its
entirety and then adapted at country level with adaptations to certain elements such as names and types of
facilities, personnel, first line drugs, etc. It is usually tested during an in-country pilot visit for final adjustments
and validation.
The tool is usually used in conjunction with supplemental modules such as the Facility Reporting Data
Verification tool (enclosed at the end of the SARA questionnaire).
The collection instruments are paper based or used in conjunction with electronic collection devices (tablets,
laptops, etc.).
Role of the interviewer
The interviewer's main responsibility is to use the questionnaire appropriately to collect information that is as
accurate as possible by asking questions of the appropriate respondents and accurately recording responses.
The health facility assessment will be completed in teams. Typically, each team will include 2 persons
responsible for data collection who work closely with a field supervisor.
The data collectors main tasks include:
Visit health facilities and collect information.
Verify geographic coordinates (if relevant).
Complete a SARA data collection paper form and/or an electronic form, as well as the facility reporting
data verification and other modules if relevant.
Back up electronic data on a memory card/USB key.
Report back to the field supervisor at the end of each day.
Survey regulations
The following survey regulations have been established to ensure the success of the Service Availability and
Readiness Assessment tool and will be closely adhered to by all interviewers.
The interviewer's attendance during each day of the fieldwork is required. Any person who is tardy or
absent during any part of the fieldwork (whether it is a whole day or part of a day) without prior
approval may be dismissed from the survey.
Throughout the fieldwork period, interviewers are representing the implementing agency. Your conduct
must be professional and your behaviour must be congenial when dealing with the public. You must
always be aware of the fact that we are only able to do our work with the good will and cooperation of
the people we interview. Therefore, any team member who is consistently overly aggressive, abrupt, or
disrespectful to others may be dismissed from the survey team.
For the survey to succeed, each team must work closely together. Any team member who, in the
judgment of the survey manager, is a disruptive influence on the team may be asked to transfer to
another team or dismissed.
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It is critical that the data gathered during the fieldwork be both consistent and accurate. Field staff may
be dismissed at any time during the fieldwork if the quality of their work is inadequate.
Vehicles and gasoline are provided for the survey for official use only. Any person using a vehicle for an
unauthorized personal reason will be dismissed.
Data are confidential. Under no circumstances should confidential information be passed on to third
parties. Persons breaking these rules, and therefore the confidence placed in them by respondents, will
be dismissed.
5.1.2 Planning the SARA fieldwork
The following describes the activities that concern data collectors in the planning the SARA fieldwork.
Fieldwork schedule
The field supervisor will assign each team a list of facilities to be visited for data collection. The list will include
the name and location of the facility as well as the facility identification information required in the SARA
questionnaire.
If the information is available, the list may include the name of the person in-charge at the facility, telephone
numbers or other information on how to contact the facility, and the hours during which the facility is open
and/or various services offered. The field supervisor will also provide the team with a map showing the location
(or approximate location) of all of the facilities on their list.
The team generally will need to arrive at a facility on or before the official opening hours; therefore, the
lodgings that the team will use each night must be within a reasonable distance of the facility that is to be
visited on the next day.
Advance contact with authorities/facilities
Generally, the survey manager or another senior member of the team will have notified appropriate authorities
of the nature and purpose of the health facility assessment in advance of the fieldwork. An official letter from
the managing authority for the facilities being surveyed should have been sent to the regional or district offices
for that organization. Each team should also have a copy of the letter to show at facilities if necessary
Logistical arrangements
Prior to departure for fieldwork, the field supervisor must ensure that the team has the questionnaires and
other materials necessary to complete the assignment.
Each morning before leaving for field visits, the team should check that they have all necessary materials.
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54
Checklist of materials for data collectors:
A list of data collection teams and contact information.
The contact details of the field supervisor, including a mobile phone number to call in case of difficulty
in the field (with sufficient credit) .
A schedule of visits to survey sites.
The contact details of the sites to be visited.
Details of backup facilities to be visited if scheduled visits are not possible.
Copies of letter of introduction.
The SARA data collectors' guide (part1 and part2).
A SARA data collection form for each health facility to be visited that day (with cover page pre-filled by
field supervisor).
A SARA data collection form for each backup site that may need to be visited that day.
An EDC/tablet/laptop (fully charged with CSPro installed and loaded with the SARA questionnaire) a
charger and battery.
A memory card/USB stick for data backup.
A fully charged and accurately configured GPS unit (if relevant).
A fully charged cell phone with credit
Pens (pencils should not be used to record data), a clipboard and other supplies.
A notebook to record any significant events or findings.
A field allowance for local expenses.
An identity document with a photograph for each data collector.
5.1.3 Activities during facility visit
There are a number of general procedures to be followed by a survey team during a visit to a survey facility.
These procedures are outlined in the following sections.
Locating and verifying the survey facility
The field supervisor has provided you with a list of the facilities you are responsible for surveying. Every
attempt should be made to conduct the survey at each facility on your list. If after contacting local authorities,
you cannot locate a health facility on your list, or are not sure about whether a facility that you have found is
actually the one identified on the facility list, contact your field supervisor. If a facility included in the
assignment has closed, no interview will be necessary, just note that fact on the cover sheet of the assigned
questionnaire. Finally, no facility not listed in the sample should be visited and interviewed unless specifically
approved by the survey manager.
Validating the cover page of the questionnaire
Before starting the data collection, the data collectors should check that the information on the first page of
the data collection form (cover page) is complete and correct (pre-filled by the field supervisor). If there is any
mistakes, inform the field supervisor at the end of the day. If applicable, enter this information on the
electronic form on the electronic data collection device/tablet or laptop.
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The following information should be completed by the data collectors on the first page of the data collection
form prior to starting the survey:
Date
Name of the data collectors (interviewer)
Number/code of the interviewers’ team (given by the field supervisor prior to the fieldwork)
Geographic Positioning System data collection
Upon arrival at the health facility to be surveyed, fill out the geographic coordinates section of the
questionnaire included in the cover page. The global positioning system (GPS) which is a space-based satellite
system will be used to precisely locate the geographic position of the site. Step-by-steps instruction on using a
GPS device is available on Section V.
Gaining permission to survey the health facility
Data collection teams will be visiting facilities operated by the government, others operated by non-
governmental organizations, and perhaps other private health facilities. All facilities must give permission for
the survey to be conducted on their premises. The day of the survey data collectors may provide reassurance
to facility staff that results will only be provided so that no individual respondent can be identified.
The first contact at the site should be made by asking to speak with the person in charge. If the official “in-
charge” is not present the day of the survey, the data collection team should ask to see the person acting “in-
charge” for the day. The data collectors will then:
introduce themselves
explain the purpose of the visit and the activities that are a part of the survey
give the person in-charge the introductory letters from the relevant organization and the letters
explaining the survey and giving the authorization to visit the facility.
when consent obtain, sign the inform consent section in the cover page of the questionnaire to indicate
the consent from the person in-charge has been obtained.
If you are refused an interview in the facility and nothing you say can make the in-charge reconsider, contact
the field supervisor, and provide the name of the facility, its managing authority, and location. The field
supervisor will make every attempt to contact appropriate persons who can help to convince the health facility
staff to allow the interview.
Meeting with the person in-charge of the facility
An important objective of the survey is to obtain correct and consistent answers to the questions. As the
questions relate to a facility and not to a specific person, the information can be obtained from a variety of
respondents as long as they are knowledgeable about the topic. During the interview, interviewers may need
to speak with various respondents in order to obtain complete and correct information.
The data collectors are responsible for working out a plan for completing all components of the questionnaire
at each facility. They should discuss the plan with the in-charge. It may be helpful to meet with relevant
supervisors (at large facilities) and other staff who may be requested to allow interviews and observations
during the team’s visit. For a small facility this may be relatively easy since most services are in the same
general area. For larger facilities, this may involve different departments.
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56
Duration of the survey
Duration of the interview will depend on the size of the facility and the availability of suitable staff to provide
the answers to the questions, but generally should be 3 5 hours for a small health post or health centre and
up to a day for a hospital*.
* For conducting both the SARA and the Facility Reporting Data Verification Tool
5.2 Interviewer skills
Collecting data that accurately reflect health services available at a facility, whether it is a small health post or
an urban hospital, requires skill and practice. This section provides general instructions on the skills required
for gathering this information. The data collectors should remember that the survey findings are only as good
as the data from which they are calculated. The quality of that data depends to a large extent on the
interviewer.
Below are some basic instructions on the practices that should be used when interviewing respondents and tips
for how to handle difficult situations that you might encounter while conducting an interview.
5.2.1 General interviewing practices and techniques
In order to obtain accurate information from a health provider at work in a health service setting, it is very
important that they be engaged in the data collection process. There are several basic ways to gain the
provider’s cooperation while collecting accurate and specific information.
Showing respect for the respondent
The interaction between the interviewer and all respondents is very important. All respondents should be
treated respectfully and politely. The respondents should know that their cooperation and the time they are
taking to help make the survey successful is very much appreciated.
A respondent's first impression of the interviewer will strongly affect his/her willingness to fully participate in the
interview. Therefore, it is important that the interviewer approach each person to be interviewed and his/her
colleagues at work in a friendly, respectful, and professional manner.
One basic way to show respect for a health worker at work is to be considerate of what they need to accomplish
during their workday and to let them know that there will be no interference with their client-related tasks. Two
ways to accomplish this are: 1) If the health worker to interviewed is busy with a client, the interviewer should wait
until that visit is completed before approaching him/her; and 2) the interviewer should wait until there are no
clients around or until there is a qualified person available to complete the questionnaire. The interviewer will
discover other ways to fit smoothly into the health worker's busy schedule while gaining more experience gathering
data in a variety of health service settings during the survey implementation.
If it appears that there will never be a convenient time for collecting the data, the interviewer should discuss with
the health worker or the staff member in charge to determine the best approach for collecting the required data
with the least interference possible.
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Listening carefully to the respondent
Listening carefully to what the respondents say is as important as asking the questions on the questionnaire,
and demonstrates respect. Some questions in the questionnaire require the interviewer to listen to what the
respondent says and record it by simply circling a printed response category. Sometimes, the interviewer must
write down exactly the answer given by the respondent if the answer does not fit in any of the listed categories.
In either case, the interviewer should listen well. He/she should not rush into circling the code category before
he/she has really listened to the respondent. This may be taken as a sign of disrespect or not paying attention.
More importantly, people who rush into coding a response are often in danger of attributing their own biases,
preferences, and favourite response categories to their respondents.
Requesting consent from the respondent prior to asking questions
There is a consent form and some background information that should be read to the respondent prior to
beginning the interview. This is located at the start of each questionnaire. The interviewer is required to read
the information in its entirety to the respondent and then request his/her consent before starting to ask
questions. Without the respondent's consent the interview cannot proceed beyond the cover section.
Answering the respondent's questions without pressuring them
Some respondents may question the interviewer about the purpose of the survey before agreeing to
participate. In this situation, the interviewer should answer the respondent's questions as directly as possible.
If the respondents feel that the information is important and that the interviewer is sympathetic to their
situation, they will be more straightforward with responses and will be more likely to answer questions to the
best of their ability. If they feel pressured to respond, or feel that the interview is a burden, they may not
carefully think about responses.
Offering no opinions or advice on specific health facility practices or patient care
issues
If a respondent has specific questions that require the interviewer’s medical opinion or advice, he/she should
politely respond by saying that he/she is here to collect information to provide an overview of the services, and
that he/she is interested in the systems and practices at this facility. Explaining this and then simply stating, “I
am not in a position to provide any advice or opinions” may be sufficient. It is important to remember that the
job is not to educate respondents, but only to collect information from them.
Reading every question exactly as written and in sequence
The wording of each question has been carefully chosen and for that reason it is essential that the interviewer
read each question to the respondent exactly as it is written. It is very important for this survey that each
question is asked to each respondent in exactly the same manner. Each section of the questionnaire also has
an introductory paragraph that must be read to the respondent (when applicable) in its entirety.
The interviewer should speak slowly and clearly so that the people who are interviewed will have no difficulty in
hearing or understanding the question. At times, the interviewer may need to repeat a question in order to be
sure the respondent understands it. In these cases, the interviewer should not paraphrase the question but
repeat it exactly as it is written. If, after the question has been repeated the respondent still does not
understand it, the question may have to be restated. The interviewer should be very careful when changing the
wording not to alter the meaning of the original question. During the practice sessions conducted at a facility
not included in the survey sample, if the interviewer find that they have to repeat the same question to several
respondents, a note of this should be made and reported to the field supervisor so that if necessary, the
wording can be changed on the questionnaire.
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Being straightforward
There are some questions in the survey where the interviewer is asking about the availability of items, and then
asking to see them. Providers will be more cooperative if they know beforehand what to expect. If the
interviewer ask questions and then later ask to see items, people may think you are trying to trick them, or
“checking up” on their answer. In order to have the greatest amount of cooperation, the interviewer should
always tell the respondent what is coming. For example:
“I am interested in knowing if the following basic equipments and supplies used in the provision of client
services are available in the general outpatient area of this facility. For each item, please tell me if it is available
today and functioning. I will need to see the item so that I can completely fill in this questionnaire.”
Probing for a response
Occasionally, a respondent may answer a question incompletely, or seems to have misunderstood the question.
The first thing to do is simply to repeat the question as written a second time. If this does not help, the
interviewer will have to probe to obtain the response. Probing is a way of asking for further information
without influencing the response. For example, “Could you explain that a little more?” or “Could you be more
specific about that?The interviewer must never interpret a respondent's answer and then ask the respondent
if the interpretation is correct.
There is not a uniform understanding, even between health service providers within the same health facility,
on some of the issues for which we are collecting data or on terms used to describe items or practices. If it
appears that the respondent is not understanding what the interviewer is asking, or the response does not
seem consistent with other information the interviewer has collected, he/she may rephrase or describe in more
detail the item or practice that he/she is asking about, using examples, to ensure that the respondent completely
understands the question to which he/she is responding.
In cases where it may be necessary to provide additional clarification, the interviewer should provide only the
minimum information required for an appropriate response.
If, however, the respondent appears to understand the question and the response still is not consistent, the
interviewer must record the response as given by the respondent.
Never suggesting answers to the respondents
If the respondent's answer is not relevant to a question, the interviewer should not prompt them by saying
something like “I suppose you mean that…Is that right?. In many cases, the informants will agree with the
interviewer’s interpretation of their answer, even when that is not what they meant. Rather, in most cases, the
interviewer should probe in such a manner that the informants themselves come up with the relevant answer,
e.g.
“Can you explain a little more?” “There is no hurry. Take a moment to think about it”.
Specific questions for which it may be necessary to provide additional clarification will be discussed in the
detailed instructions for completing the SARA questionnaires. Even in these cases, the interviewer should
provide only the minimum information required for an appropriate response. Except when specifically
instructed, the interviewer should never read out the list of coded answers to the respondents, even if they
have trouble in answering the question.
Remaining neutral
The job as an interviewer is to obtain the facts. An interviewer should be friendly, but firm; neutral, but
interested. The tone of voice, facial expressions, and even bodily postures all combine to establish the rapport
you create with your respondent. The interviewer should not express surprise, pleasure, or disapproval at any
response or comment made by the respondent.
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Asking all applicable questions
In most cases, the interviewer will ask questions in the sequence in which they appear in the questionnaire.
However, because the organization of facilities often differs, the interviewer may find that to complete one
section he/she has to talk to more than one respondent, or go to different areas of the facility. It is up to the
interviewer to ensure that when sections of the questionnaire are skipped because the information must be
collected from a different respondent or location, that those sections are completed before departure from the
facility.
Not raising expectations of immediate changes in the situation of the staff or
facility
The interviewer should not raise expectations that he/she can immediately assist with solving problems that
the staff or clients raise as problems. He/she is going to provide information to decision makers and health
planners and administrators, but any changes as a result of the survey will most likely occur over an extended
period of time, and be gradual in implementation. If clients or staffs complain about the poor state of repair of
the facility, equipment, or supplies or other problems, the interviewer should provide a neutral or non-
judgmental response (e.g., “I know these things are difficult”).
Not separating questionnaires
The interviewer should never separate stapled or bound questionnaire forms to speed up the process of data
collection. Experience has shown that this strategy may result in lost pages.
Thank the respondent at the end of the interview
At the end of every interview, the interviewer should thank the respondent for taking time out of his/her busy
schedule, telling him/her it was very much appreciated. They should be asked if he/she can direct the
interviewer to the next appropriate clinic/unit and/or person.
5.2.2 Tips on handling difficult interview situations
The respondent is reluctant to participate
Occasionally, a potential respondent will refuse to participate in the survey. The interviewer should not take
the initial unwillingness of a respondent to cooperate to mean a final refusal. He/she should try to put
himself/herself in the position of the respondent and think of factors that might have brought about this
reaction. The respondent may not be in the right mood at that particular time or he/she may have
misunderstood the purpose of the visit. The interviewer should try to find out why the respondent is unwilling
to participate, and respond accordingly. Some points can be used to persuade a respondent to participate:
The information he/she provides will help the Ministry of Health and the government to better
understand the effectiveness of programs and make improvements to the program that will ultimately
help the clients.
If confidentiality is an issue, the interviewer should reassure the respondent that everyone working on
the survey has pledged to maintain confidentiality and that the respondent's name will not be shared
with others, including his/her supervisors or colleagues.
The respondent cannot be replaced by anyone else.
However, in some circumstances a respondent may continue to refuse. In this situation, the interviewer should
respect the respondent's right to refuse, and thank the respondent for his/her time. The interviewer should not
take these refusals personally.
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The respondent seems bored
There may be other situations where the respondent simply says, “I don’t know, gives an irrelevant answer,
acts bored or detached, contradicts something they have already said, or refuses to answer the question. This
happens most when the respondent is concerned about their other clinic/unit responsibilities and wants to get
back to them. In these cases the interviewer must try to re-interest the respondent in the conversation. For
example, if the interviewer sense that the respondent is growing restless, he/she should be reassured that
there are not many more questions and that his/her responses are very valuable.
The respondent is very talkative
If an informant is giving irrelevant or elaborate answers or complaining about something, the interviewer
should not stop him/her abruptly or rudely, but listen to what they have to say. Then the interviewer should
try to steer him/her gently back to the original question. The interviewer can also write down what he/she
says and tell him/her that it is duly noted. A good atmosphere must be maintained throughout the interview.
The best atmosphere for an interview is one in which the respondent see the interviewer as a friendly,
sympathetic, and responsive person who cares about him/her.
5.3 Completing the SARA
questionnaire
The interviewer's main responsibility is to use the questionnaire to appropriately collect information that is as
accurate as possible by asking questions to the appropriate respondents and accurately record the responses.
The instructions and examples below explain the questionnaire form, the various types of questions and
instructions, and procedures for correctly recording information.
5.3.1 Recording the responses
When completing a paper version of the questionnaire, all responses are to be recorded using pens with blue
ink. Blue ink is used because it can be distinguished from the black ink in which the questionnaires are printed.
Red or green ink should never be used in recording responses since these colours are reserved for the survey
manager and field supervisor to use in correcting the questionnaires in the office.
The information recorded in the fields of the questionnaire form will eventually be entered into an electronic
database. At that point, it is very difficult to correct for errors or omissions in the questionnaires. Consequently,
it is very important that all answers be correctly recorded and special instructions in the questionnaire be
followed.
The procedures for recording responses will vary according to the type of question being asked. There are
some basic types of questions in the questionnaire such as pre-coded questions and questions requiring a
numeric response. Samples of all types of questions, and combinations of them, are reviewed below giving
examples.
NEVER LEAVE A RESPONSE BLANK! A blank is recorded as “missing information” because it is not known if
the question was asked or not. If a response is negative, the negative response must be circled. Likewise, if a
response is “don’t know”, the number corresponding to the “don’t know” response must be circled.
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This questionnaire is typically divided into four columns, as shown below. The first column contains the
question number with each question numbered separately within each section. The second column contains
the questions and instructions to the interviewer for posing questions, the third column contains the response
categories, and the fourth column contains skip and other instructions, if necessary.
5.3.2 Instructions
Instructions for the interviewer
It is important to ask the questions exactly as they are written in the questionnaire and in the order in which
they appear. Questions are often accompanied by a set of instructions for the interviewer. Instructions are
usually located in the question column and appear as bold faced CAPITAL LETTERS. Instructions will help you
to remember important directions for asking questions, making correct observations, and recording
information. These instructions should not be read to respondents.
Example:
It is important to pay attention and follow consistently the instructions because they will help the interviewer
complete the questionnaire as accurately and completely as possible.
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Introducing a set of questions
There are sentences throughout the questionnaire that provide information to the respondent about the next
set of questions to be asked. These sentences must be read to the respondent, so that they know what to
expect from the next set of questions. Respondents who are provided information up front are less likely to be
surprised or uncomfortable about certain questions and much more likely to respond sincerely. Below is an
example of a set of sentences found in the questionnaire that are to be read to the respondent so that they will
know what to expect.
Example:
If, during the training or the pretest, the interviewer finds that information such as this would be useful prior to
a set of questions where there is no narrative, it should be reported to the field supervisor so that the
questionnaire can be modified if necessary.
Skip Instructions
The questionnaire is set up to avoid as much redundancy as possible and to ask only appropriate questions
given a situation. This is accomplished through the use of skip patterns. It is very important to follow these
skips for they will make the questionnaire more concise and relevant and thus increase the cooperation of the
respondent. In the sample question below, if the answer to question 301 is “No”, the providers in the health
facility do not have to answer the following question about overnight observations. The interviewer will skip
the following questions (302-304) and go to question 305. If the answer is “Yes” the interviewer will ask
question 302.
Example:
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Available and functional Instructions
Throughout the questionnaire many questions ask if equipment and supplies used in different services are
available and if so if there functional. The following pattern should be followed to fully answer the question:
Section A: “Availaible”
The respondent is asked if a specific item is available. It the answer is NO, the response “2” should be circled.
As indicated by skip on the questionnaire, the interviewer will go directly to the next item. If the answer is YES,
the answer “1” should be circled. The interviewer should now skip to the section B “functional”
Section B: “Functioning”
The interviewer will need to determine if the item available is functioning at the time of the visit. For these
cases the following criteria will be used:
“1” for “YES”: Staff reports that the item is in working order thus functional.
“2” for “NO”: The item does not function if the staff member indicates that it is not in working order.
“8” for “DON’T KNOW”: The respondent is not certain if the item is in working condition or not, and you
cannot verify the functioning condition (e.g. the place where the item might be is locked and cannot be
accessed at the time of the survey and the respondent does not know about the item).
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Observation Instructions
Throughout the questionnaire many questions ask if drugs and commodities are present. The following criteria
are to be used for classifying the presence of the item (observed and with valid expiration date on the day of
the assessment):
"1" for "OBSERVED AND VALID": The item was seen in the service provision area or in an adjacent room
where it can easily be used. The expiration date of the drug or commodities (at least one of them) has
been checked and confirmed valid.
“2” for “OBSERVED BUT NOT VALID”: The item was seen in the service provision area or in an adjacent
room where it can easily be used. The expiration date of the drugs or commodities has been checked
and confirmed not valid.
"3" for "REPORTED AVAILABLE BUT NOT SEEN": Staff reports that the item is located in the facility or
immediately adjacent, where it can easily be used, but for some reason (e.g., key to cabinet is missing or
room is locked), the interviewer cannot observe the item. This answer should also be selected when
staff indicates that the item is brought to the service delivery area only at the time services are provided
(thus not being observed by the interviewer).
“4” for “NOT AVAILABLE TODAY”: Staff reports that the item is usually available in the facility but not on
the day of the assessment.
“5” for “NEVER AVAILABLE”: Staff reports that the item is never available in the facility.
5.3.3 Question types
Pre-coded questions
For some questions, we can predict the types of responses a respondent will give. The responses to pre-coded
questions are listed in the questionnaire. To record a respondent’s answer, the number (code) that
corresponds to the response should be circled. When numbers indicate coding categories, the interviewer
records only one response for each question. The interviewer should make sure that each circle surrounds only
a single number.
Example:
In some cases, a pre-coded question will include an “other” category. The “other” code should be circled when
the answer provided is different from any of the pre-coded responses. The “other” response should be
specified and written in the space provided. If more room is needed, the margins can be used. The interviewer
should also pay attention to any skip linked to a pre-coded answer.
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Example:
Sometimes responses to particular questions must be entered in response grid (table). When recording a
response in one of these grids, the interviewer has to be sure that the answer is entered in the proper row and
column.
Example:
Numeric responses
Several questions require a numeric response. These should be recorded in the appropriate available boxes in
the right column of the table.
Example:
Whenever respondents do not know the answer to a numeric question, the interviewer must circle the “Don't
know” response option. If “Don't know” is not one of the responses then you must probe to get a numeric
response to fill in the boxes. All boxes should have a number recorded in them. Anytime a respondent's
answer requires fewer digits than provided for in the response column, the interviewer must record zeros (0) in
the left-hand box and the respondent's answer in the right hand box.
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5.3.4 Ensuring quality
All members of the survey team are responsible for ensuring that the data that is collected at each facility is as
accurate and comprehensive as possible. Each interviewer is responsible for:
Checking that questionnaires filled are complete at the end of each interview, ensuring that all answers
are clear and reasonable, and that your handwriting is legible.
Returning to the original respondent(s) if questions are omitted or there appears to be errors, in order
to complete the questionnaire. In this situation, the interviewer should apologize, explain that a mistake
was made, and then ask the question again.
Notifying the field supervisor whenever there are problems in completing the daily assignment.
Taking into account the field supervisor’s feedback and recommendation on the field work/interview
procedures based on the on-going assessment work.
Correcting mistakes
If a mistake was made while recording an answer or the respondent changes his/her reply, two diagonal lines
through the incorrect response should be used. The interviewer should not try to erase an answer, use white-
out, or write over an answer. It is particularly hard for data entry staff to understand which of two numbers is
correct, if the interviewer has tried to write over a response.
Example:
The interviewer should remember that if there are two responses for a particular question that requires only
one response, it may be impossible later, when the data are being entered, to determine which the correct
answer is. Also, if he/she writes over an answer, the data input staff frequently cannot determine which of the
two responses you meant as the correct response.
Questionnaire editing
Interviewers are required to edit their questionnaires before considering an interview complete. If questions
are omitted or there appear to be errors, he/she must returns to the original respondent(s) if possible. He/she
should apologize, explain that an error was made, and ask the question again.
Editing should be done on the spot in order to avoid the need for re-contacting respondents, which is
impractical given the time frame for fieldwork completion, as well as inconvenient for both the interview teams
and the respondents.
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Check list
All questionnaires should be reviewed from beginning to end for the following:
Verify that the interviewer has signed the verbal consent.
Verify that all skip and filter instructions have been respected.
Verify that the responses are legible.
Verify that only one response code is ticked for each question.
Verify that any corrections made by the interviewer are done legibly
according to the instructions above.
Check that all questionnaires contain the correct number of pages.
Check that there are no missing responses.
5.4 Using CSPro for data entry
Electronic data collection facilitates collection of more accurate and reliable data in a more efficient, timely
manner. For the SARA survey, electronic data collection is carried out through the use of the Census and Survey
Processing System (CSPro) software. CSPro was developed jointly by the U.S. Census Bureau, Macro
International, and Serpro, SA, with major funding from the U.S. Agency for International Development. CSPro is
in the public domain. It is available at no cost and may be freely distributed.
For information about the Census and Survey Processing System (CSPro), including free download, visit:
http://www.census.gov/population/international/software/cspro/
5.4.1 Installing CSPro
1. Download the CSPro application from http://www.census.gov/ipc/www/cspro/index.html
2. Install CSPro 5.0.3 to your computer by double-clicking on cspro50.exe.
This will start the installation wizard.
3. The setup process takes you through a series of dialog boxes that prompt you for setup information.
Selecting components for installation
CSPro allows you to select which components of the system you want to install. During the installation you will
see the following component screen:
You have the following choices:
CSPro (all components): Select this if you plan to
develop applications.
Data Entry Operator (only): Select this if you are
installing a data entry application on a production
machine. The operator will be able to run an already-
created data entry application, but will not be able to
make any changes to it. The Data Entry, Compare Data,
Text Viewer, and Table Viewer components are installed.
At any later time, you can change the components installed by rerunning the installation.
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5.4.2 SARA data entry application
Open the SARA data entry application in CSPro
To open the SARA data entry application, click on the “SARA_2_0_Menu.pff” shortcut available on the
desktop.
A new form (Case) opens. You can now start filling the Cover page information:
The question text is located on the yellow top window. For each question a pop-up window will appear.
Select your answer and validate your choice by clicking on the green check mark (or press the ENTER
button).
Filling in the SARA data entry forms
Fill in all the responses for the cover page. When the consent is received from the respondent select “1”
for the answer Q015; the main Menu will automatically open.
From the main Menu select the form you want to fill-in. Click on the green check mark to validate your
choice.
Please note that it is required to fill-in form 8 on “Obstetric and newborn care” prior to being able to fill in form
19 on “Surgery” and form 18 on “Tuberculosis” prior to being able to fill in form 23 on “Diagnostics” .
The selected form opens and can be filled. The text question appears
on the yellow top window. The green check mark in the pop-up window is
used to validate the answers.
To save the file go to: File/Save partial case
The following pop-up window appears. Click “Ok” to continue the
data entry.
Remember to save regularly while filling in the case to avoid any data lost .
At the end of the form the following pop-up window will appear:
Text of the
question
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Click “Yes” to validate the data entry for the form. You
will then automatically return to the main Menu
The completed form now appears in the back list.
Stopping data entry in middle of a form
If you are in the middle of filling a form and need to exit the form for some reasons click on the “X” at
the top right end of the form to close it . A pop-up window opens:
Select “Partial save” to save the data entered. Another pop-up window will open indicating that “The
current case has been saved”. Click “Ok” to return to the main menu.
The incomplete form appears on the menu (“incomplete” is indicated into parenthesis.
Note that all forms should be completed prior to leaving the facilities.
Finalizing an incomplete form
To complete a form, select it from the main Menu and click on the green check mark to validate your
selection
The form opens and can be finalized. When completed and accepted the form will appear on the back
list and the “(incomplete)” indication should have disappeared.
Closing a case
When all forms have completed select “Exit” from the main Menu and select the green check mark. The
following pop-up window will appear:
Re-opening a case
Click on the SARA_2_0_Menu.pff” on the desk top
A menu opens. Select the case you want to open and double click on it.
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The Cover page of the form (case) opens.
If no edits have to be done to the Cover page, select 1 from the Consent pop-up window and click on the
green check mark to validate your selection.
The main Menu opens.
Viewing and editing a module
If you want to view/edit a module that has already been fully completed, select the option 98 at the
bottom (View/change module already finished) and click on the green check mark. You can now choose
from the list the form that need to be revised.
Indicate the number of the form you want to review at the right bottom of the window and click ENTER
to validate your choice
Review the form answers as needed.
To exit the form click on the last question and press ENTER. The following pop-up window will appear.
Click “Yes” to validate your review and go back to the main Menu
Open the SARA data entry application in CSPro
To open the SARA data entry application, click on the “SARA_2_0_Menu.pff” shortcut available on the
desktop.
A new form (Case) opens. You can now start filling the Cover page information:
Text of the
question
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The question text is located on the yellow top window. For each question a pop-up window will appear.
Select your answer and validate your choice by clicking on the green check mark (or press the ENTER
button).
Filling in the SARA data entry forms
Fill in all the responses for the cover page. When the consent is received from the respondent select “1”
for the answer Q015; the main Menu will automatically open.
From the main Menu select the form you want to fill-in. Click on the green check mark to validate your
choice.
Please note that it is required to fill-in form 8 on “Obstetric and newborn care” prior to being able to fill in form
19 on “Surgery” and form 18 on “Tuberculosis” prior to being able to fill in form 23 on “Diagnostics” .
The selected form opens and can be filled. The text
question appears on the yellow top window. The green check
mark in the pop-up window is used to validate the answers.
To save the file go to: File/Save partial case
The following pop-up window appears. Click “Ok” to continue the
data entry.
Remember to save regularly while filling in the case to avoid any data lost .
At the end of the form the following pop-up window will appear:
Click “Yes” to validate the data entry for the form. You will then automatically return to the main Menu
The completed form now appears in the back list.
Stopping data entry in middle of a form
If you are in the middle of filling a form and need to exit the form for some reasons click on the “X” at
the top right end of the form to close it . A pop-up window opens:
Select “Partial save” to save the data entered. Another pop-up window will open indicating that “The
current case has been saved”. Click “Ok” to return to the main menu.
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The incomplete form appears on the menu (“incomplete” is indicated into parenthesis.
Note that all forms should be completed prior to leaving the facilities.
Finalizing an incomplete form
To complete a form, select it from the main Menu and click on the green check mark to validate your
selection
The form opens and can be finalized. When completed and accepted the form will appear on the back
list and the “(incomplete)” indication should have disappeared.
Closing a case
When all forms have completed select “Exit” from the main Menu and select the green check mark. The
following pop-up window will appear:
Re-opening a case
Click on the SARA_2_0_Menu.pff” on the desk top
A menu opens. Select the case you want to open and double click on it.
The Cover page of the form (case) opens.
If no edits have to be done to the Cover page, select 1 from the Consent pop-up window and click on the
green check mark to validate your selection.
The main Menu opens.
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Viewing and editing a module
If you want to view/edit a module that has already been fully completed, select the option 98 at the
bottom (View/change module already finished) and click on the green check mark. You can now choose
from the list the form that need to be revised.
Indicate the number of the form you want to review at the right bottom of the window and click ENTER
to validate your choice
Review the form answers as needed.
To exit the form click on the last question and press ENTER. The following pop-up window will appear.
Click “Yes” to validate your review and go back to the main Menu
Viewing and editing a module
Start the application by double clicking on the icon on the desktop
In the menu, go to Mode, select “Add case”
A new form opens.
5.5 Using GPS for geographic
coordinates collection
This section introduces required steps for geographic data collection using GPS devices. For the purpose of the
description the Garmin eTrex device has been used. Complete functionality of the device are described in the
user manual provided with the Garmin eTrex.
The functions described on this section only focus on the essential steps to collect health facilities geographical
coordinates to complete the national Master Facility List.
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5.5.1 Features of the Garmin eTrex GPS unit
The eTrex GPS device comprises 5 main buttons as described below:
It requires two AA batteries that should be place on the back of the device (take off back cover).
5.5.2 Overview of the GPS functions
All of the information needed to operate the GPS is found on 4 main “pages” (or display screens).
These pages are:
4. Satellite
5. Map
6. Navigation
7. Menu
Simply press the PAGE button to switch
between pages.
Use the ENTER, UP, and DOWN buttons to access the different functions of a page.
Satellite
The satellite page shows the eTrex gathering all the necessary
satellite information in order to work. There are two display
options on the Satellite page: Normal Skyview and Advanced
Skyview. Normal Skyview shows you the satellites, satellite signal
strength, and the eTrex's estimated location accuracy. Advanced
Skyview shows the numbered satellites the eTrex is using, their
proximity to your current position, and their individual signal
strengths. To navigate from one to the other, select the ENTER
button and choose the preferred skyview.
Map
The Map Page shows where you are (the animated figure) and provides a real picture
of where you are going. As you travel (the animated figure "walks") and leaves a
"trail" (track log). Waypoint names and symbols are also shown on the map.
LCD Display
(with backlight)
POWER button
PAGE button
Internal GPS Antenna
UP button
DOWN button
ENTER button
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Navigation
The Navigation Page helps guide you to a destination. When you are moving with no
particular destination in mind, the navigation page shows you your moving direction
and speed. When you are moving towards a specific destination, the navigation page
shows you the name of the location, the distance and time to go, and displays a
direction arrow in the compass ring. To navigate, simply follow the arrow.
Menu
The Main Menu gives you access to the eTrex's more advanced features.
With the main menu, you can create and view waypoints, create a route,
save and track logs, or access the system setup features.
5.5.3 Setup for map units
From the MENU page, select SETUP, then select the category UNITS in order to specify units of measure.
5.5.4 Where to collect GPS coordinates
The rules for GPS data collection are as follows:
1. Single facility in a building
The geographic coordinates should be recorded in front of the main sign attached to the building of the
facility.
If there is no sign attached to the building then the geographic coordinates should be recorded in front
of the main door or reception area of the facility.
2. Multiple facilities in a single building
The geographic coordinates should be recorded in front of the sign(s) that lists what facilities are located
in that building (if the sign is outdoors and attached to the building).
POSITION FRMT
hddd.ddddd
MAP DATUM
WGS 84
UNITS
metric
NORTH REF
magnetic
ANGLE
degree
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If there is no sign listing what is in the building (or if the sign is indoors), the geographic coordinates
should be recorded in front of the main entrance door or reception area of the building.
3. Single facility in multiple buildings
The geographic coordinates should be recorded in front of the door or main entrance to the reception
area of the facility (preferably where the main sign for the facility is). If there is no reception area, the
geographic coordinates should be recorded in front of the door to the administrative offices of the
facility.
5.5.5 Using the GPS for collecting geographic data
Once you have configured the settings on the GPS receiver, you can use it to record the geographic coordinates
of a facility. Make sure that if the receiver had been previously used to collect data, the internal memory has
been cleared.
1. Move to main entrance of the building and stand within 30 meters of the main door. It is necessary to
be placed in an open area that has a clear view of the sky and hold the GPS receiver parallel to the
ground so that its antenna is able to receive signals.
2. Collect coordinate only when the receiver indicates that is has acquired signal from enough satellites
to produce and accurate reading. The message "Ready to navigate" should appear on the GPS receiver
(SATELLITE page) and the accuracy should be lower than 20 meters. In case you do not get the
message "Ready to navigate", wait at the same place for 5 minutes.
3. When the signal is sufficient and the accuracy is at the recommended level, the geographic
coordinates can be recorded:
Go to the MENU page and select MARK
Highlight the WAYPOINT number and press ENTER. You can now enter
the facility code (maximum 6 digits or letters)
Press ENTER and scoll down to OK
Press ENTER to go back to the MARK page
Highlight OK using the UP and DOWN button and press ENTER
The WAYPOINT is now registered
5.5.6 Retrieving waypoints list from the GPS receiver
To retrieve the waypoints from the list of GPS coordinates collected:
Go to the MENU page and select WAYPOINTS
Using the UP and DOWN button you can now look for a waypoint just or previously entered
You can now report the geographic coordinates on the SARA paper questionnaire as well as electronic form (if
applicable).
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Latitude and longitude
Latitude is the north/south value measured from the equator. Longitude is the east/west value measured from
the Prime Meridian that runs through West Africa and Western Europe. A latitude and longitude identifies an
exact location on the earth’s surface. Thus, based on the location of the health facility positive (+) (North/East)
or negative (-) (South/West) coordinates should be properly reported.
In order to conserve battery life, switch off the GPS receiver once the geographic coordinates are recorded.
5.5.7 Checklist for GPS units
Each morning before you leave for visits, check that you have all the necessary materials with you and
remember the following when collecting GPS coordinates.
Check battery level and verify that the device is properly working.
Check the settings of your GPS receiver.
Have questionnaire for data collection ready to be used.
Make sure to be properly placed for reliability of data collection.
Report coordinates taking into account location to the Equator and Greenwich meridian.
Make sure that all information relative to the collected point has been reported
(in the paper SARA form as well as electronic form if applicable).
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6. Supervisor’s guide
6. Supervisor’s guide
80
The Service availability and readiness assessment (SARA) is designed to function as a systematic tool to support
annual verification of data and service delivery at the facility level. It intends to cover public as well as private
and faith-based health facilities. The goals of the survey is to provide evidence based data on health system
progress to inform the annual health sector review, identify gaps and weaknesses responsible for sub-optimal
service provision and intervention coverage that need to be addressed. It also provides a baseline for planning
and monitoring scale-up intervention for service delivery improvement for maternal and child health, HIV,
TB,malaria and NDCs among others .
The SARA survey requires visits to health facilities with data collection based on key informant interviews and
observation of key items. Supervisors have a key role to ensure that the field data is properly conducted.
The Supervisor’s Guide is designed to provide supervisors with:
Clear understanding of their roles and responsibilities in managing the field data collection and
supervising the data collectors’ teams
Details of the field data collection procedures and protocols required steps to ensure quality data
collection work
Steps in using CSPro for electronic data verification and validation
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6.1 Roles and responsibilities
Field supervisors are responsible for overseeing all aspects of data collection in the survey area(s) for which
they are responsible. This includes:
Organizing data collection visits in facilities (making initial contact, preparing a schedule of data
collection visits, etc).
Preparing the necessary materials for data collection.
Supervising data collection activities:
Make sure data collection protocols are followed
Arrange for regular communication with data collection teams
Check data collection forms at the end of each day for completeness and legibility
Ensure data are transferred to computer at the end of each day and at national level by the end of
the assessment
Validating data collection by re-conducting the survey at 10% of facilities comparing results to those of
data collectors.
Collecting and storing data collection forms, and sending them to the survey manager.
Transferring electronic data from electronic data collection devices to survey area computer/laptop.
Field supervisors have a crucial role to play in ensuring data quality and consistency.
6.2 Conducting field activities
6.2.1 Preparing for data collection
1. Schedule survey visits and identify replacement facilities
The survey manager will provide you with a list health facilities and replacement facilities for your survey area.
1. Contact (in person or by phone) each health facility and replacement facility to introduce the
survey and seek permission for data collection:
Introduce the survey and its objectives
Use the letter of endorsement and introduction provided by the survey manager
Stress that individual facilities will not be identified in the results
2. Make an appointment for data collection at a date and time which is convenient for the facility,
avoiding peak hours.
Plan for approximately 3-4 hours for each data collection visit, plus travel time
More time should be allotted for large facilities/hospitals (1 day for hospital)
3. Note the name and telephone number of the contact person at each health facility.
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4. Explain about the possibility of a second visit for 'validation,' which may take place in 10% of the
surveyed health facilities.
5- If a facility refuses to participate, alert the survey manager who will contact the health facility
directly, and if necessary, provide you with an alternative site. Luckily, this rarely happens.
2. Prepare a schedule of data collection visits for each pair of data collectors
1. Prepare a schedule for each pair of data collectors, including:
Date and time of each visit
Name, number, sector and contact person for each health facility
Address and location of each health facility
Contact information for replacement facility to be visited if necessary
Example:
Date and time of
appointment
Name of
facility
Contact
person
Location
Managing
authority
ID Number
replacement
facility- name
and contact
details
April 20
10h00
ABC Health
center
Mrs
Nguyen
45 Main
Street
Eastern City
Tel: +22 414
00
Govt
01234
XYZ Health
Center-
59 main
street
Eastern City
2. Call each facility and confirm appointment the day before the data collection
3. Arrange for regular communications and transport
Once all of the survey sites are known, transportation should be arranged according to the number of sites to
be visited, the number of teams going into the field, and the number of people per team.
6.2.2 Preparing the necessary materials for data collection
1. Prepare data collection form for each facility to be visited
1. The survey manager will provide you with a separate data collection form for:
Each sample health facility in your survey area;
Each replacement facility; and
Each validation visit.
Make sure that there are enough forms according to the list of facilities in the survey area prior to starting the
field data collection.
2. Complete the front page of the SARA questionnaire data collection form with the identifying
information of each sample facility.