Contribution of Survey to Health Systems Performance Monitoring: experience with the World Health Survey THE MALAYSIAN EXPERIENCE September 2006 Montreux, Switzerland

Introduction World Health Survey 2002World Health Survey 2002 –Nationwide community survey –Multistage stratified sampling representative of population –Stratified for state & urban rural location –National & rural/urban location estimates –Where possible estimates across various socio- demographic variables –Institutionalised population excluded (<3%)

Introduction World Health Survey 2002World Health Survey 2002 –Data collection early March – mid April 2003 –200 personnel of various categories including temporary research assistants –MOH facilities & vehicles –Nationwide publicity

Field Preparation –Organisational structure Advisory/Steering committeeAdvisory/Steering committee Central Research TeamCentral Research Team Field Data Collection teamField Data Collection team Data Entry TeamData Entry Team

ORGANISATIONAL STRUCTURE

Implementation strategy More rural Less densely populated areas Less rural high density areas (larger sample size) Very highly density areas (larger sample size) Mobilization of survey teams across districts & states

–Budget proposal (Oct-02) –Translating & Pre-testing instruments (Oct-Nov 02) –Road shows (16-20 Dec 02) –Recruitment of research assistants (Jan-Feb 03) –Field preparation- (sampling & procurement) ( Jan-Feb 03) –Identification of EBs and Tagging exercise (Jan- Feb 03) –Training (17 Feb- 15 Mar 03) – Launching (28 Feb 03) –Data collection (Mac-April 03) –Publicity in various media (Feb – April 03) –Data entry (Mac-April 03) Survey implementation schedule

–Presentation of preliminary findings (July 03) Programme heads and service providersProgramme heads and service providers Share contents of WHS 2002Share contents of WHS 2002 Identify additional questions relevant for programme needsIdentify additional questions relevant for programme needs –Further assistance with analysis from WHO (July 05) –Mini-conference (September 2005) Invited resource person from WHOInvited resource person from WHO Senior officers from programmes and various operational levelSenior officers from programmes and various operational level –Clinicians, public health specialists, public health engineers, nutritionists, human resource personnel Survey implementation schedule

–Report writing (October 2005 – June 2006) 5 volumes5 volumes 4 drafts4 drafts –3 volumes already with printers (August 2006) –Proposed presentation to senior management (Nov – Dec 2006) Survey implementation schedule

WHS 2002 Snapshot of Data Quality

WHS 2002 Sample size = Response Rate = 80.2% Analysis (as per WHO) done in 2005.

Sampling

Response Rate Location UrbanRuralTotal Household interviews Selected Interviewed HH RR (%) Individual interviews Selected Interviewed Individual RR (%)

HH Sample Deviation Index

Individual level Sample Deviation Index

Missing Data

Reliability

HH Level: Sociodemographic Profile (weighted) Mean Household size = 4.2 Male : Female ratio =0.98 Geographical location: Majority in urban areas Household size Q1poorest4.00 Q24.11 Q34.16 Q44.29 Q5richest4.89 Missing3.57

HH Level: Sociodemographic Profile (weighted)

Presentation & Utilisation of findings To date, results yet to be formally presented to top management General impression of findings –Value added as it provides a better perspective (new dimensions) of country HS performance –Better performance in some aspects but eye-opener in others! Application found downstream at various levels

Utilisation of findings National levelNational level –Key input into development of National Health Financing Mechanism Volume 5 (Responsiveness section)Volume 5 (Responsiveness section) –Areas respondents were not satisfied –State of hospital –Utilisation pattern –Cost of care Volume 4 (H Expenditure)Volume 4 (H Expenditure) –OOP, perception on risk pooling Volume 3 (Coverage)Volume 3 (Coverage) –understanding of current situation of service provision Volume 2 (Risk factors)Volume 2 (Risk factors) –What should go into the basic benefit package –ANC, HIV transmission amongst mothers, condom use for prevention

Utilisation of findings Programme level –Responsiveness component used in development of soft skills training modules for health workers & evaluation of front line customer services –Input into development of Patient/People - centred services –Verify effectiveness of current programmes and related activities –Support (evidence-based) the justification of newly introduced activity –Recommend development of new strategies/activities to specific risk groups –Identification of new research to look into impact

Potential application Evaluation of Mid term review of performance of 9 th Malaysia Plan

What we have learnt….. Objectives have been achievedObjectives have been achieved –Contribution to development of cross-country measure –Assess country HS performance –Transfer of technology (to some extent!)

What we have learnt….. Costly affairCostly affair –Human & financial resource intensive Need for buy-in from all sectorsNeed for buy-in from all sectors –To ensure successful survey implementation –To ensure usage of findings

What we have learnt….. Need for advanced planning (at least 1yr!!)Need for advanced planning (at least 1yr!!) –Negotiation with operational managers for manpower assistance & other logistics –Budget proposal and approval

What we have learnt….. Instrument itselfInstrument itself –Translation into local language poses a challenge! –Complicated & lengthy (2.5 hrs mean completion time) –Some aspects politically sensitive (8000 series were omitted) –Definitions of certain variables differ from own country Uneasiness & defensive about country performance by various programme heads –E.g. HIV & Human resource In retrospective –Should allow for 2 sets of definitions

What we have learnt….. Analysis & InterpretationAnalysis & Interpretation –Stata software Limited expertise –Complex analysis CHOPIT (done by WHO team, Geneva) Some analysis still pending –E.g. Y star results for adjustments for cross country comparison (responsiveness section still pending) Duration of whole activity (data collection to analysis to report writing)Duration of whole activity (data collection to analysis to report writing) –Too long

What we have learnt….. Lack of expertise to translate research findings into action –e.g. interpreting findings, writing policy briefs

Our conclusion… In general, –WHS 2002 a useful tool for management –Provides good info/added value about our HS performance not found in routine M & E But…. – A costly affair –A painful exercise (blood, sweat & tears!) of negotiations, personal sacrifices, energy sapping, etc And….. –Success requires careful planning

Our recommendations…. Have sufficient budget for implementation Ensure top management commitment Allow countries to adopt & adapt sections applicable to them Need to simplify – vignettes – health status We have the mean score but as there is no benchmark, results not really meaningful Need to make instrument brief Assist countries without capacity to undertake national community surveys

Our recommendations…. Assist countries to market findings to policy makers –Translation into policies –Help to see implications of findings to current policies Need to build greater in-country capacity from beginning to end

Thank you