QST PHC-BHCPF Kwara Mobile Version Welcome to the BHCPF Quality Scoring Tool for PHCs (Facility Assessment Tool) #####Section 1. **Permission** 1. Do you agree to be interviewed? Yes yes No no 2. What is your reason for refusal. Any additional notes #####Section 2. **Facility Information** 1. State Abia abia Adamawa adamawa Anambra anambra Akwa-Ibom akwa_ibom Bauchi bauchi Bayelsa bayelsa Benue benue Borno borno Cross River cross_river Delta delta Ebonyi ebonyi Edo edo Ekiti ekiti Enugu enugu Federal Capital Territory federal_cap Gombe gombe Imo imo Jigawa jigawa Kaduna kaduna Kano kano Katsina katsina Kebbi kebbi Kogi kogi Kwara kwara Lagos lagos Nasarawa nasarawa Niger niger Ogun ogun Ondo ondo Osun osun Oyo oyo Plateau plateau Rivers rivers Sokoto sokoto Taraba taraba Yobe yobe Zamfara zamfara 2. Local Government Area 3. Wards 3. Ward 4. Health Facility Name 4. Health Facility Name 4a. Type in facility name Please remember to take necessary steps to add this facility to the master facility list 5. Health Facility Type Primary health center primary_health_center Primary health clinic primary_health_clinic Health post health_post 6. Health Facility Code General Hospital (GH) – 001 general_hospital Comprehensive Health Centre (CHC) – 002 com_health_centre Primary Health-care Centre (PHC) – 003 prim_health_centre Clinic/Maternity home – 004 clinic_mat_home Health Post – 005 health_post Mobile Clinic – 006 mobile_clinic Dispensary – 007 dispensary 7. Is the facility rural or urban? Rural rural Urban urban Peri-Urban peri-urban 8. Is the building rented Yes yes No no 9. Arrival time for first visit 10. Collect the GPS coordinates of this facility. #####Start of Survey #####Section 3. **General Information** 1. Full name of Respondent [First-name Last-name] 2. Phone Number of Respondent 3. Are you the OIC? Yes yes No no 4. Which position do you occupy in this facility? Medical officer medical_doctor Nurse/Midwife nurse_midwife Registered nurse registered_nurse Midwife Mid_wife Community Health Extension Worker chew Junior Community Health Extension Worker Jchew Pharmacist pharmacist Lab technician Lab_technician Health records officer Health_records_officer Environmental health officer Environmental_health_officer Other other Specify other. 5. Who owns this facility? Government (public) government Private not-for-profit/NGO Private_not-for-profit/NGO Private not-for-profit/Faith-based private_not-for-profit/Faith-based Private for-profit private_for-profit Other other Specify other. 6. Who mainly pays the salaries of staff at this facility? Government (public) government Private not-for-profit/NGO Private_not-for-profit/NGO Private not-for-profit/Faith-based private_not-for-profit/Faith-based Private for-profit private_for-profit Other other Specify other. 7.Who mainly pays for medical supplies (equipment, drugs, commodities) for this facility? Government (public) government Private not-for-profit/NGO Private_not-for-profit/NGO Private not-for-profit/Faith-based private_not-for-profit/Faith-based Private for-profit private_for-profit Other other Specify other. 8. Who mainly pays for operation & maintenance costs for this facility? Government (public) government Private not-for-profit/NGO Private_not-for-profit/NGO Private not-for-profit/Faith-based private_not-for-profit/Faith-based Private for-profit private_for-profit Other other Specify other. 9. What type of health facility is this? Primary health center primary_health_center Primary health clinic primary_health_clinic Health post health_post 10. How many rooms does this health facility have? 11. Take a picture of the waiting area in the health facility *If applicable 12. Take a picture of the consulting room in the health facility *If applicable 13. What is the traveling time by car, in minutes, to the state capital in the DRY season? 0-10 minutes zero_to_ten_minutes 11-20 minutes eleven_to_twenty_minutes > 20 minutes greater_than_twenty_minutes 14. What is the traveling time by car, in minutes, to the state capital in the RAINY season? 0-10 minutes zero_to_ten_minutes 11-20 minutes eleven_to_twenty_minutes > 20 minutes greater_than_twenty_minutes 15. Does this facility have a specified catchment area—that is a defined geographic area for which the facility has direct responsibility for serving? Yes yes No no 16. How many people live in the catchment area for this facility? #####Section 4. Administrative System and Infrastructure Administrative System 1. Does the health facility offer 24 hour's services? Yes yes No no 2. Does the facility have a functioning mobile phone with ability to charge? Yes yes No no 3. Does this facility have a functioning computer? Yes yes No no 4. Is there access to email or internet within the facility today? Yes yes No no 5. Are there arrangements for emergency transport? Yes yes No no 6. Take a picture of the ambulance vehicle 6a. What type of arrangements does this health facility have for emergency transport? [state all] Ambulance owned by facility ambulance_owned_facility Ambulance available on call ambulance_on_call Official vehicle (not an ambulance) owned by facility official_vehicle_owned_by_facility Official vehicle (not an ambulance) available on call official_vehicle_on_call Private vehicle (not ambulance) available on call private_vehicle_on_call Emergency patient transport emergency_patient_transport No ambulance/vehicle in the facility no_vehicle_in_facility Other other Specify other. 7. Is there a driver on call/available 24 hours? Yes yes No no 8. Is fuel available in the vehicle today? Yes yes No no 9. What was the purpose of the last trip that the vehicle or ambulance made? Transport health worker to another post transport_health_worker Transport a patient to another health facility transport_patient Not Applicable na Other other Specify other. 10. Do patients have to pay to use this vehicle or ambulance? Yes yes No no 10a. How much? 11. Does this facility have any guidelines on standard precautions for infection prevention? Yes yes No no 12. Does this facility have any guidelines on health care waste management? Please ask to see the guidelines Yes yes No no 13. Have you or any provider(s) received training in health care waste management practices in the past two years? Yes yes No no 14. Do you have a Quarterly (Business/Work) Implementation Plan? Ask to see the document Yes yes No no a. When did the facility submit the Quarterly (Business/Work) Implementation Plan for approval? b. When did the facility receive written approval from the relevant authorities for the Quarterly (Business/Work) Implementation Plan? c. Was there a delay in receiving Quarterly (Business/Work) Implementation Plan approval from the relevant authorities? Yes yes No no Not Applicable na d. Why was there a delay? Delay in submission of QIP by facility delay_in _submission Headquarters not approving QIP hq_not approving_qip Other other Specify other. 15. Does your health facility have a Quality Improvement Plan (QIP)? ask to see the document Yes yes No no a. Is the QIP costed? Yes yes No no Not Applicable na 16. Did the facility/hospital receive a supervision visit from the LGA-PHC in this calendar year? Yes yes No no a. Did they leave a copy or written feedback? Yes yes No no b. Did they use a checklist? Yes yes No no Not Applicable na Infrastructure 1. What is the current state of the building? Good; does not require renovation no_renovation Requires light renovation light_renovation Requires modest renovation modest_renovation Requires significant renovation significant_renovation 2. Take a picture of the FRONT VIEW of the facility building 3. Take a picture of the SIDE VIEW of the facility building 4. Take a picture of the BACK VIEW of the facility building 5. What is the current state of the roof? Good; does not require renovation no_renovation Requires light renovation light_renovation Requires modest renovation modest_renovation Requires significant renovation significant_renovation 6.Take a picture of the roof of the health facility 6a. Take a second picture of the roof of the health facility 7. Take a picture of the facility ceiling 7a. Take a second picture of the facility ceiling 8. What is the current state of the fence? Good; does not require renovation no_renovation Requires light renovation light_renovation Requires modest renovation modest_renovation Requires significant renovation significant_renovation No Fence nofence a. Take a picture of the fence of the health facility b. Take a second picture of the fence of the health facility 9. Are the consulting rooms clean, clearly demarcated with adequate sitting and examination facility? Yes yes No no 10. Take a picture of the consulting room in the health facility 11. Are the walls free from cracks? Yes yes No no 12. Does the health facility have functional doors with functional locks? Yes yes No no 13. Is there any source of electricity? Yes yes No no a. What is the main source of power or electricity for this facility? Electric power grid electric_power_grid Fuel operated generator fuel_operated_generator________ Battery operated generator battery_operated_generator Solar system solar_system Other electricity source other_electricity_source b. Specify power or electricity source Please remember to take necessary steps to add this facility to the master facility list 14. How many hours per day does this facility have electricity from the main source? 15. Does this facility use any of the following as alternative power sources? No alternative source of power supply no_source_of_power_supply Fuel operated generator fuel_operated_generator Battery operated generator battery_operated_generator Solar system solar_system Other alternative power source other_alternative_power_source 15a. Specify alternative power source 16. Is there any form of water? Yes yes No no a. What is the main source of water for the facility? Piped into facility piped_into_facility Piped onto facility grounds piped_onto_facility_grounds Public tap/standpipe public_tap_standpipe Borehole borehole Protected dug well protected_dug_well Unprotected dug well unprotected_dug_well Protected spring protected_spring_______________ Unprotected spring unprotected_spring Rainwater rainwater Bottled water bottled_water Cart w/small tank/drum cart_w_small_tank_drum Truck truck Surface water surface_water Other source of water other_source_of_water b. Specify other water source 17. What is the average walking time, in minutes to and from the main source of water? (including waiting time) 0-10 minutes 0_10_minutes 11-20 minutes 11_20_minutes > 20 minutes >_20_minutes 18. Is water from this source available within 500 meters of the facility? Yes yes No no 19. Does this facility have any of the following as an alternative source of water supply? No alternative water source no_water_source Piped into facility piped_into_facility Piped onto facility grounds piped_onto_facility_grounds Public tap/standpip public_tap_standpip Borehole borehole Protected dug well protected_dug_well Unprotected dug well unprotected_dug_well Protected spring protected_spring_______________ Unprotected spring unprotected_spring_____________ Rainwater rainwater Bottled water bottled_water Cart w/small tank/drum cart_w_small_tank_drum Tanker truck tanker_truck Surface water surface_water Other alternative water source other_alternative_water_source a. Specify alternative water source b. What is the average walking time, in minutes, to and from the alternative source of water? (including waiting time) 0-10 minutes 0_10_minutes 11-20 minutes 11_20_minutes > 20 minutes >_20_minutes 20. Is there a functioning toilet (latrine) for use by patients in the facility? Yes yes No no a. Type of open defecation used 21. What type of toilet (latrine) is available for use by outpatients? No functioning toilet no_functioning_toilet Bush bush Flush toilet flush_toilet Flush toilet (but no water) flush_toilet_but_no_water VIP latrine vip_latrine Covered pit latrine covered_pit_latrine_no_slab____ Uncovered pit latrine w/ slab uncovered_pit_latrine_w__slab Other (specify) other_specify 22. Other type of toilet(latrine) available 23. How many of the mentioned (outpatient) toilets/latrines are there? 24. How many of the mentioned (outpatient) toilets/latrines are currently functioning? 25. Do outpatients and inpatients use the same toilets? Yes yes No no 26. What type of toilet (latrine) is available for use by inpatients? No functioning toilet no_functioning_toilet Bush bush Flush toilet flush_toilet Flush toilet (but no water) flush_toilet_but_no_water VIP latrine vip_latrine Covered pit latrine covered_pit_latrine_no_slab_ Uncovered pit latrine w/ slab uncovered_pit_latrine_w__slab Other (specify) other_specify 27. Other type of toilet(latrine) available for use by inpatients 28. Take a picture of the inpatient toilet in the health facility 29. How many of the mentioned (inpatient) toilets/latrines are there? 30. How many of the mentioned (inpatient) toilets/latrines are currently functioning? 31. Does this facility finally dispose of sharps waste (e.g., filled sharps boxes)? Yes yes No no a. How does this facility finally dispose of sharps waste (e.g., filled sharps boxes)? [state all] should be 2m deep, 15m from facility, 100m from water source and 50m from households Incinerator incinerator 1 chamber drum/brick 1_chamber_drum Flat ground - no protection flat_ground_no_protection Flat ground - with protection flat_ground_with_protection Pit or protected ground pit_protected_ground Covered pit or pit latrine covered_pit Open pit - no protection open_pit_no_protection Protected ground or pit protected_ground_pit Stored in covered container covered_container Stored unprotected stored_unprotected Facility never has sharp waste facility_no_sharp_waste Waste collection agency waste_collection_agency Other other Specify other. 32. Does this facility finally dispose of medical waste other than sharps boxes? Yes yes No no 33. How does this facility finally dispose of medical waste other than sharps boxes? [state all] It should be 2m deep, 15m from facility, 100m from water source and 50m from households Incinerator incinerator 1‐chamber drum/brick 1‐chamber_drum_brick Flat ground ‐ no protection flat_ground_‐_no_protection Flat ground with protection flat_ground_with_protection Pit or protected ground pit_or_protected_ground Covered pit or pit latrine covered_pit_or_pit_latrine Open‐pit ‐ no protection open‐pit_‐_no_protection_ Protected ground or pit protected_ground_or_pit_ Stored in covered container stored_in_covered_container Stored unprotected stored_unprotected_____________ Facility never has sharp waste facility_never_has_sharp_waste Waste collection agency waste_collection_agency Other other Specify other. 34. Are black bins for non-contaminated waste available? Yes yes No no 35. Are yellow and red bins for contaminated medical waste available? Yes yes No no 36. Is a security box for sharps available? Yes yes No no 37. Is the incinerator functional today? Yes yes No no 38. Is the power source for the incinerator available today? Yes yes No no 39. Is there an inpatient ward in this facility? Yes yes No no 40. Is the ward functional? Yes yes No no 41. Does the patient wards appear clean and in good condition? Yes yes No no 42. Take a picture of the in- patient ward in the facility 43. Is the facility equipped with in-patient beds? Yes yes No no 44. How many inpatient beds does the facility have? 45. Do you have a maternity waiting room where women can stay prior to giving birth? Yes yes No no 46. Is there staff accommodation in this facility? Yes yes No no 47. Is there a call room for staff on call duty? Yes yes No no 48. Is the on-call room equipped with basic conveniences (bed/couch, bed linen and ventilation)? Yes yes No no #####Section 5. Financial System 1. Does this facility have a staff responsible for the financial/accounting system of the facility? Yes yes No no 2. Has he/she received financial training by appropriate organization/partner? Yes yes No no Financial Bookkeeping 1. Which of the following financial management tools do you have? Receipt books receipt_books Payment voucher payment_voucher Cash books cash_books Check Issue/Register check_issue_ledger General Ledger/Vote book general_legder_vote_book Stores Records stores_records Statement of expenditure statement_of_expenditure Did not receive any tools did_not_receive_tools Other other Specify other. 2. Have you submitted the financial report for the last quarter? [ask to see transmittal evidence] Yes yes No no 3. Monthly financial report (income and expenditure books) available and correctly filled and signed by the Health Facility Officer in Charge Yes yes No no 4. How often was the facility visited by a state/LGA/Ward level accounts person in the last calendar year? Weekly weekly Biweekly (every two weeks) biweekly Monthly monthly Quarterly quarterly Yearly yearly Other other Specify other. 5. Does the facility share its financial information with the facility management committee? Yes yes No no 6. How does the facility share the information? Hard copy reports hard_copy_reports During meetings during_meeti Chalkboard chalk_board Posters posters Other other Specify other. Operational Funds 1. Did the facility receive any non-salary, operational funds from the state/local government in the calendar last year? Yes yes No no 2. Which level of government provided funds for non-salary, operational expenses in the last year? State government only state Local government only local Both state and local government state_local 3. Did the facility experience any delay in receipt of non-salary, operational funds from state/local government? Yes yes No no 4. Which level of government delayed funding for non-salary, operational expenses in the last year? State government only state Local government only local Both state and local government state_local 5. Please indicate the principle reason for the delays Delay in submission of quality (business/work) implementation plan delay_submission_quality Delay in receiving authority to incur expenses (AIE) from authorities delay_receive_authority Unable to provide timely accounts to LGA or state treasury unable_provide_timely_account Audit issues raised on facility's account audit_issues Capacity problems at LGA or state treasury capacity_problems Other other Specify other. 6. Does the facility have alternate sources of funding? Yes yes No no 6a. Which of the following have been alternative sources of funding in the last year? Drug revolving drug_revolv Registration registration Development partners/NGOs dev_partners_ngos Other other Specify other. 7. Does this health facility have a bank account? Yes yes No no 7a. How many active Bank accounts does the facility operate? 8. Are user fees/charges displayed at the facility? Yes yes No no NHIS/Fee-for-service Processing 9. Do you have the appropriate NHIS utilization and claim forms? Yes yes No no a. Does the utilization and claims data correspond and are accurate? Yes yes No no b. The information of the enrollee is complete (including patient identification number, age, gender and contact details) - up to date for the preceding month Yes yes No no c. Is there evidence to show that NHIS utilization claims are submitted regularly as required? (assumes monthly submission - cutoff date TBD Yes yes No no QIP/Business Plan Financing 10. What proportion of facility allocation is spent on QIP and business plan? There is no alignment between spending and the plans no_alignment Less than 60% of allocation spent on QIP less_than_60_spent ≥ 60% of allocation spent on QIP more_than_60_spent Services and Costs Please insert the costs of the health services below 1. Registration 2. Consultation- 5 years or older 3. Consultation- under 5 years of old 4. Laboratory: Malaria Test 5. Laboratory: Random blood sugar 6. Laboratory: Haemoglobin (Hb) 7. Laboratory: urinalysis 8. Laboratory: Other (Specify) 9. Drugs: Amoxicillin Syrup 10. U 5 services (Immunization, Diarrhea treatment, ARI) *Insert service cost a. Immunization b. Diarrhea c. Acute Respiratory Infection 11. ANC Visit *Insert service cost a. Registration b. Drugs *Insert cost 12. Normal Delivery 13. Family Planning 14. Malaria Drugs *Insert service cost a. Artesunate/Artemisinin combination therapy (ACT)/ Lumefantrine b. Sulfadoxine/Pyramethamine(Fansidar), Chloroquine, Others 15. HIV/AIDS *Insert service cost a. Counselling b. Screening c. ARVs 16. TB *Insert service cost a. Sputum test b. Chest x-ray c. Treatment/DOTS 17. Are the user fees/charges displayed at the facility service charters? Ask to see the boards Yes yes No no 18. In your facility, who is exempted from paying user fees? Yes yes No no a. Patients with chronic diseases Yes yes No no b. Elderly patients Yes yes No no c. Very poor people Yes yes No no d. Facility staff Yes yes No no e. Relatives of staff Yes yes No no 19. What was the value for Waivers/Exemptions during the last financial year? #####Section 6. Human Resources Management 1. How many health workers are employed in this facility Doctors, nurses, midwives, CHEWs, lab scientist/technician, dentist, pharmacy scientist/technician, environmental officer, and medical record officer 2. How many non-health workers are employed in this facility Drivers, cleaners, gardeners, security personnel, and health attendants/ward miads 3. Do your staff experience delay in payment of salary? Yes yes No no 3a. How frequently? Seldom (Once in a year) seldom Often (Once every 3-6 months) often Always always 4. Are there measures (attendance system) against lateness/absenteeism? No attendance register available none Attendance register available but not monitored avail_no_monitoring Attendance register available and verified by the health facility supervisor avail_monitored 5. Are there laid down procedures for contract staff recruitment There are no laid down procedures for staff none Procedures exists but are not documented proc_exist_not_monitor Documented procedures exists and are implemented doc_proc_exist_implemented Please allow me to ask you a few questions about each health worker who works in this facility starting with you. Could you give me the name of the employee in the various categories starting with the physicians or medical officers? *Only health workers information should be collected ######Staff Roster ######Staff Roster - Add staff details 1. First Name 2. Last Name 3. Cadre Superintendent super_intindent Specialist specialist Medical officer medical_officer Community Health Officer comm_health_officer CHEW chew Junior CHEW junior_chew Environmental Health Officer environ_health_offic BSc Nurse bsc_nurse Registered Nurse regist_nurse Registered Midwife regist_midwife Psychiatric Nurse psych_nurse Dentist dentist Pharmacist pharmacist Laboratory Technician / Technologist Lab_technician_technologist Volunteer (indicate cadre) volunteer Other other Specify other. 3a. Volunteer (Specify) 4. Gender Male male Female female 5. Age 6. Does

regularly perform outpatient consultation

Yes yes No no 7. Is

currently in the facility?

Yes yes No no 8. Reason for absence Sick / maternity sick_maternity In training / seminar training_seminar Official mission official_mission Approved absence approved_absence Not his / her shift not_his_her_shift Doing fieldwork or outreach work field_outreach_work Not approved absence not_approved_absence Gone to retreive salary retreive_salary On strike strike Other other Specify other. #####Section 7. Maternal and Child Services Family Planning 1. Are family planning services offered here? Yes yes No no 2. Which type of family planning services are offered here? Counselling services couns_services Counselling and commodity services couns_comm_services 3. Which family planning methods (commodities) are available today? None none Condoms condoms Oral pills oral_pills Injectibles injectibles Implants implants IUC iuc 4. Are FP individual cards available and filled according to the format? Yes yes No no 5. How many qualified staff are trained in Family Planning? Antenatal Care 1. Does this facility provide antenatal care services? Yes yes No no 2. Is Antenatal Risk Assessment form (ARAF) used for ANC? No antenatal risk assessment form none Antenatal risk assessment form present but not used regularly for ANC araf_present_not_used Antenatal risk assessment form present and used regularly for ANC araf_present_used 3. Does this facility provide post-natal care services? Yes yes No no Obstetric Care 1. Does this facility provide Basic Emergency Obstetric Care (BEOC)? Yes yes No no 2. How many staff present are qualified to offer BEOC? Insert number and cadre 3. Do you take deliveries at this facility? Yes yes No no 4. How many qualified staff are trained on Live Saving Skills (LSS)? 5. Is the delivery room is well-maintained? (Clean, delivery couch in good condition, water accessible and well lit) Yes yes No no 6. Take a picture of the interior of the delivery room, and specifically the delivery couch, in the facility 7. Is there light in delivery room for 24 hours Yes, Electricity and rechargeable lamp elect_rech_lamp Yes, Only Electricity elect_only No no 8. Is a partograph used for delivery? (Check via case note audits –5 case notes) No partograph in the facility none Partograph is present but not used present_unused Partograph is present and used for delivery present_used 9. How many case notes (out of 5 above) are with partographs? Management of Childhood illnesses 1. Does this facility provide routine immunization services? Yes yes No no 2. How many staff have been trained on Integrated Management of Childhood Illnesses (IMCI)? by appropriate agency e.g. MOH, Dev partners, certified CBOs and others 3. Do you offer growth monitoring services to all U5 patients? The facility does not offer growth monitoring services not_offered There is no evidence that the facility offers growth monitoring services no_evidence There is documented evidence that the facility offers growth monitoring services docum_evidence 4. Does the facility have basic nutritional assessment guide? (MUAC) No measuring tapes available no_tapes Measuring tapes available but there is no documentation on MUAC tapes_avail_no_doc Measuring tapes and documentation available for MUAC tapes_doc_avail #####Section 8. Priority Area: Patient Care Management Available Equipment (1/6) 1. Adult weighing scale Yes (observed and functional) yes_obs No no 2. Child weighing scale (250g gradation) Yes (observed and functional) yes_obs No no 3. Infant weighing scale (100g gradation) Yes (observed and functional) yes_obs No no 4. Thermometer Yes (observed and functional) yes_obs No no 5. Stethoscope Yes (observed and functional) yes_obs No no 6. Foetoscope Yes (observed and functional) yes_obs No no 7. Sphygmonometer Yes (observed and functional) yes_obs No no 8. Angle poised lamp Yes (observed and functional) yes_obs No no 9. Centrifuge, manual Yes (observed and functional) yes_obs No no 10. Chart holder Yes (observed and functional) yes_obs No no Available Equipment (2/6) 11. Cooking pot (A set of 6) Yes (observed and functional) yes_obs No no 12. Delivery couch Yes (observed and functional) yes_obs No no 13. Dissecting forceps Yes (observed and functional) yes_obs No no 14. Dressing forceps Yes (observed and functional) yes_obs No no 15. Dressing scissors Yes (observed and functional) yes_obs No no 16. Dressing trolley Yes (observed and functional) yes_obs No no 17. Drip stand Yes (observed and functional) yes_obs No no 18. Enema can Yes (observed and functional) yes_obs No no 19. Episiotomy scissors Yes (observed and functional) yes_obs No no 20. Examination couch Yes (observed and functional) yes_obs No no 21. Fire extinguishers Yes (observed and functional) yes_obs No no 22. Forceps jar Yes (observed and functional) yes_obs No no 23. Growth charts Yes (observed and functional) yes_obs No no 24. Galipot(medium) Yes (observed and functional) yes_obs No no 25. Incision and drainage kit Yes (observed and functional) yes_obs No no 26. Instrument cabinet Yes (observed and functional) yes_obs No no Available Equipment (3/6) 27. Instrument tray Yes (observed and functional) yes_obs No no 28. Fire extinguishers Yes (observed and functional) yes_obs No no 29. Kidney dishes(large) Yes (observed and functional) yes_obs No no 30. Kidney dish(medium) Yes (observed and functional) yes_obs No no 31. Surgical Knives Yes (observed and functional) yes_obs No no 32. Length measure for babies Yes (observed and functional) yes_obs No no 33. Linen cupboard Yes (observed and functional) yes_obs No no 34. Mackintosh Yes (observed and functional) yes_obs No no 35. Microscope cover slides (pack of 100) Yes (observed and functional) yes_obs No no 36. Newborn bag and mask (ambubag) Yes (observed and functional) yes_obs No no 37. Oro-pharyngeal airway (set of 7) Yes (observed and functional) yes_obs No no Available Equipment (4/6) 38. Pedal bin Yes (observed and functional) yes_obs No no 39. Perineal sheet Yes (observed and functional) yes_obs No no 40. Autoclave (pressure and wet heat) Yes (observed and functional) yes_obs No no 41. Electric boiler or steamer (no pressure) Yes (observed and functional) yes_obs No no 42. Electric dry heat sterilizer Yes (observed and functional) yes_obs No no 43. Non-electric pot for boiling/steam or Heat source from non-electric equipment (stove or cooker) Yes (observed and functional) yes_obs No no 44. Delivery bed Yes (observed and functional) yes_obs No no 45. Battery – powered torch Yes (observed and functional) yes_obs No no 46. Partogram Yes (observed and functional) yes_obs No no 47. Sterilizable scissors Yes (observed and functional) yes_obs No no 48. Sterilizable cord ties Yes (observed and functional) yes_obs No no 49. Snellen's chart Yes (observed and functional) yes_obs No no 50. Soap box Yes (observed and functional) yes_obs No no Available Equipment (5/6) 51. Soap/disinfectant dispenser Yes (observed and functional) yes_obs No no 52. Stainless bedpan Yes (observed and functional) yes_obs No no 53. Stainless ear syringe Yes (observed and functional) yes_obs No no 54. Stitch removal/ suture scissors Yes (observed and functional) yes_obs No no 55. Stitch removal/suture Yes (observed and functional) yes_obs No no 56. Stool specimen bottles(pack of 100) Yes (observed and functional) yes_obs No no 57. Stretcher trolley Yes (observed and functional) yes_obs No no 58. Suction pump Yes (observed and functional) yes_obs No no 59. Suture kit Yes (observed and functional) yes_obs No no 60. Suture needles Yes (observed and functional) yes_obs No no 61. Swivel stool Yes (observed and functional) yes_obs No no 62. Tape dispenser Yes (observed and functional) yes_obs No no 63. Tape measure Yes (observed and functional) yes_obs No no 64. Tenaculum forceps Yes (observed and functional) yes_obs No no 65. Test tube rack Yes (observed and functional) yes_obs No no Available Equipment (6/6) 66. Theatre gown Yes (observed and functional) yes_obs No no 67. Tissue forceps Yes (observed and functional) yes_obs No no 68. Tongue depressor Yes (observed and functional) yes_obs No no 69. Tourniquet Yes (observed and functional) yes_obs No no 70. Tray test tube Yes (observed and functional) yes_obs No no 71. Tripod stand Yes (observed and functional) yes_obs No no 72. Umbilical cord clamp, pack of 100 Yes (observed and functional) yes_obs No no 73. Urinal, female Yes (observed and functional) yes_obs No no 74. Urinary catheter Yes (observed and functional) yes_obs No no 75. Urine dipstick (multstix) Yes (observed and functional) yes_obs No no 76. Urine dipstick for sugar and albumin, pack of 100 Yes (observed and functional) yes_obs No no 77. Vacuum extractor(manual) Yes (observed and functional) yes_obs No no 78. Vaginal speculum (sim) set of 3 Yes (observed and functional) yes_obs No no 1. Are there documented rosters for facility staff or health workers? spot check workers in ANC, OPD and family planning against roster The facility does not have any duty roster no_duty_roster The facility has a duty roster but is not followed duty_ros_not_foll The facility has a duty roster that is being followed duty_ros_foll 2. Is there a documented referral and follow up system available for services (E.g. HIV, TB, and chronic illnesses) Cross check referral register, facility copy of form and return/feedback slips. Yes yes No no 3. Where does the facility refer its patients to? 4. How many patients did the facility refer to another facility in the prior 3 months? please check the referral register 5. Using the most common means for transportation, how long does it take for a referred patient to go from your facility to the most commonly used next level for referral during the DRY season? 0-10 minutes zero_to_ten_minutes 11-20 minutes eleven_to_twenty_minutes > 20 minutes greater_than_twenty_minutes 6. Using the most common means for transportation, how long does it take for a referred patient to go from your facility to the most commonly used next level for referral during the RAINY season? 0-10 minutes zero_to_ten_minutes 11-20 minutes eleven_to_twenty_minutes > 20 minutes greater_than_twenty_minutes HIV/TB Services 1.Does this facility provide HIV/AIDS prevention and care services? Yes yes No no 2. Are staff trained in testing and counseling? by appropriate structure e.g. LGA, development partners, MOH, certified CBOs Yes yes No no 3. Does this facility provide STI control services? Yes yes No no 4. Does this facility treat TB patients? Yes yes No no Disease Management Is there evidence of protocol being implemented in case notes? Randomly select 1 case note each from malaria+anaemia,ANC,PPH,Pneumonia, OPD, ANC and child clinic. Use checklist as appropriate against one consultation. Case Study: Malaria + Anemia History Taking Yes yes No no 1. Duration of fever Yes yes No no 2. Pattern of fever/Presence or history of fever Yes yes No no 3. Shiver or sweat Yes yes No no 4. Convulsions Yes yes No no 5. Vomiting Yes yes No no 6. Appetite Yes yes No no 7. Diarrhoea Yes yes No no 8. Cough Yes yes No no 9. Severity of cough Yes yes No no 10. Difficulty in breathing Yes yes No no 11. Type of cough (productive or dry) Yes yes No no 12. Type of medication given Yes yes No no 13. Amount of dose given Yes yes No no 14. Vaccinations Yes yes No no Notes/ Other questions Physical Examination carried out Yes yes No no 15. Hands (palmar pallor) Yes yes No no 16. Tongue Yes yes No no 17. Eyes, sunken? Yes yes No no 18. Eyes, pale colour? Yes yes No no 19. Responsiveness / general condition Yes yes No no 20. Skin condition Yes yes No no 21. Temperature Yes yes No no 22. Pulse Yes yes No no 23. Neck stiffness Yes yes No no 24. Puffy face Yes yes No no 25. Swelling of the feet Yes yes No no 26. Abdomen/liver Yes yes No no 27. Weight Yes yes No no 28. Respiratory rate Yes yes No no Notes/ Other questions Tests administered Yes yes No no 29. Microscopy/ Blood slide for malaria parasite Yes yes No no 30. Rapid Diagnostic test Yes yes No no 31. Hb / Full Blood Count Yes yes No no Diagnosis Yes yes No no 32. Malaria Yes yes No no 33. Anemia Yes yes No no 34. Malaria with Anemia Yes yes No no 35. Severe Malaria Yes yes No no Notes/ Other questions Treatment Yes yes No no 36. Artemizinin combination Yes yes No no 37. Paracetamol Yes yes No no 38. Adequate fluids and nutrition Yes yes No no 39. Chloroquine 1.5 tabs x 1/day x 3 days Yes yes No no 40. Quinine intramuscular injection Yes yes No no 41. Artesunate Amodiaquin Yes yes No no 42. Sulphadoxine Pyrimethamine .5 tab 250 mg tds x 3 days Yes yes No no Notes/ Other questions Was the patient counselled on any of the following (Confirm if documented in the case notes) Yes yes No no 43. Adherence to treatment. Yes yes No no 44. Prompt return if symptoms worsen Yes yes No no 45. Increased fluid intake Yes yes No no Notes/ Other questions Case Study: Antenatal Care Yes yes No no 1. History taken Yes yes No no 2. Clinical examination conducted Yes yes No no 3. Estimated date of delivery calculated Yes yes No no 4. Blood pressure taken Yes yes No no 5. Maternal height/weight measured Yes yes No no 6. Haemoglobin test conducted Yes yes No no 7. Rapid Plasma Reagin performed Yes yes No no 8. Urine tested Yes yes No no 9. Rapid ph performed Yes yes No no 10. Counselled and voluntary testing for HIV Yes yes No no 11. Tetanus toxoid given Yes yes No no 12. Iron and folic acid supplementation provided Yes yes No no 13. Calcium supplementation provided Yes yes No no 14. Information for emergencies given Yes yes No no 15. Clinical examination for anaemia Yes yes No no 16. Urine test for protein Yes yes No no 17. Uterus measured for excessive growth or poor growth Yes yes No no 18. Instructions for delivery/transport to institution and recommendations for lactation, and contraception done Yes yes No no 19. Antenatal card completed and given to woman. Woman told to bring it when in labour Yes yes No no Notes/ Other questions Case Study: Post-partum Hemorrhage History Taking Yes yes No no 1. Were other symptoms reported? Yes yes No no 2. Was the blood loss quantified? Yes yes No no 3. Were the number of pads used indicated? Yes yes No no 4. Was the parity recorded? Yes yes No no 5. Was the duration of labor recorded? Yes yes No no 6. Was the mode of Placenta delivery indicated? Yes yes No no 7. Is there a record of medicines given to speed up delivery during Labor Yes yes No no 8. Is there a record of history of excessive bleeding after delivery? Yes yes No no 9. Is there a record of history of prolonged menses (Fibroids)? Yes yes No no 10. I there a record of excessive (amniotic) fluids during pregnancy? Yes yes No no 11. Confirm record of Attendance of ANC Yes yes No no 12. Is there a record of multiple pregnancy? Yes yes No no 13. Is there a record of Placenta praevia? Yes yes No no 14. Is there a record of Hypertension? Yes yes No no Notes/ Other questions Physical examination carried out Yes yes No no 15. Temperature Yes yes No no 16. Pulse Yes yes No no 17. Weight Yes yes No no 18. Respiratory rate Yes yes No no 19. Retained placenta Yes yes No no 20. Blood pressure Yes yes No no 21. Ruptured uterus Yes yes No no 22. Laceration / tears of genital tract (cervical / vaginal / vulvoperineal tears) Yes yes No no 23. Uterine palpation Yes yes No no 24. Genital examination Yes yes No no Tests Administered Yes yes No no 25. Blood for grouping and cross matching Yes yes No no 26. Hemoglobin level Yes yes No no 27. Bleeding time Yes yes No no 28. Clotting time Yes yes No no 29. Coagulation factors Yes yes No no Diagnosis Yes yes No no 30. Post-partum Hemorrhage It will take some time to get the results. Please make a preliminary diagnosis. Yes yes No no Notes/ Other questions Which of the following treatments were administered Yes yes No no 31. IV line Yes yes No no 32. Blood taken for grouping and cross matching Yes yes No no 33. The self retaining catheter foley was inserted Yes yes No no 34. Was a bimanual uterine massage carried out?: this may also provoke contractions Yes yes No no 35. Was an oxytocin drip with dextrose saline given 20 units in 500 ml dextrose or normal saline to run at 20 drops per minute for about 2 hours Yes yes No no 36. Was prostaglandins and misoprostal given? Yes yes No no 37. Was the patient referred? Yes yes No no Notes/ Other questions Case Study: Pneumonia History Taking Yes yes No no 1. Were other symptoms recorded? Yes yes No no 2. Was the duration of cough recorded? Yes yes No no 3. Was the nature of the cough (sputum production or dry cough) recorded? Yes yes No no 4. Was the presence of blood or colour of sputum recorded? Yes yes No no 5. Was there a record of the presence of chest pain? Yes yes No no 6. Was there a record on presence of difficulty in breathing Yes yes No no 7. Was there a record of patient's appetite? Yes yes No no 8. Was there a record of fever? Yes yes No no 9. Was there a record on general condition (awake / lethargic Yes yes No no 10. Was there a record on presence of convulsions? Yes yes No no 11. Was there a record on patient's difficulty in swallowing? Yes yes No no 12. Was the presence of running nose recorded? Yes yes No no 13. Was any medication /treatment received recorded? Yes yes No no 14. Was recent history of Measles recorded? Yes yes No no 15. Was family history of Asthma recorded? Yes yes No no 16.Was the redness of the eyes observed? Yes yes No no Notes/ Other questions Physical examination carried out Yes yes No no 17. Was the respiratory rate counted? Yes yes No no 18. Was the breathing of lower chest wall in-drawing observed? Yes yes No no 19. Breathing, is there wheezing? Yes yes No no 20. Was the chest auscultated? Yes yes No no 21. Was nasal flaring observed? Yes yes No no 22. Was temperature recorded? Yes yes No no 23. Was the throat examined? Yes yes No no 24. Were the child's ears examined? Yes yes No no 25. Were the lymph nodes examined? Yes yes No no Notes/ Other questions Tests administered Yes yes No no 26. Chest X-ray Yes yes No no 27. Haemogram Yes yes No no 28. BS for MPS Yes yes No no Notes/ Other questions Diagnosis Yes yes No no 29. Pneumonia It will take some time to get the results. Please make a preliminary diagnosis. Yes yes No no Notes/ Other questions Treatment Yes yes No no 30. Treat as out-patient. Yes yes No no 31. Was Cortimoxazole 1 tab bd x 5/7 given or administered? Yes yes No no 32. Was Amoxycillin Dosage 250mg qds x 5 given or administered? Yes yes No no 33. Was Arthemeter-Lumefantrine 2 tabs x 2/day x given or administered? 3 days Yes yes No no 34. Was Artesunate+Amodiaquine 1 tabX 1/day x given or administered? Yes yes No no 35. Was Paracetamol dose 250 mg qds x 5 days given or administered? Yes yes No no 36. Were parents asked to bring child in 2 days? Yes yes No no Notes/ Other questions Was the patient counselled on any of the following (Confirm if documented in the case notes) Yes yes No no 37. Instruct parent on how to administer antibiotics for 5 days. Yes yes No no 38. Guidance on how to feed. Yes yes No no 39. Increase fluid intake. Yes yes No no 40. Instruct parent to return anytime in case the child worsens (or has any danger signs persisting fever, difficulty in breathing, poor feeding convulsions or new symptoms) Yes yes No no Notes/ Other questions Case Study: Acute Diarrohea History Taking Yes yes No no 1.Were other symptoms recorded? Yes yes No no 2. Was the duration of diarrhoea recorded? Yes yes No no 3.Was the frequency of diarrhoea recorded? Yes yes No no 4. Was the consistency of stool recorded? Yes yes No no 5. Was the presence of blood in stool recorded? Yes yes No no 6. Vomiting Yes yes No no 7. Was the mother asked if her child is breastfeeding? Yes yes No no 8. Was the mother asked if her child is breastfeeding well? Yes yes No no 9. Was the presence of cough recorded? Yes yes No no 10. Was the mother asked if her child has fever? Yes yes No no 11. Was the general condition of the child recorded? Yes yes No no 12. Was the presence of tears recorded? Yes yes No no 13. Was the mother asked if her baby started taking other food recently? Yes yes No no 14. Was the mother asked how it been given? Yes yes No no 15. Was the mother asked who prepares and feed her child?? Yes yes No no 16. Was the mother asked about her hand washing practice? Yes yes No no 17. Was the mother asked if their family members/neighbours have diarrhoea? Yes yes No no 18. Was the presence of abdominal discomfort/cramps recorded? Yes yes No no 19. Was the date of the last deworming recorded? Yes yes No no 20. Was the medication/treatment received before visiting the health facility recorded? Yes yes No no Notes/ Other questions Physical Examination Yes yes No no 21. Was the general health condition (awake/lethargic/tiredness/fatigue) recorded? Yes yes No no 22. Was the temperature recorded? Yes yes No no 23. Was the state of the child's skin recorded? Yes yes No no 24. Was the child offered a drink? Yes yes No no 25. Was the mucous membrane (oral mucosa) examined? Yes yes No no 26. Was palmar pallor (or other signs of anaemia) examined? Yes yes No no 27. Was thye stiffness of the neck examined? Yes yes No no 28. Was the ear/throat examined? Yes yes No no 29.Was the respiratory rate examined? Yes yes No no 30. Was the spleen examined? Yes yes No no 31. Was visible severe wasting examined? Yes yes No no 32. Was the weight of the child recorded? Yes yes No no 33. Sunken eyes Yes yes No no 34. Was the weight (against a growth chart) recorded? Yes yes No no 35. Was the presence of oedema of both feet (swollen feet) observed? Yes yes No no Notes/ Other questions Tests administered Yes yes No no 36. Stool for rota/adeno virus. Yes yes No no 37. Stool for ova and cyst. Yes yes No no Notes/ Other questions Diagnosis Yes yes No no 38. Acute diarrhoea with severe dehydration It will take some time to get the results. Please make a preliminary diagnosis. Yes yes No no Notes/ Other questions Treatment Yes yes No no 39. Were Oral Rehydration Salts given/administered? Yes yes No no 40. Was 100ml/kg Ringer's Lactate Solution given or administer? Yes yes No no 41.Was the patient referred immediately? Yes yes No no 42. Was antibiotics given/administered? Yes yes No no 43. Were vitamin A capsules given or administered? Yes yes No no 44. Were zinc tablets given or administered? (one daily for 10days). Yes yes No no Notes/ Other questions Was the patient counselled on any of the following (Confirm if documented in the case notes) Yes yes No no 45. Education on using (ORS) Yes yes No no 46. Hand-washing education Yes yes No no 47. Proper cleaning of feeding utensils. Yes yes No no 48. Emphasis on not withholding feeding especially breast feeding Yes yes No no 49. Giving plenty of oral fluids. Yes yes No no 50. Notes/ Other questions 51. Is there evidence of implementation of universal precautions? No appropriate PPE (gloves, aprons, covered footwear, face masks, etc.)/job aids guidelines no_ppe Appropriate PPE/job aids available but no evidence of implementation ppe_unused Appropriate PPE/job aids available and visibly in use ppe_used 52. Are there handwashing facilities available at all service points? Yes yes No no 53. Is privacy/confidentiality provided for clients? No privacy/confidentiality provided for clients no_privacy Provision for privacy/confidentiality is inadequate privacy_inadequate Privacy/confidentiality is provided for clients and is adequate privacy_adequate 54. Do you treat malaria at this facility? Yes yes No no 55. Do you offer curative treatment for patients? Yes yes No no #####Section 9. Minimum Drugs and Commodities Availability of Drugs and Vaccines Drugs Yes (observed and functional) yes_obs No no 1. Oxytocin (injectable) Yes (observed and functional) yes_obs No no 2. Misoprostol (cap/tab) Yes (observed and functional) yes_obs No no 3. Sodium chloride (Saline Solution)(injectable solution) Yes (observed and functional) yes_obs No no 4. Azithromycin (inj/cap/tab or oral liquid) Yes (observed and functional) yes_obs No no 5. Calcium gluconate (tablets) Yes (observed and functional) yes_obs No no 6. Benzathinebenzylpenicillin powder (for injection) Yes (observed and functional) yes_obs No no 7. Magnesium sulfate (inj/tab/cap) Yes (observed and functional) yes_obs No no 8. Dexamethasone (injectable) Yes (observed and functional) yes_obs No no 9. Ampicillin powder (for injection) Yes (observed and functional) yes_obs No no 10. Nifedipine (cap/tab) Yes (observed and functional) yes_obs No no 11. Gentamicin (injectable) Yes (observed and functional) yes_obs No no 12. Medroxyprogesterone acetate (Depo-Provera)(injectable) Yes (observed and functional) yes_obs No no 13. Metronidazole (inj/tab) Yes (observed and functional) yes_obs No no 14. Folic Acid Supplements (cap/tab) Yes (observed and functional) yes_obs No no 15. Iron supplements (cap/tab) Yes (observed and functional) yes_obs No no 16. Amoxicillin (syrup/suspension/dispersible tablet) Yes (observed and functional) yes_obs No no 17. Amoxil (syrup/suspension) Yes (observed and functional) yes_obs No no 18. Oral Rehydration Salts (ORS sachets) Yes (observed and functional) yes_obs No no 19. Ampicillin (powder for injection) Yes (observed and functional) yes_obs No no 20. Zinc (tablets) Yes (observed and functional) yes_obs No no 21. Zinc tablet (For Diarrhoea) Yes (observed and functional) yes_obs No no 22. Anti snake bites serum injection Yes (observed and functional) yes_obs No no 23. Anti tetanus immunoglobulin injection Yes (observed and functional) yes_obs No no 24. Zinc (oral liquid) Yes (observed and functional) yes_obs No no 25. Ceftriaxone (powder for injection) Yes (observed and functional) yes_obs No no 26. Artemisinin combination therapy (ACT-tablet) Yes (observed and functional) yes_obs No no 27. Vitamin A (capsules) Yes (observed and functional) yes_obs No no 28. Benzylpenicillin (powder for injection) Yes (observed and functional) yes_obs No no 29. Ergometrine tablet Yes (observed and functional) yes_obs No no 30. Ergometrine injection Yes (observed and functional) yes_obs No no 31. Anti Asthma Drugs: Beclomethasone inhaler Yes (observed and functional) yes_obs No no 32. Salbutamol inhaler Yes (observed and functional) yes_obs No no 33. Salbutamol tablet Yes (observed and functional) yes_obs No no VACCINES Yes (observed and functional) yes_obs No no 1. Measles vaccine injection Yes (observed and functional) yes_obs No no 2. Rabies immunoglobulin injection Yes (observed and functional) yes_obs No no 3. Tetanus vaccine injection Yes (observed and functional) yes_obs No no 4. Polio vaccine (live attenuated) Yes (observed and functional) yes_obs No no 5. Diphteria + pertussis + tetanus vaccine Yes (observed and functional) yes_obs No no 6. BCG vaccine and diluent Yes (observed and functional) yes_obs No no 7. Pneumococcal (PCV 10) vaccines Yes (observed and functional) yes_obs No no 8. DTP-HepB-Hib vaccine Yes (observed and functional) yes_obs No no Supply of Minimum Drugs and Commodities 1. Does the facility have a staff responsible for managing the ordering of medical supplies? Yes yes No no 2. Who is responsible? Officer-in-Charge off_in_charge Medical Officer medical_officer Pharmacy Technician pharm_tech Pharmacy Assistant pharm_ass Pharmacist pharmacist CHEW chew JCHEW jchew Lab Technician lab_tech Other other Specify other. 3. Who determines this facility's resupply quantities? Officer-in-Charge off_in_charge Medical Officer medical_officer Pharmacy Technician pharm_tech Pharmacy Assistant pharm_ass Pharmacist pharmacist CHEW chew JCHEW jchew Lab Technician lab_tech Other other Specify other. 4.How are the facility's resupply quantities estimated? Facility itself (pull mechanism) fac_itself Higher level facility (push mechanism) high_level_fac Combination combination Other other Specify other. 5. Who is the direct supplier of health commodities to your facility? LGA Store lga_store NGO/Donors ngo_donors Open Market open_market Other other Specify other. 6. How are the drugs from the main supplier delivered to this facility? Supplier delivers to facility supplier_to_facility Facility arranges delivery facility_arrange_del Other other Specify other. 7. Who bears the transportation cost of delivery to facilities Supplier supplier Facility facility Other other Specify other. 8. What was the date for the last delivery of essential medicines and/or medical supplies? 9. What was the date on which the order that corresponded to the last delivery was placed? 10. Was the last delivery of essential medicines and supplies verified and signed off by the health facility management committee? Yes yes No no 11. Was the community informed of the last delivery of essential medicines and supplies? Yes yes No no 12. How were they informed? Hard copy reports hard_copy_reports During meetings during_meeti Chalkboard chalk_board Posters posters Other other Specify other. Stock Control 1. Did the facility procure any out-of-stock items in the last quarter (3 months)? Yes yes No no 2. In the last quarter, did the facility purchase any essential medicines and medical supplies locally? Yes yes No no 3. Did any essential medicines in the facility expire during the last quarter (3 months)? Yes yes No no 4. Are stock control cards present & updated for the latest delivery? Yes yes No no 5. Are up-to-date records of expired drugs or losses kept? No record of expired drugs or losses kept no_record Record of expired drugs kept but not up to date record_not_uptodate Record of expired drugs kept are up to date records_uptodate 6. Is there proper storage and security (cool, dry place with a lock) for all drugs & consumables in the facility? Yes yes No no 6a. Take a picture of the facility medicines storage 7. How many of the staff involved in essential medicines and supplies management have received training on quantification and ordering of such products? 8. In the last fiscal year, how often was the facility visited by a qualified pharmacist for support supervision? Weekly weekly Biweekly (every two weeks) biweekly Monthly monthly Quarterly quarterly Yearly yearly Other other Specify other. 9. Are drug price lists displayed? No drug price list available no_drug_list Drug price list present but not displayed list_pres_not_displayed Drug price list present and displayed list_pres_displayed Availability of Minimum Commodities (1/2) Yes (observed and functional) yes_obs No no 1. Disposable syringes with disposable needles Yes (observed and functional) yes_obs No no 2. Vaccine carrier(s) Yes (observed and functional) yes_obs No no 3. Auto-disable syringes Yes (observed and functional) yes_obs No no 4. Set of ice packs for vaccine carriers (Note: 4-5 ice packs make one set) Yes (observed and functional) yes_obs No no 5. Clean running water (piped, bucket with tap, or pour pitcher) Yes (observed and functional) yes_obs No no 6. Hand-washing soap/liquid soap Yes (observed and functional) yes_obs No no 7. Alcohol based hand rub Yes (observed and functional) yes_obs No no 8. Waste receptacle (pedal bin) with lid and plastic bin liner Yes (observed and functional) yes_obs No no 9. Environmental disinfectant (e.g., chlorine, alcohol) Yes (observed and functional) yes_obs No no 10. Sharps container Yes (observed and functional) yes_obs No no 11. Disposable Gloves Yes (observed and functional) yes_obs No no 12. Condoms Yes (observed and functional) yes_obs No no Availability of Minimum Commodities (2/2) 13. Are vaccines stored at this facility? Yes (observed and functional) yes_obs No no 14. Does the facility have a working refrigerator for the storage of vaccines? Observe functioning Yes (observed and functional) yes_obs No no 15. Take a picture of the facility refrigerator 16. Take a picture of the facility vaccine coldchain box 17. Is there a functional thermometer to maintain a cold chain? Yes (observed and functional) yes_obs No no 18. If there is no storage at the facility, are the facility's vaccines stored at another facility (and picked up from when vaccine services are being provided)? Yes (observed and functional) yes_obs No no **About how many weeks' supply of the following medicines is currently available in the facility?** 1. Amoxicillin (syrup/suspension/dispersible tablet) 2. Injectable antibiotics 3. Chlorhexidine 4. Magnesium sulfate (injectable) 5. Misoprostol (cap/tab) 6. Oxytocin (injectable) 7. Oral Rehydration Salts (ORS sachets) 8. Zinc (tablets) 9. Emergency contraception 10. Female condoms 11. Contraceptive implants 12. Antenatal corticosteroid (ANCs) 13. Newborn Resuscitation Device #####Section 10. Laboratory 1. Is there a laboratory? Yes yes No no 2. Laboratory is open every day of the week Yes yes No no 3. Is there a laboratory scientist/technician available at least 5 days a week? Yes yes No no 4. Are laboratory price lists displayed? No laboratory price list available no_lab_list Laboratory price list present but not displayed list_pres_not_displayed Laboratory price list present and displayed list_pres_displayed 5. The facility offers PHC Laboratory services (According to the essential laboratory services in the tool) (Please tick as appropriate) Heamatology (PCV, Haemoglobin) heam_pcv Pregnancy test preg_test Urine dipsticks for sugar and protein sugar_protein_test Syphillis rapid test syph_rap_test Malaria diagnostics mal_diag HIV diagnostics hiv_diag Dried Blood Spots (DBS) preparation dbs_prep TB diagnostics tb_diag venous collection for CD4 ven_collect_cd4 ######Section 11. Health Management Information System **Are relevant HMIS forms/Registers available in the facility?** Yes yes No no 1. NHMIS Health facility monthly summary form Yes yes No no 2. NHMIS health facility daily attendance register Yes yes No no 3. NHMIS health facility daily GMP (growth monitoring) register Yes yes No no 4. NHMIS health facility Immunization register Yes yes No no 5. NHMIS health facility Immunization Tally Sheet register Yes yes No no 6. NHMIS health facility TT register Yes yes No no 7. NHMIS health facility daily ANC register Yes yes No no 8. NHMIS health facility daily OPD register Yes yes No no 9. NHMIS health facility daily FP register Yes yes No no 10. NHMIS health facility daily PMTCT ARVs register Yes yes No no 11. NHMIS health facility labour/delivery register Yes yes No no 12. NHMIS health facility IPC register Yes yes No no 13. Are HMIS forms / register up to date and completed correctly? No relevant HMIS forms/registers available no_form_reg Some HMIS forms/registers available but not up to date (month prior to assessment) some_form_avail_not_uptodate All relevant HMIS forms/registers available and up to date (month prior to assessment) all_form_avail_uptodate 14. Is HMIS information displayed graphically? HMIS information not represented graphically not_rep_graph HMIS information represented graphically, but not displayed rep_graph_not_display HMIS information represented graphically and displayed rep_graph_display 15. Are the NHMIS data analysed and shared with the facility management committee? Not analysed not_analyzed Analysed analyzed Analyzed and shared analyzed_shared Analysed and used for decision (minutes available) analyzed_decision 16. Did the facility send last month's monthly summary form to the LGA? Yes yes No no 17. Does the information in the registers correspond with HMIS data sent to LGA? Compare summary sheet (last 3 months) with register for ANC, immunization and FP The information registers does not correspond with the HMIS data sent to LGA info_not_corres Some of the information in the registers correspond with the HMIS data sent to LGA some_info_corres All the information in the register correspond with the HMIS data sent to LGA all_info_corres 18. Do you participate in any LGA monthly M&E review meetings? Yes yes No no 19. Is HMIS information discussed in the facility management meetings (check for minutes of meetings) Yes yes No no #####Section 12. Utilization and Clinical Outcomes Utilization Pattern 1. How many deliveries have been conducted at this facility during the past 3 months? a. Month 1 b. Month 2 c. Month 3 d. Total Utilization Pattern 2. How many general outpatient visits have you had at this facility in the past 3 months? a. Month 1 b. Month 2 c. Month 3 d. Total Utilization Pattern 3. How many in-patient bed-days have you had during the past 3 months? a. Month 1 b. Month 2 c. Month 3 d. Total Utilization Pattern 4. How many Under-5 visits have you had at this facility in the past 3 months? a. Month 1 b. Month 2 c. Month 3 d. Total Utilization Pattern 5. How many immunization visits have you had at this facility in the past 3 months a. Month 1 b. Month 2 c. Month 3 d. Total Utilization Pattern 6. Number of ANC attendance in the past 3 months a. Month 1 b. Month 2 c. Month 3 d. Total Utilization Pattern 7. Number of PNC attendance in the past 3 months a. Month 1 b. Month 2 c. Month 3 d. Total Utilization Pattern 8. Number of pregnant women who had ANC 1st (booking) visit before 20 weeks? a. Month 1 b. Month 2 c. Month 3 d. Total Utilization Pattern 9. Number of patients screened for hypertension a. Month 1 b. Month 2 c. Month 3 d. Total Utilization Pattern 10. Number of patients screened for diabetes a. Month 1 b. Month 2 c. Month 3 d. Total Clinical Outcomes 11. Number of deaths (in relation to registered pregnant women) in the past 3 months? a. Month 1 b. Month 2 c. Month 3 d. Total 12. Number of deliveries resulting in still births in the past 3 months? a. Month 1 b. Month 2 c. Month 3 d. Total 13. Rate of re-admission of patients a. Month 1 b. Month 2 c. Month 3 d. Total 14. Infection due to treatment in the health facilities a. Month 1 b. Month 2 c. Month 3 d. Total #####Section 13. Community Involvement Outreach Services 1. Does this facility carry out planned community outreach services? No community outreach services occurring no_outreach Community outreach services are occurring but not scheduled outreach_occ_not_scheduled Planned community outreach services are occurring outreach_plan_occ 2. Does the PHC staff conduct outreach to the community? Yes yes No no 3. How often does the PHC staff conduct outreach to the community? Weekly weekly Biweekly (every two weeks) biweekly Monthly monthly Quarterly quarterly Yearly yearly Other other Specify other. 4. Is there evidence of publicity (poster, flyers, signage, etc.) of available health services? No publicity of available health services no_pub_avail There is no evidence of publicity of available health services no_evidence_pub There is evidence of publicity of available health services evidence_pub_avail 5. Is there evidence that local communities are involved in outreach planning and implementation? Outreaches are solely planned and executed by facility exec_by_fac_sole Outreaches are planned with local community/Facility Management Committee only, execution is solely carried out by facility staff plan_w_local_comm Outreaches are planned and implemented in collaboration with the local community/Facility Management Committee plan_impl_w_loc_fac_man 6. Is there evidence that this facility do hold review meetings with important community members in attendance? None exist none Review meeting does not occur regularly not_regular Review meetings are held regularly (monthly) regular_monthly Community Governance 1. Is there a Ward Development Committee (WDC)/Village Development Committee (VDC)/Community Development Committee (CDC) in place in this community? Yes yes No no 2. Has the committee met at least once in the last year? Yes yes No no 3. How often does the WDC/VDC/CDC meet? Weekly weekly Biweekly (every two weeks) biweekly Monthly monthly Quarterly quarterly Yearly yearly Other other Specify other. 4. Did any member of this WDC/VDC/CDC visit the PHC during the prior 3 months? Yes yes No no 5. How many visits were made during the prior 3 months? **Which of the following activities did the WDC/VDC/CDC carry out in the last 12months?** 6. Supported or helped improve the health facility Yes yes No no 7. Repairs to facility Yes yes No no 8. Mobilized community to use facility Yes yes No no 9. Provided transport for home visits Yes yes No no 10. Gave in-kind contributions Yes yes No no 11. Improved security (facility) Yes yes No no 12. Improved water supply Yes yes No no 13. Improved water quality Yes yes No no 14. Supported training for CHEWs Yes yes No no 15. Support to outreach teams Yes yes No no 16. Provided new infrastructure Yes yes No no 17. Provided drugs Yes yes No no 18. Supported environmental sanitation Yes yes No no 19. Other 1. Is there a Health Facility Management Committee in place for the facility? Yes yes No no 2. Has the committee met at least once in the last year? Yes yes No no 3. How often does the health facility management committee meet? Weekly weekly Biweekly (every two weeks) biweekly Monthly monthly Quarterly quarterly Yearly yearly Other other Specify other. 4. How many members does the committee currently have? 5. Was the Health Facility/Hospital management committee involved in workplan development? Yes yes No no 6. Is the Officer-in-Charge a member of the committee? Yes yes No no 7. Are community members represented on the committee? Yes yes No no 8. How were community representatives selected? 9. Are the minutes available for all the meetings? Yes yes No no **Which of these sub committees are in existence & operational?** Yes yes No no 1. Finance Committee Yes yes No no 2. Procurement Committee Yes yes No no 3. Audit Committee Yes yes No no 4. Quality Assurance Committee Yes yes No no **Client View – exit interview for 1 adult client** 1. Is the health facility clean today? Yes yes No no 2. Were health staff courteous and respectful today? Yes yes No no 3. Did the health workers do a good job of explaining your condition today? Yes yes No no 4. Do you trust in the skills and abilities of the health workers of this facility? Yes yes No no 5. Were the health workers in this facility friendly and approachable? Yes yes No no 6. Are you confident that the health workers will maintain the confidentiality of your discussions? Yes yes No no 7. How long (in minutes) did you wait in the health facility before being seen for consultation by the health worker? *In minutes Enumerator name(s) Enumerator (s) Phone Number Enumerator(s) email address Any additional comment Departure time for first visit End of Survey Consent not given. End of Survey